Ear Infections

WHAT ARE EAR INFECTIONS (OTITIS MEDIA) IN CHILDREN?

The Ear

The ear is the organ of hearing and balance and is organized into external, middle, and internal areas.

The outer ear collects sound waves that are conducted through a canal to the tympanic membrane , commonly called the eardrum.
The tympanic membrane is a tissue that is lined on the inside with mucus. Like a drum, it vibrates to the incoming sound waves, converting them into mechanical energy.
This energy resonates through the middle ear, a complex structure filled with air and composed of tiny bones that vibrate to the rhythm of the ear drum and pass the sound waves on to the inner ear.
The inner ear is filled with fluid. Here, hair-like structures stimulate nerves to convert the mechanical waves to electrochemical impulses that are carried by a network of nerve cells to the brain, which senses these impulses as sounds.
The inner ear also contains three semi-circular canals that function as the body's gyroscope, regulating balance.
The Eustachian tube, an important structure in the ear, runs from the middle ear to the passages behind the nose and the upper part of the throat. This tube ventilates the ear and equalizes the air pressure in the middle ear to the outside air pressure. Problems here are primary factors in most cases of ear infection.

Ear Infections (Otitis Media) in Children

Ear infections are often defined by whether they are acute (acute otitis media) or chronic (otitis media with effusion).

Acute Otitis Media (AOM). Acute otitis media (AOM) is an infection in the middle ear that causes an inflammation behind the tympanic membrane.

Often it develops during or after a cold or a flu.
Middle ear infections are extremely common in children but are infrequent in adults.
In children, ear infections often recur, particularly if they first develop in early infancy.

Otitis Media with Effusion (OME) . Otitis media with effusion (OME) occurs when an effusion (fluid) builds up in one or both middle ears. When this is chronic and severe the fluid is very sticky and is commonly called "glue ear."

It is not painful and the only clue that it is present is a feeling of stuffiness in the ears, which can feel like "being under water."
Children who are susceptible to OME can have frequent episodes for more than half of their first three years of life.
The episodes can last from weeks to months.

WHAT CAUSES MIDDLE EAR INFECTIONS IN CHILDREN?

Otitis media (middle ear infection) is most often the result of a combination of factors that increase susceptibility to infections by specific organisms in the middle ear.

Causes of Increase in Incidence of Ear Infections and Other Airway Infections and Disorders

Increased diagnosis of other disorders and infections of the upper and lower airways, such as asthma, allergies, and sinusitis, have paralleled the rise in ear infections. For example, the same bacteria are often responsible for both ear infections and sinusitis. In one study, 38% of children with ear infections also had sinusitis, and other studies have reported that nearly half of children with OME have concurrent sinusitis. These studies may have overestimated the extent of clinically important sinus disease, but nonetheless, the association is significant but causal relationships are unclear. Researchers are looking for common risk factors:

Increase in Day Care Center Attendance. Although ear infections themselves are not contagious, the respiratory infections that precipitate them can pose a risk for children with close and frequent exposure to other children. Some experts believe, then, that the increase in ear and other infections may be due to the higher attendance of very small children, including infants, in day care centers beginning in the 1970s. For children who had the condition for a long time, however, neither day care attendance nor any other risk factor, including a history of upper respiratory tract infections or family history of OME, appeared to be relevant. Attendance in day care centers, then, may explain part, but not all, of the current increase in ear infections and other upper airway disorders.
Increase in Allergies. Some experts believe that the increase in allergies is also partially responsible for the higher number of ear infections, which is unlikely to be related to day care attendance. Studies indicate that 40% to 50% of children over three years old who have chronic otitis media also have allergic rhinitis (hay fever). Allergies are also associated with asthma and sinusitis.

The rise in the rate of otitis media, then, is probably due to a combination of factors that are also responsible for the increase in these other airway problems.

Conditions that Predispose a Person to Ear Infections

Problems in the Eustachian Tube. Many bacteria thrive in the passages of the nose and throat. Most are benign and some are even important in preventing harmful bacteria from getting out of control. In addition, the body has a number of defenses that prevent the harmful bacteria from replicating and infecting deeper passages, such as those in the ear.

However, various factors can impair these defenses. Common factors may include but are not limited to the following:

Viral infection.
Smoke particles.
Allergies, such as hay fever, that affect the nasal passages (allergic rhinitis).

In general, these or other irritants can produce the following conditions that lead to ear infection:

Irritation from viruses, smoke particles, or allergies can cause the membranes along the walls of the inner passages to become inflamed, swell, and obstruct the airways.
If this inflammation blocks the narrow Eustachian tube so that it can not drain the middle ear properly, fluid builds up.
This fluid can then become a reservoir and breeding ground for bacteria and subsequent infection.

The Eustachian tubes in all children are shorter and smaller than in adults and therefore more vulnerable to obstruction. Children with shorter-than-normal and relatively horizontal Eustachian tubes are at particular risk for recurrent infections.

Genetic Factors. Several studies suggest that multiple genetic factors may play a role in making a child susceptible to otitis media.

For example, genetic susceptibility to certain bacteria may result in development of persistent and recurrent otitis media.
Abnormalities in genes that affect the defense systems (cilia and mucus production) and the anatomy of the skull and passages would also increase the risk for ear infections.
Abnormalities in genes that regulate a powerful immune factor called interleukin 1 have been identified in some patients with recurrent otitis media who did not have any allergic disorders. Interleukin 1 plays a major role in producing inflammation in tissues and cells during heightened immune activity. Abnormalities in interleukin production may possibly result in a persistent inflammatory response.

Researchers are hoping that these findings may encourage primary care physicians to closely monitor children who are offspring or siblings of individuals with a history of unusually frequent or severe upper respiratory tract infections.

Medical or Physical Conditions the Affect the Middle Ear. Any medical or physical condition that reduces the ear's defense system can increase the risk for ear infections. Examples include inborn structural abnormalities, such as cleft palate, or genetic conditions, such as Kartagener's syndrome, in which the cilia (hair-like structures) in the ear are immobile and cause fluid build up.

Infecting Agents

Bacteria. Certain bacteria are the primary causes of acute otitis media (AOM) and are detected in about 60% of cases. The bacteria most commonly causing ear infections are:

Streptococcus pneumoniae (also called S. pneumoniae or pneumococcus) is the most common bacterial cause of acute otitis media, causing about 50% to 80% of cases in the US.
Haemophilus influenzae is the next most common culprit and is responsible for 20% to 30% of acute infections.
Moraxellacatarrhalis is also a common infectious agent, responsible for 10% to 15% of infections.
Less common bacteria are Streptococcus pyogenes and Staphylococcus aureus .

Of note, about 15% of these bacteria are now believed to be resistant to the first-choice antibiotics.

Viruses. Studies have reported the presence of viruses in the middle ear fluid in about 40% of children with ear infections. While viruses are not usually a direct cause of otitis media, they may play an important role by causing inflammation in the nasal passages and impairing defense systems, such as cilia, in the ear.

Respiratory syncytial virus (RSV), a common virus responsible for upper and lower respiratory infections, and influenza viruses ("Flu") are prime suspects in this process. In one study, it was detected more often than any other virus in children with AOM..
Rhinovirus, a cause of the common cold, has been found in between 1% and 8% of otitis media cases, and, in one study 74% of patients with rhinovirus caused colds had middle-ear pressure abnormalities.

Causes of Otitis Media with Effusion (OME)

Direct Causes of OME. In some cases, otitis media with effusion develops after an acute otitis media attack, although often the direct cause of OME is unknown. The role of allergies, bacteria, or other conditions may play some role in susceptible children, but their roles have not been clearly defined:

Allergies. In one study, 89% of patients with OME also had allergic rhinitis (e.g., hay fever), suggesting a possible causal relationship in susceptible children. Some evidence suggests that allergies produce high levels of white blood cells called neutrophils in the ears of patients with OME.
Bacteria. It is not clear what role bacteria or other infectious agents play. Standard tests do not detect bacteria in 40% to 60% of cultures taken from fluid in OME-affected ears. (In one study, a sophisticated test found genetic evidence of Haemophilus influenza bacteria in about a third of specimens in which no bacteria were detected by standard culture techniques.)
Gastroesophageal Reflux Disorder. Gastroesophageal reflux disorder (GERD), in which acid backs up into the esophagus, is a common cause of heartburn in adults. In infants, GERD may occur when muscles in the upper part of the stomach are still immature and force acid and other compounds to back up. GERD has become associated with many upper airway problems, including ear infections and sinusitis, although some experts argue that GERD is normal in children and the association is unfounded.

Conditions that Make Children Susceptible to OME. Even when the conditions discussed above are present, however, most children do not develop OME. Susceptibility to OME is almost always due to an abnormal or malfunctioning Eustachian tube that causes a negative pressure in the middle ear, which, in turn, allows fluid to leak in through capillaries. Problems in the Eustachian tube can be due to viral infections, second-hand smoke, injury, birth defects, such as cleft palate, or genetic diseases that affect the defense systems, such as Kartagener's syndrome.

WHO GETS EAR INFECTIONS?

Acute ear infections account for more than 20 million visits to the doctor each year in the US, and are, in fact, that most common reason why an American child sees the doctor. About 62% of children can expect to have a least one attack of acute otitis media (AOM) in their first year and 80% will have had an infection by age three. And, the incidence of AOM has been rising over the past decades, although some experts believe this condition is simply overdiagnosed.

Gender and Age

Boys are more apt to have infections than girls are, and the risk is higher the younger the child:

About 17% of all children under two have recurrent ear infections (i.e., three or more episodes within a six-month period). The earlier a child has a first ear infection the more susceptible he or she is to recurrent episodes. The peak incidence occurs between seven and nine months of age.
As children grow, however, the structures in their ears enlarge and their immune systems become stronger. By 16 months the risk for recurrent infections is rapidly declining. Still, about two-thirds of children have had at least one acute ear infection by the time they are three years old.
Half of the cases of otitis media with effusion (OME) appear to develop within the first year of life. In one study, 18% of healthy children between birth and age three had frequent recurrences of OME in one or both ears. (Because OME has fewer symptoms than acute otitis media, however, its prevalence among very young children is unclear.)
After age five, most children have outgrown their susceptibility to any ear infections.

Other Risk Factors

Specific children at higher risk for ear infections have one or more of the following:

Allergies.
Enrollment in day care.
Exposure to second-had cigarette smoke.
Being bottle-fed as infants.
Having siblings with recurrent ear infections.
Being in lower socioeconomic groups.
Possibly having a higher number of cavities. (The study suggesting this was small. More research is needed.)
Obesity. One 2001 study found a link between ear infections and childhood obesity. Eardrum abnormalities increased the more the child weighed, which might explain the association. The researchers also suggested that parents may be confusing their children's fussiness due to the ear infection with hunger, and therefore overfeeding them.
Certain medical disorders, including Down's syndrome, cleft palate, Kartageners syndrome, and immunosuppressive disorders, such as HIV, increase the risk for ear infections.

Parental Behavior

The behavior of parents can increase a child's risk for otitis media.

Parents who smoke pose a significant risk for both otitis media with effusion (OME) and recurrent acute otitis media (AOM) in their children. (Passive smoking does not appear to be a cause of initial ear infections, however.)
Pregnant women who drink alcohol put their babies at risk for birth defects that can cause a number of problems, among them hearing loss and OME.
Babies who are bottle-fed may have a higher risk for otitis media than do breast-fed babies.
Several studies have found that the use of pacifiers place children at even higher risk for ear infections. Sucking increases production of saliva, which is a vehicle for bacteria that can travel up the Eustachian tubes to the middle ear.

WHAT ARE THE SYMPTOMS OF EAR INFECTIONS IN CHILDREN?

Symptoms of Acute Otitis Media

Symptoms of acute otitis media usually develop suddenly and can include:

Pain or discomfort in the ear. (It is difficult to determine if a preverbal child or infant has an ear infection. Some children may indicate pain if they have trouble swallowing food and rejecting it. Some parents believe that tugging on the ear indicates an infection, but this gesture is more likely to indicate pain from teething.)
Coughing.
Nasal congestion.
Fever.
Irritability.
Loss of appetite.
Vomiting.
Pus in the ear may cause hearing loss in some children.
If the ear infection is severe, the tympanic membrane may rupture causing the parent to notice pus draining from the ear. (This usually brings relief from pain.)

Fevers and colds often make children irritable and fussy, so it is difficult to determine if otitis media is present as well. In about a third of children with acute middle ear infection, symptoms are not apparent.

Symptoms of Otitis Media with Effusion

Otitis media with effusion (OME) often has no symptoms at all. Some hearing loss may occur, but it is often fluctuating and hard to detect even by observant parents. The only signal to a parent that the condition exists may be when a child complains of "plugged up" hearing. There are some indications that older children with OME may have difficulty targeting specific sounds in a noisy room. (In such cases, some parents or teachers may attribute their behavior to lack of attention or even to an attention deficit disorder.) OME is often diagnosed only during a regular pediatric visit.

HOW SERIOUS ARE EAR INFECTIONS IN CHILDREN?

Acute Otitis Media in Infancy

Any infant under three months old who shows signs of ear infection should be seen by a physician promptly, since acute otitis media in babies can sometimes be a sign of a more wide-spread infection, sometimes including meningitis.

Hearing Loss and Delayed Development

Evidence strongly suggests that severe cases of recurrent acute otitis media and persistent otitis media with effusion (OME) impair hearing. The effect of long-term hearing problems may have the following effects:

Learning Delays . Hearing loss in children slows down language development and reading skills. Children with even mild hearing loss may miss spoken words and have trouble making sense out of a conversation or a lesson in school. It is not clear, however, even after years of research, if OME and its attendant reduced hearing have any significant and long-term effects on learning. Some research suggests that these effects may last into the teens. Many studies suggest that any effect on learning is not significant. And some even posit that lower learning scores reported may actually be due to the fact that children with ear infections tend to be in lower socioeconomic groups and so have less home attention. Nevertheless, a 2001 study that targeted teenagers reported that those with a history of OME had more verbal and reading problems than others, regardless of their socioeconomic status. Research continues.
Behavioral and Social Problems. Children with impaired hearing may appear to be distracted, inattentive, unintelligent, and may even be inaccurately diagnosed as having attention deficit hyperactivity disorder. As with learning, studies have been mixed on the significance of long-term effects of OME on behavior. Considering the increased usage of medications for attention deficit disorder and the social burdens carried by children diagnosed with emotional and learning disabilities, more research is essential for clarifying this relationship.
Speech Problems. A few small studies have found speech problems in some young children with OME, but it is not clear if this is a significant issue.

Physical and Structural Injuries in the Face and Ears

Serious complications or permanent physical injuries from ear infections are very uncommon but may include the following:

In severe or recurrent otitis media, certain children may be at risk for structural damage in the ear.
Cysts in the ear known as cholesteatomas are an uncommon complication of recurrent or severe ear infections.
In rare cases, even after a mild infection, certain children, possibly because of immune abnormalities, develop calcification and hardening in the middle and, occasionally, in the inner ear.

Mastoiditis

Before the introduction of antibiotics, mastoiditis, an infection in the bones located in the skull, was a major and serious complication of otitis media. This condition is difficult to treat and requires intravenous antibiotics and drainage procedures. Surgery may be required. If pain and fever persist in spite of antibiotic treatment of otitis media, the physician should check for mastoiditis. Even without antibiotics this is a rare complication; at present, cases of mastoiditis are generally not associated with ear infections.

Other Possible Complications

Impaired Balance. Some studies have indicated that children with chronic OME have problems with motor development and balance.

Facial Paralysis. Very rarely, a child may develop facial paralysis, which is temporary and relieved by drainage surgery.

HOW ARE EAR INFECTIONS IN CHILDREN DIAGNOSED?

Medical History

The physician should be sure to ask the parent for a history of any recent cold, flu, or other respiratory infections. If the child complains of pain or has other symptoms of otitis media, such as redness and inflammation, the physician should be sure to rule out any other causes of such symptoms. They may include, but are not limited to the following:

Otitis media with effusion. OME is commonly confused with acute otitis media. It must be ruled out because it does not respond to antibiotics.
Dental problems (such as teething).
in the outer ear. Symptoms include pain, redness, itching, and discharge. Infection in the outer ear, however, can be confirmed by wiggling the ears, which will produce pain. (This movement will have no significant effect if the infection is in the middle ear.)
Foreign objects in the ear. This can be dangerous and a physician should always check for this first when a small child indicates pain or problems in the ear.
Viral infection can produce redness and inflammation. Such infections, however, are not treatable with antibiotics and resolve on their own.
A parent's or child's attempts to remove earwax.
Intense crying can cause redness and inflammation in the ear.

Physical Examination

An ear examination should be part of any routine physical examination in children, particularly because the problem is so common and many children have no symptoms.

The physician first removes any ear wax (called cerumen) in order to get a clear view of the middle ear.
The physician employs a small flashlight-like instrument called an otoscope to view the ear directly. This is the most important diagnostic step. This instrument will reveal signs of acute otitis media, bulging eardrum, and blisters. The physician will also check color.
To determine ear infection the physician should always use a pneumatic otoscope. This device detects any reduction in eardrum motion. It has a rubber bulb attachment that the physician presses to push air into the ear. Pressing the bulb and observing the action of the air against the eardrum allows the physician to gauge the eardrum's mobility.
Some physicians may use tympanometry to evaluate the ear. In this case a small probe is held to the entrance of the ear canal and forms an airtight seal. While the air pressure is varied, a sound with a fixed tone is directed at the eardrum and its energy is measured. This device can detect fluid in the middle air and also obstruction in the Eustachian tube.
A procedure similar to tympanometry, called reflectometry, also measures reflected sound to detect fluid and obstruction but does not require an airtight seal at the canal.

It should be noted that neither tympanometry nor reflectometry are substitutes for the pneumatic otoscope, which allows a direct view of the middle ear. The physician will then assess the results of this examination to determine a diagnosis.

A normal eardrum is grayish-pink and translucent. An eardrum with acute otitis media is opaque and can be red, white, or yellowish. It is also less mobile.
If the eardrum is red and inflamed but mobile, the cause is more likely to be irritation rather than a bacterial infection.
If the eardrum is clear and translucent but is not mobile and if fluid is present, then otitis media with effusion (OME) is likely to be present.
A scarred, thick, or opaque eardrum may make it difficult for the physician to distinguish between acute otitis media and OME.

Tympanocentesis

On rare occasions the physician may need to draw fluid from the ear using a needle for identifying specific bacteria, a procedure called tympanocentesis. This procedure can also relieve severe ear pain. This is most often performed by ear, nose, and throat (ENT) specialists, and usually only in severe or recurrent cases. In most cases tympanocentesis is not necessary in order to obtain an accurate enough diagnosis for effective treatment.

Determining Hearing Problems

Hearing tests performed by an audiologist are usually recommended for children with persistent otitis media with effusion. A hearing loss below 20 decibels usually indicates problems.

Determining Impaired Hearing in Infants and Small Children. Unfortunately, it is very difficult to test children under two years old for hearing problems. One way to determine hearing problems in infants is to gauge the baby's language development:

At four to six weeks most babies with normal hearing are making cooing sounds.
By around five months the child should be laughing out loud and making one-syllable sounds with both a vowel and consonant.
Between six and eight months, the infants should be able to make word-like sounds with more than one syllable.
Usually starting around seven months the baby babbles (makes many word-like noises) and should be doing this by 10 months.
Around 10 months, the baby is able to identify and use some term for the parent, dada, baba, or mama.
The baby speaks his or her first word usually by the end of the first year.

If a child's progress is significantly delayed beyond these times, a parent should suspect possible hearing problems.

Determining Impaired Hearing in Older Children. Hearing loss in older children may be detected by the following behaviors:

They may not respond to speech spoken beyond three feet away.
They may have difficulty following directions.
Their vocabulary may be limited.
They may have social and behavioral problems.

WHAT ARE THE MEASURES FOR PREVENTING EAR INFECTIONS?

Avoiding Pacifier Use

There is some evidence to suggest that use of pacifiers may increase risk of otitis media in children under three years old. Nevertheless, some physicians believe any association is exaggerated and that the comfort a child derives from sucking (either thumb, breast, or pacifier) is more important than any presumed increase risk for ear infection.

Breast-Feeding

Breastfeeding offers protection against many early infections, including ear infections. For one, the mother's milk provides immune factors that help protect the child from infections. Also, to be breast fed, infants are held in a position that allows the Eustachian tubes to function well. If possible, new mothers should breast feed their infants for at least six months. For bottle-fed babies, to improve protection mothers should not lay babies down with their bottle; they should hold the infants in the same way they would to breast-feed them.

Preventing Colds and Flus

Good Hygiene. A very common method for transmitting a cold is by shaking hands. Everyone should always wash his or her hands before eating and after going outside. Ordinary soap is sufficient. Waterless hand cleaners that contain an alcohol-based gel are also effective for every day use and may even kill cold viruses. (They are less effective, however, if extreme hygiene is required, In such cases, alcohol-based rinses are needed.) Antibacterial soaps add little protection, particularly against viruses. In fact, one study suggests that common liquid dish washing soaps are up to 100 times more effective than antibacterial soaps in killing respiratory syncytial virus (RSV), which is known to cause pneumonia and has been associated with ear infections.

Daily diets should include foods such as fresh, dark-colored fruits and vegetables, which are rich in antioxidants and other important food chemicals that help boost the immune system.

Researchers are also studying the possible protective value of certain strains of lactobacilli, bacteria found in the intestines. Some of these strains, particularly acidophilus, are used to make yogurt. According to one Finnish study, children attending day care who ate milk containing the strain lactobacilli GG could reduce respiratory infections in these children by 10% to 20%. More research is warranted. (The strain used was not the kind found in most commercial yogurt products,)

Reducing Stress. Interestingly, giving children affection and helping them relax could help prevent colds. More than one study has reported that people with low stress who also have an active social life have fewer colds than people who have high stress levels or those who have low stress and few social connections.

Alternative Cold Remedies. Alternative agents, such as echinacea, are sold as remedies for prevention or reduction of respiratory infections. Echinacea can cause allergic reactions, and parents should not give their children remedies that have not been regulated or standardized and for which evidence is weak. Vitamin C has been purported to reduce cold symptoms, but children should be never been given high doses of any vitamin. [For more information see Well-Connected Report #94, Colds and Influenza (the Flu) .]

Avoiding Exposure to Cigarette Smoke

Parents or others should not smoke around children. Several studies have found that children who live with smokers have a significant risk for ear infections. One study even suggested that the more the mother smoked the higher the risk.

Vaccines

Children who are susceptible to recurrent ear infections should probably be given vaccinations against influenza viruses and pneumococci.

Viral Influenza Vaccines. Vaccinations now protect against influenza in between 70% and 100% of healthy adults when the virus and the vaccine are well matched. In the absence of a match and among the elderly and children, they are fully protective in 30% to 60% of people. Even in people with a weaker response, the vaccine is usually protective against serious flu complications, particularly pneumonia, if such people get the flu. Additionally, studies are finding that the more people that are vaccinated, the healthier the community at large.

Vaccines are designed to recognize foreign agents (called antigens) in the body and to attack them. Vaccines against influenza currently employ inactivated (not live) viruses to produce an immune response that will then attack the active virus. Vaccines are now given by injection in the fall, usually between October and December.

A live but weakened intranasal vaccine (Flumist) known as a cold-adapted, live, attenuated, trivalent, intranasal influenza vaccine (CAIV-T) has been investigated for some time. Because it doesn't need to be injected, it may increase the number of children being vaccinated if it proves to be safe. It is engineered to grow only in the cooler temperatures of the nasal passages, not in the warmer lungs and lower airways.

The current flu vaccines may be slightly less effective in the elderly, the very young, and patients with certain chronic diseases than in healthy young adults. (Even vaccinated patients may still experience some flu symptoms, such as nasal congestion or sore throat.) Even in people with a weaker response, however, the vaccine is usually protective against serious flu complications, particularly pneumonia.

The following children over six months should be vaccinated against influenza:

Any child with a condition that requires regular medical care. In fact, in 2002 the American Academy of Pediatrics (AAP) and the CDC recommended the vaccination for all healthy children under two years of age.
Any child who has been hospitalized for a serious illness (particularly lung, kidney, diabetes, sickle-cell, or immune deficiencies). The effects of the influenza vaccine on children with asthma are not entirely clear. Some studies have reported more severe asthma symptoms in children with the lung condition. A 2000 study of asthmatic children, however, reported no increased risk. In fact, there was some indication that the vaccination helped reduce asthma attacks over time. More research is needed to confirm or refute these results.
Children who are receiving long-term aspirin therapy should also be immunized against the flu because they are at higher risk for Reye's syndrome, a life-threatening disease, if they get the flu.

Although such high-risk children have considerable risk for hospitalization from influenza, most of these children are not being vaccinated.

Possible negative responses include the following:

Allergic Reaction. Newer vaccines contain very little egg protein, but an allergic reaction still may occur in people with strong allergies to eggs.
Soreness at the Injection Site. Almost a third of people who receive the influenza vaccine develop redness or soreness at the injection site for one or two days afterward.
Symptoms. Other side effects include mild fatigue and muscle aches and pains. They tend to occur between six and 12 hours after the vaccination and last up to two days. It should be noted that these symptoms are not influenza itself but an immune response to the virus proteins in the vaccine. Anyone with a fever, however, should not be vaccinated until the ailment has subsided.

Pneumococcal Vaccines. The pneumococcal vaccine protects against S. pneumoniae (also called pneumococcal) bacteria, the most common cause of middle ear infections and other respiratory infections. It is very effective in children, and some experts believe that universal vaccinations for infants would prevent a million cases of ear infections as well as serious infections, such as pneumonia. In one study, a similar vaccine under investigation protected not only children in day care from serious respiratory infections, but their younger unvaccinated siblings had fewer infections as well. In pregnant women who are immunized, the vaccine may actually protect against ear infections in their infants.

The pneumococcal vaccine is now recommended by many experts for the following groups:
All children up to age two. The pneumococcal vaccine (Prevnar or PCV7) has now been added to the Recommended Childhood Immunization Schedule. The pneumococcal vaccine (Prevnar or PCV7) is very effective in children. Studies are suggesting that it prevents common ear infections as well as serious infections, such as pneumonia. In one study, a similar vaccine under investigation protected not only children in day care from serious respiratory infections, but their younger unvaccinated siblings had fewer infections as well.
Children up to age five who are at risk for pneumonia or complications of influenza, such as children with sickle disease, those with immune deficiencies, or children with chronic medical conditions.
Other children age two to five who are higher risk for serious pneumococcal infections should be considered for vaccinations. They include African or Native Americans, children in group child care, socially or economically disadvantaged children, or those who have had frequent or complicated acute middle ear infections within the past year. (In one study, the vaccine reduced the number of ear infections episodes by 6%.)

The recommended schedule of immunization for Prevnar (PCV7) is four doses, given at two, four, six, and 12 to 15 months of age. Infants starting immunization between seven and 11 months should have three doses. Children starting their vaccinations between 12 and 23 months only need two doses. And those who are over two years old need only one dose.

Experimental Agents

Interfering Bacteria. Researchers have observed that the noses and throats of children who are prone to ear infections harbor smaller numbers of the "friendly" bacteria that help prevent overproduction of the harmful bacteria, than children without frequent infection. Interesting research is underway using a nasal spray containing harmless bacteria called alpha-streptococcal, which are normally found in the throat and competes for space with harmful bacteria. In early studies, the nasal spray has helped to protect against recurrent otitis media in susceptible children. This is very promising because it could significantly reduce antibiotic use; more research is warranted.

Antiviral Agents. In one study, when the anti-viral drug, zanamivir (Relenza), was administered in the nasal passages of adults with influenza, middle-ear abnormalities were reduced from 73% to 32%. This drug is available for children greater than seven years old for treatment of influenza, but no research has determined it value for preventing or treating otitis media in children.

Xylitol. Xylitol, a sugar alcohol produced naturally in birch, strawberries, and raspberries, has properties that fight Streptococcal pneumonia bacteria. Studies are reporting that children who chew gum or swallow a syrup containing xylitol experience significantly fewer ear infections. It also reduces cavities. Chewing gum (Clen Dent) may be more effective than the syrup. Although in one study, xylitol did not reduce bacteria in the nose and throat, it did prevent ear infection. (It does not appear to prevent ear infections in children who are having colds or flus.) Some health providers report that even children one and a half years old can learn to chew and not swallow gum. Studies have not been clinically tested children between six and 18 months, the highest-risk age group for otitis media. This is an area for further research. The gum is not widely available in the US although it can be purchased on the Internet (http://www.xylitolworks.com/).

WHAT ARE THE GENERAL GUIDELINES FOR TREATING EAR INFECTIONS?

Although ear infections in children are extremely common, the research on this condition is oddly unclear. Experts continue to argue about the best approach for treating ear infections. The major debates rest on the use of antibiotics, surgery, and watchful waiting in both acute otitis media and OME. Treatments for ear infections cost the country between three and four billion dollars each year, and evidence is mounting that many of these treatments, particularly heavy antibiotic use and surgical procedures, may be unnecessary.

Deciding Whether to Use Antibiotics for Acute Otitis Media

Antibiotics have been the mainstay treatments of acute otitis media. Nearly every American child who visits a doctor with an ear infection receives antibiotics. In one region of the US more than 70% of children received antibiotics before they were seven months old, and the most common reason for these medications was otitis media. Antibiotics are also heavily used to treat otitis media in children all over the world. [ See What Are the Antibiotic Choices for Treating Otitis Media?]

Overuse of Antibiotics. Nevertheless major studies indicate that between 80% and 90% of all children with uncomplicated ear infections ear recover within a week without antibiotics. (About 70% of severe cases can even be cured without antibiotics.) In a 2001 Baltimore study, for example, 89% of children who were given pain-relieving ear drops experienced resolution of their infection without antibiotics. Unfortunately, there are no objective tests available to determine specifically the small percentage of children with AOM that would actually benefit from antibiotics. [ See What Are the Antibiotic Choices for Treating Otitis Media?]

Emerging Bacterial Resistance. And importantly, such intense use of antibiotics is leading to a serious global problem. Of major concern is a worldwide increase in strains of common bacteria that have become resistant to the standard antibiotics used to treat them. For example, according to reports in 2002 and 2001, the rates of penicillin-resistant Streptococcus pneumoniae are 15% in Canada, between 30% to 40% in the US, and between 70% and 80% in Hong Kong. And, furthermore, in the US about 23% of S. pneumoniae are currently resistant to at least three antibiotics. In general, regions and institutions with the highest rate of resistance are those in which antibiotics are heavily prescribed.

According to one study, children at highest risk for both ear infections and harboring bacterial strains resistant to antibiotics are boys who attend day care, who are exposed to cigarette smoke, who were bottle-fed, and who have siblings with recurrent ear infections. (On a positive note, a small study in Israel suggested that antibiotic-resistant pneumococcal strains carried by children in a day care center were not passed on to the adults in their households.)

Candidates for Antibiotics for Acute Otitis Media. Some experts now recommend that only children under the age of two should be treated with antibiotics, and children over two should be treated case by case.

Some reports suggest that the following guidelines may be reasonable for choosing antibiotics in older children:

Give antibiotics immediately to children with obvious, severe pain and if the eardrum is red and bulging.
Other children should be monitored for three days, during which parents can give them mild pain relievers and home remedies.
If symptoms persist after three days, antibiotics may be prescribed. [ See What Are the Antibiotic Choices for Treating Otitis Media? below.]

One British study reported that only 24% of children who followed these guidelines needed antibiotics. And, compared to other groups who were all given immediate antibiotics, there were no differences in missed school days or child distress. The antibiotic group also had much higher rates of diarrhea.

Unfortunately, given even a remote possibility of serious complications, including mastoiditis and negative effects on learning from hearing loss due to recurrent infections, most physicians and parents are very reluctant to abandon the standard use of antibiotics. And many American physicians feel pressured by patients and families into prescribing antibiotics when the patients do not really need them.

The bottom line is that parents should question their physician closely if they recommend antibiotics and feel comfortable waiting to see if they are truly necessary. They should not pressure a physician into prescribing an antibiotic if it is clearly inappropriate. The physician very often will give in .

General Guidelines for Treating Single-Episodes of AOM with Antibiotics

When antibiotics are needed, a number of different classes are available for treating acute ear infections. Amoxicillin is a penicillin antibiotic and the drug of first choice. Other antibiotics are available for children who are allergic to penicillin or who do not respond within three to five days. [ See What Are the Antibiotic Choices for Treating Otitis Media?]

Duration. If a child needs antibiotics for acute otitis media, the following are some recommendations for duration of regimens.

Five days of antibiotic therapy appears to be sufficient for most children with uncomplicated AOM. Such children are typically those over two years old, those who start to improve within 72 hours, and those who have no risk factors for complications.
A full ten to fourteen day course of antibiotics (usually amoxicillin) is typically used for younger children and for those with complications such as a perforated ear drum, facial abnormalities, or impaired immune systems.

Parents should be sure their child completes the drug regimen. Not completing it is a major factor in the growth of bacterial strains that are resistant to antibiotics.

What to Expect. Earaches usually resolve within eight to 24 hours after taking an antibiotic, although about 10% of children who are treated do not respond. Failure may be due to the following or other causes:

In many cases in which the response to an antibiotic is incomplete, a virus is often present.
In other cases, the bacteria causing ear infection may be resistant to the antibiotic and a different antibiotic may be needed.

In some children whose treatment is successful, fluid will still remain in the middle ear for weeks or months, even after the infection has resolved. During that period, children may have some hearing problems, but eventually the fluid almost always drains away.

Follow-Up. Follow-up may involve the following steps:

If the infection clears up with a single regimen in children less than 15 months old or in children with risk factors for reinfection, an examination should be scheduled two to three weeks after therapy.
If the infection clears up with a single regimen in older children with no specific risk factors, they should be reexamined three to six weeks after treatment.
If signs of infection are still present (e.g., pus is still present in the ear) within 48 hours of taking the last antibiotic dose, the child should be re-examined. (Parents are excellent judges of whether their child's condition has cleared up.)
In cases where complications are suspected, consultation with an ear, nose, and throat specialist (called an otolaryngologist) should be strongly considered. This specialist may perform a tympanocentesis or myringotomy, procedures in which fluid is drawn from the ear and examined for specific organisms. But this is reserved for severe cases.

Guidelines for Managing Persistent or Recurrent Acute Otitis Media

Persistent or recurrent acute otitis media is determined under the following circumstances:

If the child has had three or more separate ear infections every six months.
If the child has had four or more ear infections within a year.

In children with this condition, the following treatment options are available:

Watchful waiting.
Second-line and other powerful antibiotics. [For specific antibiotics in these cases, see What Are the Antibiotic Choices for Treating Otitis Media?] Antibiotics are stopped when the ear infection clears. These drugs have also been used an on-going basis for prevention of recurring infection in appropriate children, but almost all physicians are moving away from this practice because of concerns about resistance and studies suggesting that they add little value.
Tympanostomy. This is a surgical procedure that implants tubes to drain fluid and prevent build-up and infection. [ See What Are the Surgical Procedures for Ear Infections?]

Guidelines for Treating Otitis Media with Effusion (OME)

The child is typically monitored for the first three months and not given an antibiotic. Some studies have reported that OME resolved without any treatment during this period in the following:

About two thirds of all children whose OME developed without a previous ear infection.
In 90% of children whose OME had immediately followed an episode of acute otitis media.

Drugs that thin the mucus, known as mucolytics, may have some benefit. Some of these agents contain guaifenesin and are commonly available (Robitussin, Scot-Tussin Expectorant). More research is needed to confirm whether they are helpful for OME.

Allergies have been associated with OME. In one study, many children with OME had food allergies, and eliminating suspect foods also resolved OME in this group. Common suspect foods are milk, egg, beans, citrus, and tomatoes.

Antibiotics at the End of Three Months. Antibiotics are not generally helpful for the majority of patients with OME. In most cases the condition resolves in nearly all patients over three months old. Antibiotics tend to be used only if the condition persists after three months or one or both of the following has occurred within the three months period

The child is suffering.
Hearing loss occurs. (A hearing test should be conducted if the condition persists for over three months, in any case, whether antibiotics have been given or not.)

In cases when they are prescribed for OME, antibiotics are typically given for 14 to 21 days. [ See What Are the Antibiotic Choices for Treating Otitis Media?]

Treatment Failure at Six Weeks. If OME persists for six weeks in spite of antibiotic therapies, the following two options are generally considered:

Antibiotics are continued and stopped when the condition has cleared. (Although some physicians continue to prescribe antibiotics even after the condition has cleared to prevent recurrence, this practice is generally not recommended. First, its does not appear to be effective and second, it increases the risk for emerging bacteria strains resistant to antibiotics.)
Surgery (tube insertion) is usually recommended if OME is still present and there is evidence of hearing loss of over 20 decibels. Some experts prefer surgery over antibiotics in most case of chronic OME because of its safety record and because of the risk for drug-resistant strains of bacteria with antibiotic overuse. As with antibiotics, however, some experts believe surgery, too, is overused for otitis media, [ See What Are the Surgical Procedures for Ear Infections?]

Corticosteroids (commonly called steroids) have also been investigative for persistent OME. These agents reduce inflammation but have no effect on infection. Studies suggest that when steroids are used they are effective in clearing OME more quickly than antibiotics alone. They do not appear to have any lasting effect, however, and they can have severe side effects, particularly oral forms. Steroids are, therefore, not generally recommended.

Investigative Treatments for OME. Preliminary research suggests that glutathione, an antioxidant, may be an effective treatment for OME. More research is needed.

WHAT ARE THE HOME REMEDIES USED FOR EAR INFECTIONS IN CHILDREN?

Watchful Waiting

Careful monitoring of the child's condition (watchful waiting) along with home remedies and common over the counter cold medicines may be a viable alternative to antibiotic treatment for many children with a first episode of acute otitis media.

In one 2000 study, 240 children under age two who were diagnosed with acute otitis media were treated with watchful waiting. After four days, only 3% of the children required treatment with antibiotics, while the infection cleared in the other 97%.
Children, however, must be monitored carefully.
High fever, severe pain, or other signs of complications should warrant immediate attention by a medical professional.
Parents of infants should contact their doctor immediately if they have any fever, regardless other symptoms.

Natural Remedies for Ear Aches

Before antibiotics, parents used home remedies to treat the pain of ear infections. Now, with current concern over antibiotic overuse, many of these remedies are back in favor.

Depending on regional cultures, parents may have pressed a warm water bottle or warm bag of salt against the ear. Such old-fashioned remedies may still help to ease ear pain.
Drops of tea tree oil may be beneficial. This herbal treatment has mild anti-bacterial properties, but it may irritate the skin.
An Israeli study found that Otikon, an extract made of various plants, including garlic and St. John's Wort, is an effective anesthetic in treating the pain associated with ear infections.

It should be noted that herbal remedies are not standardized or regulated, and their quality and safety are largely unknown. Plants contained in Otikon may have side effects. Parents should never give their child herbal remedies, including oral remedies, without approval from a physician.

Valsalva's Maneuver. A simple technique called the Valsalva's maneuver is useful in opening the Eustachian tubes and providing occasional relief from the chronic stuffy feeling accompanying otitis media with effusion. It may also be useful for unplugging ears during air travel descent as well. It works as follows:

The child takes a deep breath and closes the mouth.
He or she then blows the nose gently while, at the same time, pinching it firmly shut.
The parent should be sure to instruct the child not to blow too hard or the ear drum could be harmed.

This technique should not be used if an infection is present.

Pain-Relievers

A number of pain relievers are available to help relieve symptoms.

Either acetaminophen (e.g., Tylenol) or ibuprofen (e.g., Advil) is the pain-reliever of choice in children.
Older children may be able to take prescription pain relievers that contain codeine if the pain is severe.
Eardrops containing anesthetics (Auralgan) are also available by prescription. In one study Auralgan provides effective short-acting pain relief and helps children endure ear discomfort until an oral pain reliever takes effect. In one study, 89% of children who took eardrops were able to avoid antibiotics. Parents should check with a physician before using them. Eardrops could cause damage in children who have a ruptured eardrum. This might be indicated by fluid drainage from the ear canal.

Note: Aspirin and aspirin-containing products are not recommended for children or adolescents. Reports of Reye's Syndrome, a very serious condition, have been associated with aspirin use in children who have chicken pox or flu.

Cold and Allergy Remedies

Many non-prescription products are available that combine antihistamines, decongestants, and other ingredients, and some are advertised as cold remedies for children. Researchers have found little or no benefits for acute otitis media or for otitis media with effusion using decongestants, antihistamines, or combination products, which include Dimetapp, Sudafed Severe Cold Formula, Vicks DayQuil, and Triaminic, among many others. Experts strongly recommend that in any case children not be given any of these remedies unless under a physician's direction.

Precautions when Swimming

Swimming can pose specific risks for children with current ear infections or previous surgery. Water pollutants or chemicals may exacerbate the infection, and underwater swimming causes pressure changes that can cause pain. The following precautions should be taken:

Children with ruptured acute otitis media (drainage from ear canal) should not go swimming until their infections are completely cured.
Children with AOM that is not ruptured should not dive or swim underwater.
Children with implanted ear tubes should use earplugs or cotton balls coated in petroleum jelly when swimming to prevent infection.

WHAT ARE THE ANTIBIOTIC CHOICES FOR TREATING OTITIS MEDIA?

Standard Antibiotics for Acute Otitis Media (AOM)

While many different antibiotics may be used to effectively treat otitis media, the physician needs to balance effectiveness, safety, and convenience, as well as try to minimize the emergence of bacterial resistant to antibiotics. The prevalence of such antibiotic-resistant bacteria has dramatically increased worldwide, but regions vary widely. To this end the Centers for Disease Control and Prevention (CDC) has made very clear recommendations about first and second line treatments for otitis media.

First Line of Antibiotics for AOM

The most widely prescribed oral antibiotic for acute otitis media is amoxicillin (Amoxil, Polymox, Trimox, Wymox, or any generic formulation). This is a penicillin antibiotic and is both inexpensive and highly effective against the S. pneumoniae bacteria. Unfortunately, bacterial resistance to amoxicillin has increased significantly, so the CDC has advised doubling the standard dose. Amoxicillin is also not as effective against H. influenzae . In areas where bacterial-resistance to antibiotics is high, some physicians recommend high-dose amoxicillin.
Ofloxacin (Floxin) is an antibiotic known as a fluoroquinolone (also simply called quinolone). It is available in ear drops and is now recommended as first-line therapy for children with AOM who also have perforated ear drums or infection after implanted tympanostomy tubes. Ofloxacin is proving to be very effective and safe for these children. (It should be noted that drops are effective only in these cases.) Another quinolone, ciprofloxacin, is also available in eardrop form outside the US.

Second-Line Antibiotics for AOM. If treatment fails after 72 hours, for recurrent or persistent acute otitis media, or if the patient has had other antibiotics within the past month then the following are recommended:

Amoxicillin/clavulanate combination (Augmentin). This agent is known as an augmented penicillin, and it works against a wide spectrum of bacteria. A new high-dose formulation is proving to be highly effective. Some experts believe it should be considered for first-line therapy in children under age two, in children who have taken antibiotics within the past three months, and in high-risk children (such as those who attend day care).
Cephalosporins. Cephalosporins belong to the same class as penicillins (those called beta lactam antibiotics) Certain second- or third-generation oral cephalosporin antibiotics may be good second-line options. Of these cefuroxime (Ceftin) and cefpodoxime (Vantin) have the best record to date among the cephalosporins for coverage against bacteria that infect the upper respiratory tract. (Their safety and effectiveness in infants under six months old are not proven.) Ceftriaxone (Rocephin), an injectable cephalosporin, is also an option. Administering it in a single injection may be sufficient for some children, although a 2001 study reported that a three-day regimen was more effective for children with non-responsive otitis media. It should be noted that a person who is allergic to penicillin has a 5% to 14% chance of being allergic to a cephalosporin.

Specific Antibiotics for Other Circumstances

More powerful and expensive antibiotics are available for children under other circumstances, including the following:

For children who are allergic to penicillin, cephalosporins, of both.
For children with persistent or recurrent episodes of acute otitis media who do not respond to first- or second line agent (and who probably have bacterial strains resistant to those antibiotics).

These antibiotics are usually very expensive, however, and are not commonly used. They include the following:

Macrolides include erythromycin, azithromycin (Zithromax), clarithromycin (Biaxin), and roxithromycin (Rulid). Azithromycin is generally equivalent to Augmentin in effectiveness and needs to be taken for only five days. In fact, the FDA has now approved both a one-dose and three-dose regimen of Zithromax for treatment of AOM. These antibiotics are effective against S. pneumoniae and M catarrhalis , but macrolide-resistance rates doubled between 1995 and 1999 as more and more children were being treated with these antibiotics. They are not effective against H. influenzae .
Trimethoprim-sulfamethoxazole (Bactrim, Cotrim, Septra) or a combination of erythromycin and sulfisoxazole (Eryzole, Pediazole) are useful for people allergic to penicillin. It should not be used in patients whose infections occurred after dental work or in patients allergic to sulfa drugs. Allergic reactions can be very serious. Bacterial resistance to these agents has increased dramatically, however, and failure rates are high in certain regions. An oral solution (Primsol) uses trimethoprim alone. It poses less risk for an allergic reaction than the combination and yet is still effective.
Clindamycin (Cleocin). This antibiotic is known as a lincosamide and is useful against many S. pneumoniae bacteria but not against H. influenzae.

Side Effects of Antibiotics

The most common side effects of nearly all antibiotics are gastrointestinal problems, including cramps, nausea, vomiting, and diarrhea. This can be a significant problem in infants and small children. One study reported that giving such children a soy-based formula that contained fiber (Isomil DF) was helpful in reducing these side effects.
Allergic reactions can also occur with all antibiotics but are most common with medications derived from penicillin or sulfa. These reactions can range from mild skin rashes to rare but severe, even life-threatening anaphylactic shock.
Some drugs, including certain over-the-counter medications, interact with antibiotics; patients should report to the physician all medications they are taking.

WHAT ARE THE SURGICAL PROCEDURES FOR EAR INFECTIONS?

General Guidelines for Surgery

Surgery to drain the ear drum ( myringotomy) with or without implanted ventilation tubes to drain the fluid ( tympanostomy) is the basic surgical procedure for otitis media. It is the second most frequently performed procedure for children under two (circumcision is first). In 1996 tubes were placed in the ears of one out of every 110 American children. And, an estimated 280,000 children younger than three years of age underwent the operation.

Controversies Concerning Surgery and Candidates. Surgery is as controversial as antibiotic treatment, however. Arguments supporting tubal procedures are based on the following observations, among others:

Hearing is almost always restored following tympanostomy.
One 2000 study indicated that the operation significantly improves many aspects of a child's quality of life, including emotional distress, impaired hearing and speech, and limitations in activity.

However, important studies in 2000 and 2001 and others have suggested that the procedures in very young children (one and two years old) who had persistent OME did not make any difference in language development by the time the child reached the age of three. Still, researchers in one of the studies believed the procedures could helpful for specific children.

Surgery may still be warranted for children with recurrent acute otitis media or otitis media with effusion (OME) under they following circumstances:

They have not responded to aggressive antibiotic treatment or antibiotic treatment is not warranted, and
They have fluid-build up for more than three months in both years or 135 days in one year, and/or
They with moderately severe hearing loss.

According to one study, the best results occur in a patients who also have the adenoids and tonsils removed.

Myringotomy and Standard Tympanostomy

Myringotomy. Myringotomy is used to drain the fluid. It may be used as a single procedure in unresponsive acute otitis media or used in combination with tympanostomy. It involves the following steps.

The surgeon makes a very small incision in the eardrum.
Fluid is sucked out using a vacuum-like device.
The fluid is usually examined for identifying specific bacteria.
The eardrum heals in about a week.

Myringotomy and Tympanostomy. If otitis media with effusion persists in spite of drug therapy or if it is caused by structural or inborn problems, a tympanostomy is also performed. It involves the following:

A general anesthetic is required but children typically recover completely within a few hours.
Myringotomy is performed.
After myringotomy, the physician inserts a tube to allow continuous drainage of the fluid from the middle ear.
It is a simple procedure, and the child almost never has to spend the night in the hospital.
Some children report almost no discomfort after surgery and find acetaminophen (Tylenol) sufficient for any pain. About half of children, however, require codeine or more powerful pain relievers. One study found that lidocaine eardrops were effective in relieving pain and stress after the procedure.

Complications. Otorrhea, which is drainage of secretion from the ear, is the most common complication after surgery and can be persistent in some children. It is usually treated with antibiotic ear drops, such as ofloxacin (Floxin). One study suggests that wearing earplugs may alleviate the problem.

Serious complications of the operation are very uncommon:

General anesthetic poses risks, although rare, for allergic reactions or other side effects.
Sometimes the tubes become blocked from sticky secretions or clotted blood after the operation.
Persistent ear drum perforation is the most common serious complication, but it too is rare.
Scarring can also occur, particularly in children who require more than one procedure, but it almost never affects hearing.
Small keratin (skin cell) containing cysts called cholesteatomas develop around the tube site in over 1% of patients. This raises some concern about the long-term safety of the procedure, although other studies have indicated that this complication is rare. More studies are needed.

Success Rates. Hearing is almost always restored following tympanostomy. Failure to achieve normal or near-normal hearing is usually due to complicated conditions, such as preexisting ear problems or persistent OME in children who have had previous multiple tympanostomies. In one 10 year study, hearing loss was still present in 12.5% of people who had had surgery, although in half of these individuals, hearing loss was very mild (loss was below 20 decibels). Persistent fluid was the main reason for continued impaired hearing. Only 1.9% of hearing loss cases could be attributed to complications of the operation itself.

Precautions. While the tubes are in place, children may take the following precautions:

Many doctors feel that children should use earplugs when swimming as long as the tubes are in place in order to prevent infection. (Cotton balls coated with petroleum jelly are effective alternatives to ear plugs.)
Children may shower without earplugs.

Some physicians feel that as long as the child does not dive or swim underwater, earplugs may not be necessary, but parents should consult their own child's doctor on this subject.

Follow-Up. After surgery, the children may experience the following course.

Eventually, the tubes fall out as the hole in the eardrum closes. This may happen between several months to over a year. This is painless and the patient and parents may not even be aware that the tubes are out.
The operation may need to be repeated, occasionally several times, if, after the tubes fall out, the effusion and hearing loss still persist.
Antibiotics are often prescribed after surgery to prevent such recurrence.

Adenoid and Tonsil Removal

Adenoids are collections of spongy lymph tissue in the back of the throat. Removal of the adenoids, called adenoidectomy, is sometimes considered if they are overly enlarged and interfere with Eustachian tube function. In such cases, the procedure might follow myringotomy and tympanostomy.

Removing tonsils along with adenoids ( adenotonsillectomy) may improve the results of tympanostomy, particularly if the two procedures are performed at the same time. It is commonly held, however, that, except for special circumstances, adenoidectomy should not be conducted on children under four. More research is needed to confirm any benefits in this group.

Laser-Assisted Tympanic Membrane Fenestration

A technique called laser-assisted tympanic membrane fenestration (LTMF) uses a laser to create a tiny holes and allow the fluid to drain immediately. No tubes are inserted and the child does not need general anesthesia. It is best suited for alleviating symptoms rapidly in children with very severe acute otitis media and in older children with OME, although the procedure itself can cause discomfort. The laser equipment is also extremely expensive and so the procedure is unlikely to be widespread in the near future.

WHERE ELSE CAN HELP BE FOUND FOR EAR INFECTIONS IN CHILDREN?

American College of Allergy, Asthma & Immunology, 85 West Algonquin Road, Suite 550, Arlington Heights, IL 60005. Call (847-427-1200) or fax (847-427-1294) or ( http://allergy.mcg.edu/ )

This organization publishes information sheets on specific allergies and offers a number for referrals to allergists in local areas. Its web site is excellent.

National Jewish Center for Immunology and Respiratory Medicine, 1400 Jackson Street, Denver, CO 80206. Call (800-222-LUNG or 303-355-LUNG) or for the recorded service Lung Facts call (800-552-LUNG) or (http://www.njc.org/ ).

American Academy of Otolaryngology, Head and Neck Surgery, One Prince Street, Alexandria, VA 22314-3357. Call (703-836-4444) or (http://www.entnet.org/ )

American Rhinologic Society, c/o Frederick J. Stucker, MD, Dept. of Otolaryngology/Head and Neck Surgery, LSU School of Medicine in Shreveport, 1501 Kings Highway, PO Box 33932, Shreveport, LA 71130. Call (318-675-6262)

Federal Agency for Health Care Policy and Research (AHCPR), AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907.

Call (800-358-9295) or (http://text.nlm.nih.gov/ftrs/dbaccess/ahcpr ) or (http://www.ahcpr.gov ).

Request a free parent guide, published in both English and Spanish, that describes middle ear fluid (otitis media with effusion), outlines the main evaluation and treatment options, and provides guidance on working effectively with health care providers.

A website that sells xylitol gum (http://www.xylitolworks.com/ )

The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed physician should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. Copyright 2002 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.

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