Middle Ear Infections
Childhood Ear Infections (Acute Suppurative Otitis Media)
Background
This bacterial infection of the middle ear is very common in childhood. Few children will escape an episode. Bacteria can reach the middle ear space via its normal drainage tube, the Eustachian tube, via a hole in the eardrum or rarely by the bloodstream. Bacterial infection may be a primary event or may follow initial viral infection. The result is the formation of pus in the middle ear. It is a self-limiting condition in the vast majority of cases; for the unfortunate few middle ear infections can progress to major and life-threatening complications.
Clinical Presentation
The patient is most often a child. There is often a cold or flu like illness leading up to the ear infection. Infection of the middle ear results in severe earache, a loss of hearing and a child who is unwell and has a high temperature. In very young children who cannot describe what is happening ear infections may cause crying and screaming along with ear pulling and generalised restlessness.
Examination of the eardrum shows a red inflamed appearance which eventually progresses to a bulging yellow ear-drum (the yellow is the pus in the middle ear) and finally if untreated to a perforation of the ear –drum and a wet, runny ear. Once the eardrum perforates and the ear discharges the pain, temperature and hearing loss begin to get better. Sometimes this natural resolution doesn’t happen and complications may occur. (See below)
Investigation
Clinical examination – reveals a red or bulging drum. At a later stage there is obvious ear discharge and a hole in the eardrum.
No other investigations are usually required. In some cases, an ear swab will be taken to guide antibiotic treatment.
Management
Most cases are seen and managed in general practice.
- Pain killers - Paracetomol and Ibuprofen are useful.
- Antibiotics - recently there has been a great deal of debate whether antibiotics are effective in this common and often self-limiting disease. They tend to be used in children less than 2 in whom complications are more common, in severe infections and in infections that are not settling spontaneously after 48-72 hours. If they are used amoxycillin is as effective as more expensive drugs as a first line therapy. Failure to respond indicates possible drug resistance and the need for second line antibiotics such as Augmentin or a cephalosporin.
- Some children develop recurrent bouts of ear infection requiring frequent medical attention. For some of these children surgical insertion of drainage tubes into the ear-drum (Grommets) to ventilate the middle ear can alleviate the pain associated with frequent infection and reduce the number of infections.
Complications of Suppurative Ear Infections
Complications within the ear:
- Glue Ear - in 10% of children following the ear infection there is persistent mucus formation in the middle ear. This can lead to a hearing loss and sometimes delayed speech development.
- Hearing loss - as well as glue ear, ear infections can have direct toxic effects on the organ of hearing (the cochlea) producing a sensori-neural hearing loss, this is generally not reversible. Hearing loss can also be the result of damage to the delicate bones in the middle ear or due to a large perforation of the eardrum.
- Dizziness - acute infection may spread to the balance organ resulting in dizziness.
- Facial nerve weakness - in around 4 % of the population the nerve that supplies movement to the face travels through the middle ear cavity without its normal covering of bone. These patients are at risk of facial nerve paralysis during a bout of ear infection. This weakness should return to normal once the ear infection has settled.
- Mastoiditis – infection can spread to the bone behind the ear, the mastoid. Mastoiditis usually shows up as an ear infection that progresses to swelling and or an abscess over the mastoid. This requires surgical drainage and often a mastoidectomy operation to clear the infection.
Complications outside the ear
These conditions are rarely seen following acute ear infections:
- Neck abscess - Pus tracks from mastoiditis down into the neck where it causes a painful swelling.
- Intra-cranial complications - These are the much -feared complications of suppurative ear disease and thankfully these days they are extremely rare. The brain is very close to the ear and separated from it by only a flimsy bony barrier called the tegmen tympani, the roof of the middle ear. Especially in young children in whom the bone is not yet fully developed infection can spread from the middle ear to the brain. All of these complications unless they are treated by aggressive surgery and antibiotic therapy may be fatal.