The basic medical term for an ear infection is otitis. But ear infections come in different varieties and complexities. Although ear infections are a common occurrence, there is nothing simple about them. In 2015, the World Health Organization came up with a system to track every possible diagnosis. These are called ICD10 codes. To be clear, they erred on the side of leaving absolutely nothing out. There is a code for being bitten by a dolphin and another for getting sucked into a jet engine. I am not kidding. When it comes to ear infections, there are hundreds and hundreds of codes, Which ear? Is there fluid? Is it ruptured? Is it chronic or the first time? The list goes on and on. I am going to focus on the basics. The most common types of ear infections are:
- Otitis media, which is a middle ear infection.
- Serous otitis, which is fluid behind the eardrum
- Otitis externa, which is also known as swimmer's ear
Kids are so much more vulnerable to ear infections than adults.
This is because the middle ear is connected to the upper respiratory tract by a tiny channel known as the eustachian tube. Children’s eustachian tubes are smaller and more level than those of an adult. This means it is harder for them to drain well and easier to get blocked up even with mild swelling. Germs that are growing in the nose can climb up the eustachian tube and enter the middle ear. Because of these drainage issues, when kids are congested, they also may have fluid in their ear (serous otitis). This is why I am more suspicious about a possible ear infection in a child who has a cold. What may start out as a virus can turn into something bacterial. That fluid is the perfect medium for bacteria to grow. I compare it to a stagnant pond just waiting for the mosquitoes to breed. Check out Dr. Ted’s video on TikTok to learn more about eustachian tubes. Common symptoms and associated factors with ear infections: - Most of the time, an infection in the middle ear is associated with congestion, the flu, or other types of respiratory infections including RSV
- If they are still young and nonverbal, they often have extra fussiness, fever, or are tugging at their ear.
- Many kids wake up more than usual at night.
- Vomiting can be associated with ear infections.
- Some kids complain bitterly when you lay them down but seem more comfortable when they are upright.
- Some kids seem like their balance is off.
- Others seem like they are having trouble hearing. Of course we all know that all of our kids can seem deaf when we are telling them something they don’t care to hear!
Just because your child is tugging at their ear does not mean they have an infection. Some kids do it as a habit. My grandson Elliot holds onto his left ear whenever he is tired. Others do it when they are teething, especially upper teeth. Nevertheless, frequent pulling at the ear can be a clue that is worth paying attention to, especially if it accompanies any other symptoms. I realized after the fact that I had ignored my daughter Lauren’s first ear infection for more than a week when she was fairly young. Looking back at videos you can see the poor kid simply grabbing at her ear constantly. This was back when I was working at UCSF with complicated surgical cases. Thoughts of an ear infection didn’t even cross my mind. What makes it tricky?
A good number of kids don’t show any symptoms at all. I have seen patients go in for a well child exam be caught by surprise when a routine ear check revealed a raging infection. I have also seen ear infections go from ‘zero to sixty’ in no time flat. No, your doctor didn’t miss it. A child with a perfectly normal ear exam one day can have a horrible ear infection the next. Some stoic kids don’t make a noise about a severe infection while others complain bitterly about a little fluid in the ear that is not actually infected. Diagnosis To make an accurate diagnosis, for otitis media or serous otitis there is a lighted tool called an otoscope. Checking ears is a real skill that often takes practice to do well. What makes it tricky? Factors like lots of ear wax, or an uncooperative patient can add a level of complexity to the exam. If a patient is screaming bloody murder from the simple exam, that can make the eardrum appear redder than normal.
Not only is there not one standard treatment, but many times no treatment is even needed. If people blindly treated every complaint about an earache, antibiotics would end up being wildly over prescribed. This is an issue for various reasons. Not only does nobody want their kids taking medication unnecessarily, but antibiotic resistance is a potential problem for everyone. In some locations there are actual shortages right now (December 2022), so it is even more important that they are only prescribed for the people who actually need them. Treating Otitis Media If your child is diagnosed with a middle ear infection, you may get a prescription for antibiotics. If the eardrum is bulging and looks like it might rupture, the doctor will advise you that you should absolutely go ahead with the medication regardless of how your child is acting. Another reason to treat it is if your child is miserable and feverish. On the other hand, if it is not a severe infection and your child seems consolable, some wise doctors agree that it is perfectly fine to watch and see for a few days. Many ear infections can indeed clear up on their own and of course we all would like to avoid the use of antibiotics if we can. A Note about ruptured eardrums: My main agenda, aside from making the kids more comfortable, is preventing an eardrum from rupturing. An eardrum that ruptures frequently can become scarred and this can lead to hearing loss. Something to keep in mind is that a miserable screaming child might actually seem more comfortable after the eardrum finally bursts. They will also likely have lots of yellow/orange stuff draining out of the ear. The good news is that the pain of the pressure in there is gone, but the tympanic membrane (an important protective barrier) is no longer intact. Therefore, if your child does have a ruptured membrane, they need to be seen and treated even though they are no longer quite as fussy. After a rupture it is worthwhile getting the hearing tested to make sure there is no lingering hearing loss after the eardrum heals. This is even more important if it has happened more than once. Antibiotics Most pharmacists will take a moment when you pick up the prescription to go over the directions. Don’t treat this opportunity the way most of us do when the flight attendants are telling us how to buckle a seat belt. Pay attention and please make sure you are clear with the dosing instructions.
- Should it be taken with or without food?
- Does it need to be stored in the refrigerator?
- Do you need to be more cautious with sun exposure?
- Are there other medication interactions?
- Are the foods that should be avoided?
- What are common side effects?
- Are you clear about the dosage and timing?
Liquid antibiotics tend to be sticky and sweetened in order to make them more palatable. Please don’t forget to brush those teeth! In case you have a compliance issue, Here are some tips for giving the meds. Unfortunately even with the added sweetness, some are pretty nasty. Make sure that you finish the medication as directed. Don’t stop as soon as they are feeling better. That behavior can lead to antibiotic resistance. Antibiotics are not an instant magic wand. It may take the medication at least a couple of days before you notice a significant improvement. If your child is still super fussy or feverish after a full three days, have your doctor take another look in there to make sure the meds are working. Some kids who are having a really difficult time may end up getting an antibiotic injection. These hurt a bit, but they are usually quite effective. Chinese Medicine I asked local acupuncturist Dr. Den for her input on managing ear infections. She confirmed that Traditional Chinese Medicine (TCM) is a great and effective way to address ear pain and infections in your little ones. Acutherapy treatments (non-needle methods are available!) help the body to reduce inflammation and mucus, relieve pain and increase the necessary drainage. Early treatment is your best shot at avoiding antibiotics! Acutherapy treatments can also help prevent future infections, so they’re especially good for kids who tend to get an ear infection with every cold.
There are also safe pediatric Chinese herbal tinctures available and easy to use. For kids prone to ear infections, Dr. Den recommends keeping them on hand, so you can start giving them to your child at the very first signs of ear discomfort or infection. Reach out to your local pediatric TCM practitioner for specific products or advice. If you’re in San Francisco, Dr. Den is happy to help!
Dealing with Serous otitis Fluid in the ear can be really bothersome to some people and can absolutely have an impact on their hearing. Many doctors will suggest antihistamines and decongestants. The Chinese herbs can help with this as well.
There is some anecdotal evidence that gentle chiropractic adjustments/craniosacral therapy can help with drainage. Thanks to my chiropractor Sandra Roddy Adams for sharing some articles.
Kids with chronic serous otitis who get one infection after another will usually end up at the ENT doc who may put some tubes in the ear to help them drain. Melissa Wilson, Doctor of Audiology at Sound Speech and Hearing, adds that tubes are also put in to address the hearing loss that often accompanies middle ear fluid. Fluid build-up often causes a hearing loss on the order of 30-40 decibels. Average speech is about 60 decibels, so having fluid is like listening with your fingers plugging up your ears. Everything your child hears is muffled and over time, this can impact their speech and language development, and for the school-aged children this can cause issues with listening in the classroom and academics. Otitis externa (also known as swimmer’s ear) With otitis externa the outside of the ear is usually red and sore. The ears may be tender and will look inflamed. They may smell funky. These can be associated with time in water or pools but not always. This condition may be treated with ear drops rather than oral medications, depending on the severity. As opposed to the other forms of otitis, this one impacts plenty of adults as well Comfort measures/symptomatic treatment With or without the use of antibiotics there are several things you can do to ease the discomfort of a painful ear.
- Warmth usually feels good and can promote drainage. Some folks swear by a warm hair dryer held about a foot away from the ear.
- Warm compresses are another option. Try a warm wet washcloth against the ear.
- Little microwavable heat packs are great for this. If you don’t have one on hand you can make your own. Pour enough water into a clean diaper to get it nice and wet. Heat it up in a microwave for a quick heat pad that will stay warm for a while.
- Dr. Den recommends putting some uncooked rice in a sock, and then tie the sock off (if it’s long enough), or close it with an elastic band. Unless it becomes soiled, the same sock can be reheated many times, making this an easy, no mess method. Warm it briefly in the microwave.
Whichever kind of heat pack you choose, warm it up in 30 second increments to make sure it doesn't get too hot. Always test the temperature carefully before placing it against your child’s ear. It should be a comfortable warm/slightly hot temperature. - Believe it or not, my favorite remedy is garlic oil. Check the ear to make sure there is no reason to suspect a rupture; I don’t like to add any home remedy drops if there is any suspicion that the eardrum may not be intact. If there is no odor or drainage (a little wax doesn’t count) garlic oil may be a good option.
Here’s how to do it:
Saute some cloves of garlic in some olive oil. Let the oil cool until it is warm/not hot. Take a cosmetic square or cotton ball. Dip into the warm oil and stick it in the ear. Do this as often as your child will allow. - Dr. Den likes garlic mullein oil drops. These are soothing and will help fight the infection. (and you don’t need to fuss). Roll the bottle between your hands to warm it slightly, and then place 1 drop in the affected ear, up to three times per day.
If it is the middle of the night and your child is screaming, you can try any of these pain relief options until you have an opportunity to have your child checked. Persistent unrelenting misery may warrant a trip to the ER. I feel a pang for stressed out, busy parents who would love to avoid dragging their sick kids out into this germy world for an in person office visit, but virtual care is usually not adequate for an ear check. An important thing to note is that when kids have goopy eyes, many times they also have otitis, which is why a visit to your pediatrician may be needed in order to check out the eyes and the ears rather than just giving eye drops over the phone. And because pediatrics is never boring: It is also not unusual for pediatricians to find a little surprise when the ears are checked. Back when I was working at the pediatricians office, we found an assortment of little treasures in there, including little beads, unpopped popcorn kernels, and even the occasional insect.
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