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One of the most common reasons that many people find themselves going in to see the doctor in person is to rule out an ear infection. It’s one of those things you still can’t accurately diagnose from a virtual visit…… or with ChatGPT.
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. We are not kidding. There is a code for being bitten by a dolphin and another for getting sucked into a jet engine.
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. We are going to focus on the basics.
The most common types of ear infections are:
Suppurative otitis media, which is a bacterial middle ear infection.
Serous otitis media, which is un-infected 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.
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Source: https://nesilv.com/ent/
This is because the middle ear is connected to the upper respiratory tract by a tiny channel known as the eustachian tube (above). 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 media). This is why we are 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. It’s like a stagnant pond just waiting for the mosquitoes to breed.
The Classic Story
Using the pond metaphor, you can understand the most common story behind an ear infection: a young child who had a cold, seemed to be getting better, then 1-5 days later presented with fussiness (think frequent nighttime wakeups), ear pain, with or without fever. It’s more than likely they are now dealing with an ear infection.
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.
Young kids who are nonverbal, are making it clear that they are NOT comfortable or happy. They have extra fussiness, fever, or are tugging at their ear.
Many kids wake up more than usual at night or have fussiness when being horizontal (i.e. for naps). They may seem more comfortable when they are upright because being flat increases the pressure.
Vomiting can be associated with ear infections. (usually this does NOT come with diarrhea)
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. Nurse Judy’s grandson Elliot used to hold onto his left ear whenever he was tired (this one is super common). 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.
What makes it tricky?
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. A good number of kids don’t show any symptoms at all. We have seen patients go in for a well child exam be caught by surprise when a routine ear check revealed a raging infection. We 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, sometimes within 12 hours. There is a correlation between the rate of the infection’s presentation and which strain of bacteria caused it. Some build slowly, others are overnight.
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.
Factors like lots of ear wax, the angle of the ear canal (they’re all different) 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.
Treating Otitis Media
If your child is diagnosed with a middle ear infection, you may or may not get a prescription for antibiotics.
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 and all of our guts would be in ruins. Nobody want their kids taking medication unnecessarily, and antibiotic resistance is a potential problem for everyone.
If the eardrum is bulging and looks like it might rupture, the doctor will almost certainly advise you that you should absolutely go ahead with the medication regardless of how your child is acting. Another good 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, guidelines state 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.
Current guidelines support a “wait and see” approach for kids:
Who are older than 2
Have mild symptoms (pain without fever, or pain that resolves with over-the-counter pain meds)
Infection is only on one side.
For these kids, most doctors will provide a “safety net antibiotic prescription,” one that you can pick up and have in the house just in case, but not necessarily start immediately.
It is recommended that you start the prescription if your child develops:
Ear pain with fever
Ear pain that is severe (i.e. doesn’t resolve 90 minutes after Tylenol or Motrin)
Prolonged ear pain that is worsening or fails to improve after 48 hours
Many clinicians chose to have a lower threshold to treat with antibiotics before flying: the pressure in the cabin increases the risk of eardrum rupture if there is a potential infection.
A Note about ruptured eardrums:
Our main agenda, aside from making the kids more comfortable, is to protect long term hearing. Repeated severe infections or eardrum ruptures increase the risk of hearing loss because they can become scarred.
When there is a rupture, it is common to have a noticeable amount of thin yellow/white/green liquid draining out of the ear. The good news is that the pain of the pressure in there is gone, a miserable screaming child might actually seem more comfortable after the eardrum finally bursts.
The bad news is that 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 (with antibiotic ear drops and oral antibiotics) 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. They also need to avoid fully submerging their head in pools while their eardrum is open. Short baths and water running over the head are usually okay, but no hanging out under water.
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 can lead to recurrent ear infections if any of the bacteria is lingering.
Some doctors offer “ear follow up” visits: an opportunity to examine the ear after treatment to ensure that it has recovered. This isn’t mandatory, but is a good idea if:
You’ve had recurrent ear infections, especially within the last few months.
The ear drum ruptured.
The ears looked severe on the exam.
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.
Bacterial Versus Viral Ear Infections
So far we’ve been talking about bacterial ear infections. These are collections of bacterial pus, stuck behind the ear drum, that cause significant pain and fever. A provider can tell that an ear infection is bacterial because of the way it impacts the eardrum. The eardrum will look thickened, dull, dark red and is often bulging. The anatomic landmarks can’t be seen. Dr. Ted says it looks like it’s been beaten up. By contrast, viruses can cause collections of non-infected fluid. These are examples of “serous otitis media,” which can cause some pain, but the ear drum appears shiny, the fluid is clear, and the anatomic landmarks behind the ear drum are visible.
Dealing with Serous otitis
Because the fluid trapped in the ear is often viral, many of these will resolve with time as the virus passes. However, the trapped fluid is the necessary precursor to a bacterial ear infection (see above with the stagnant pond metaphor). We want to encourage drainage to prevent it from becoming infected. It is considered chronic when it lasts for at least three months.
Kids may or may not have obvious symptoms.
It’s a good idea for kids with chronic serous otitis or kids who get one infection after another to establish a relationship with an ENT doc. Among other treatment options, they may consider inserting 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.
General management of serious otitis often includes nasal saline flushes/rinses and humidifier use. Some providers might recommend decongestants or nasal steroids like Flonase if they suspect that allergies are involved.
Chinese Medicine
Traditional Chinese Medicine (TCM) can be a great and effective way to address ear pain and infections in some little ones. Acutherapy treatments (non-needle methods are available!) purport to help the body to reduce inflammation and mucus, relieve pain and increase the necessary drainage. According to TCM practitioners, early treatment is your best shot at avoiding antibiotics! Acutherapy treatments also try to help prevent future infections, so they may be 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, San Francisco’s 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.
Thinking outside ‘the box’
If you are open to other alternative options, Nurse Judy has seen some of her patients benefit from gentle chiropractic treatment for some stubborn cases of serous otitis.
Thank you to SF Chiropractor Sanra Roddy Adams for sharing this study that explores how adjustments/craniosacral therapy can help with drainage.
Otitis externa (also known as swimmer’s ear)
This is where we draw a distinction between inner and outer ear infections.
Remember that photo of the eustachian tube, above? The ear drum, or tympanic membrane, is a waterproof covering that divides the components of the middle ear from the outside world. The eardrum is why swimming does not cause inner ear infections. An intact eardrum keeps water out.
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.
Tylenol and/ or Ibuprofen are useful. Here is a dosage post .
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, Nurse Judy’s favorite remedy is garlic oil. Check the ear to make sure there is no reason to suspect a rupture; she doesn’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 for relief. This is a comfort measure: the warm oil can soothe a pained ear. It is not meant to treat a suspected bacterial ear infection. Remember: make sure there is no rupture before using it. If there is any drainage from the ear, don’t take the chance.
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.
We 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 as we mentioned above, virtual care is usually not adequate for an ear check.
An important thing to note is that when kids have goopy eyes, they may 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.
Dr. Ted’s Tidbit
This story, of a kid with goopy eyes and a parent that just wants eyedrops, is one of the most inconvenient things we have to deal with, because it really feels like a phone call and some eye drops should be the end of it. But there is a connection between eyes, tear ducts, and ears. About 20-30% of the time there is an eye infection, there is also something to be seen in the ears.
Because many bugs will infect eyes and ears together, and chatting over the phone or via a screen won’t tell you the full picture. Unfortunately, a combo eye-ear infection often needs more powerful antibiotics, so it is important to get a look at the physical ear.
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 Nurse Judy was working at the pediatricians office, the team found an assortment of little treasures in there, including little beads, unpopped popcorn kernels, and even the occasional insect.
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