- Middle ear – An air-filled space containing the ear's tiny vibrating bones located between the oval window and the eardrum.
- External ear – The outer part of the ear including the ear canal.
- Inner ear – The innermost part of the ear containing the hearing and balance apparatus.
Ear infections are categorised as follows:
- Acute otitis media – The most common and least severe ear infection. Here the middle ear becomes infected and swollen whilst fluid becomes trapped behind the ear drum.2
- Otitis media with effusion – Following an ear infection leftover fluid may remain behind the eardrum.3 This becomes hard to detect asindividuals may not exhibit symptoms therefore a healthcare professional is needed to detect whether there is any fluid remaining.
- Chronic otitis media with effusion – One of the most serious forms of ear infection. Here fluid continuously returns to gather within the middle ear regardless of whether an infection is present or not. As a result, the body’s ability to fight other infections becomes hindered and the heart’s ability is diminished.
- Chronic suppurative otitis media – Another serious form of ear infection. Here usual treatments are unable to effectively clear up an ear infection there it is not fully eradicated. Consequently, this can result in a hole in the eardrum.4
Whilst such ear infections often resolve by themselves, they can still be painful due to inflammation or the build-up of fluid. Thereforetreatment may be needed to help manage the pain and monitor the infection to prevent it from getting any worse.
Causes of ear infection
An ear infection is usually caused by bacteria or viruses within the middle ear.5 Most of the times, these infections are a result of another illness (e.g., cold, flu, or allergy) that cause the nasal passages, throat and eustachian tubes to swell and become congested. Here the different roles of the key anatomical structures, notably eustachian tubes and adenoids, are explored further.
Eustachian tube dysfunction –
Eustachian tubes are a pair of narrow tubes that connect the middle ear (of each ear) to the back of the throat, specifically behind the nasal passages. The ends of these tubes open and close to regulate the air pressure within the middle ear, resupply fresh air into the ear, and drain any of the normal secretions the ear produces.
The eustachian tubes can become swollen and eventually blocked following a respiratory infection, allergy, smoking or even changes in air pressure. This blockage results in the build-up of fluid in the middle ear.6 Ear infections arise when this fluid becomes infected by bacteria or viruses.
Children and younger individuals in general have narrower and more horizontal eustachian tubes compared to older children and adults.7 Hence, they are more susceptible to ear infections as fluid is more likely to accumulate in the tubes in addition to being more difficult to drain away thereby causing clogged eustachian tubes.
Adenoids are small pads of tissue located at the back of the nose that help protect the body against infections. As a significant contributor towards immune system activity, adenoids react to passing bacteria and viruses and occasionally trap them. The adenoids are situated near the openings of the eustachian tubes therefore if the adenoids swell, they can cause the eustachian tubes to close thereby leading to a middle ear infection.8 Ultimately, infected adenoids can result in ear infections.
Especially for children, the swelling and irritation of adenoids play a more predominant role in contracting ear infections given that compared to adults, children have relatively larger adenoids that are more active.
Signs and symptoms of ear infection
Common symptoms of an ear infection include:
- Ear pain or discomfort
- Difficulty in hearing
- Discharge of fluid from the ear
- Feeling of pressure from inside the ear
- Itchiness and irritation both within and around the ear
- Flaky or scaly skin in and around the ear
- Fever or high temperature
- Nausea or feeling sick
- Fatigue or trouble sleeping
Children may also experience:
- Constant touching of their ear (i.e., rubbing or pulling)
- Not reacting to certain sounds
- Irritability and restlessness
- Poor/reduced appetite
- Problems maintaining their balance
Management and treatment for ear infection
- When it comes to the management and treatment of ear infections there are various avenues one can take. Given that symptoms typically subside by themselves within a couple of days, most infections might not require any intervention Below are some of the different treatment options available for ear infections Managing pain – Certain measures are available over-the-counter or on prescription to help manage the pain. In particular, pain medication, such as paracetamol or ibuprofen, can help relieve pain. Meanwhile, anaesthetic drops (e.g., Otomize®, Cl-ear™, or Otex® branded ear drops) can be used for pain relief only when the eardrum does not have a hole or tear in it
- Medical treatment (antibiotics) – Doctors may prescribe antibiotics to help clear up the infection,9 mainly for bacterial or chronic ear infections .However, antibiotics are not readily prescribed due to the rise in antibiotic resistance,10 Nevertheless it is important to ensure that their full course is completed whenever prescribed.Antibiotics are not effective against viral infections
- Surgery – When usual medical treatments fail to completely eliminate an ear infection or ear infections are recurrent over a period of time then surgery may be necessary. Conditions such as chronic otitis media (i.e., repeated, long-term ear infections) or otitis media with effusion may warrant surgical intervention
There are various surgical procedures including:
- Myringotomy (i.e., ear tube) – Tiny holes are made in the eardrum to suction fluids out of the middle ear. A tympanostomy tube, which is essentially a tiny tube, is inserted to facilitate ventilation and prevent fluids from building up. Such tubes can stay in for approximately 4-18 months before falling out on their own thereby allowing the eardrum to close up again11
- Adenoidectomy (i.e., adenoid removal) – Removal of the adenoids can occur when enlarged adenoids obstruct breathing and block the eustachian tubes from functioning as they should.12 They are removed through the mouth either by making a small incision or by cauterizing (i.e., using a heated device to seal the area)
How is ear infection diagnosed?
A pneumatic otoscope is an instrument used by healthcare professionals to assist with their examination as it lights and magnifies the ears, throat and the nasal passage. This instrument enables a direct examination of the ear and more specifically the middle ear and eardrum. A puff of air is gently applied against the eardrum which would normally cause the eardrum to move. However, with an ear infection, fluid-filled within the middle ear will result in little to no movement of the eardrum. More broadly, this examination helps to detect:
- Redness, air bubbles or fluid inside the middle ear
- Fluid draining from the middle ear
- Perforation of the eardrum
- A bulging or collapsed eardrum
, some of the other tests include:
- Tympanometry – Measures how the eardrum responds to changes in air pressure r and enables to access the middle ear
- Acoustic reflectometry – Measures how much sound is reflected back from the eardrum thereby obtaining an indirect measure of how much fluid is in the middle ear
- Tympanocentesis – The procedure involves creating a tiny hole in the eardrum to drain fluid from the inner ear so that it can be tested to identify the cause of the infection
How can I prevent ear infection?
Certain precautionary measures can be taken to proactively minimise the chances of developing an ear infection, these include:
- Prevent common colds and other illnesses
- Avoiding smoking environments and second-hand smoke
- Avoid sticking cotton wool buds or fingers inside your ears
- Wear earplugs or a swimming hat over your ears whilst swimming
- Avoiding getting water or shampoo in your ears
- Treat any conditions that may affect your ears (e.g., eczema)
Specific measures for children include:
- Avoiding giving children a dummy/pacifier after 6 months of age
- Breastfeed your baby for at least 6 months. This helps provide extra antibodies
- Bottle-feed your baby in an upright position
- Ensure they are fully vaccinated (e.g., seasonal flu shots, meningitis, pneumococcal etc.)
- Limit their contact with other sick children and avoid continuously sending them to group care
Who are at risk of ear infection?
There are certain risk factors for an ear infection that include:
- Age – Between the ages of 6 months and 2 years, children are more susceptible to ear infections . The size and shape of their eustachian tubes and immune systems are not fully operational and make them more susceptible. Poor air quality – Tobacco smoke or high air pollution levels increases the risk of ear infections13
- Seasonal factors – Notably, in the fall and winter, seasonal allergies are rife when the pollen count is elevated. This,in turn, increases the risk of ear infections
- Childcare – Compared to children who stay at home, group childcare settings expose children to more infections which puts them at a heightened risk for ear infections
- Infant feeding – Compared to babies who are breastfed, babies who drink from a bottle, particularly when lying down instead of sitting tend to have more ear infections14
- Cleft palate – Children who have cleft palates, which refers to a congenital split in the roof of their mouth, present differences in their bone structures and muscles. These anatomical variations make it increasingly challenging for the eustachian tubes to drain therefore placing them at an elevated risk for ear infections15
When should I see a doctor?
A doctor should be consulted if you or your child have:
- Symptoms that persist after 3 days
- Symptoms present in a child less than 6 months old
- Severe ear pain
- A high, persistent fever
- Discharge of fluid or bloody fluid from the ear
- Swelling of the ear
- Hearing loss or noticeable deficiency in hearing ability
- Long-term medical condition (e.g., diabetes, heart disease, lung disease, kidney disease or neurological disease)
- Weakened immune system
An ear infection refers to a bacterial or viral infection of the ear that causes inflammation and fluid to build up within the ear. Such an infection commonly arises as a result of another infection one has been exposed to, or more specifically anatomical issues with their eustachian tubes or adenoids.
Numerous undesirable symptoms accompany ear infections which can be rather discomforting and difficult to lead your normal routine with. Nevertheless, such symptoms are often only temporary as ear infections are commonly self-correcting, therefore, they should subside within a couple of days. In the meantime, certain measures may be taken to help relieve some discomfort, although if the ear infection does not improve or continues to persist then antibiotics may need to be taken and in severe conditions, surgery might be an option.
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- Morris P. Chronic suppurative otitis media. BMJ Clin Evid [Internet]. 2012 Aug 6 [cited 2023 Feb 5];2012:0507. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3412293/
- Vergison A. Microbiology of otitis media: A moving target. Vaccine [Internet]. 2008 Dec 23 [cited 2023 Feb 5];26:G5–10. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7127463/
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- Szymanski A, Agarwal A. Anatomy, head and neck, ear eustachian tube. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 [cited 2023 Feb 5]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK482338/
- Skoloudik L, Kalfert D, Valenta T, Chrobok V. Relation between adenoid size and otitis media with effusion. European Annals of Otorhinolaryngology, Head and Neck Diseases [Internet]. 2018 Dec 1 [cited 2023 Feb 5];135(6):399–402. Available from: https://www.sciencedirect.com/science/article/pii/S1879729618301467
- Holm NH, Rusan M, Ovesen T. Acute otitis media and antibiotics - a systematic review. Dan Med J [Internet]. 2020 Oct 29 [cited 2023 Feb 5];67(11):A04200272.Available from: https://pubmed.ncbi.nlm.nih.gov/33215607/
- Holmes AH, Moore LSP, Sundsfjord A, Steinbakk M, Regmi S, Karkey A, et al. Understanding the mechanisms and drivers of antimicrobial resistance. Lancet [Internet]. 2016 Jan 9 [cited 2023 Feb 2];387(10014):176–87. Available from: https://pubmed.ncbi.nlm.nih.gov/26603922/
- Puhakka H, Virolainen E, Aantaa E, Tuohimaa P, Eskola J, Ruuskanen O. Myringotomy in the treatment of acute otitis media in children. Acta Oto-Laryngologica [Internet]. 1979 Jan 1 [cited 2023 Feb 5];88(1–6):122–6. Available from: https://doi.org/10.3109/00016487909137149
- Gates GA, Avery CA, Prihoda TJ, Cooper JC. Effectiveness of adenoidectomy and tympanostomy tubes in the treatment of chronic otitis media with effusion. N Engl J Med [Internet]. 1987 Dec 3 [cited 2023 Feb 5];317(23):1444–51. Available from: https://pubmed.ncbi.nlm.nih.gov/3683478/
- Zhang Y, Xu M, Zhang J, Zeng L, Wang Y, Zheng QY. Risk factors for chronic and recurrent otitis media–a meta-analysis. PLoS One [Internet]. 2014 Jan 23 [cited 2023 Feb 5];9(1):e86397. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3900534/
- Karunanayake CP, Albritton W, Rennie DC, Lawson JA, McCallum L, Gardipy PJ, et al. Ear infection and its associated risk factors in first nations and rural school-aged canadian children. Int J Pediatr [Internet]. 2016 [cited 2023 Feb 5];2016:1523897. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4764758/
- Sheahan P, Miller I, Sheahan JN, Earley MJ, Blayney AW. Incidence and outcome of middle ear disease in cleft lip and/or cleft palate. International Journal of Pediatric Otorhinolaryngology [Internet]. 2003 Jul 1 [cited 2023 Feb 5];67(7):785–93. Available from: https://www.sciencedirect.com/science/article/pii/S0165587603000983