Ear Infections: What You Need to Know

Dr. Steven Dyer, DO, Pediatric Ear, Nose and Throat Surgeon with Saint Francis Children’s Physicians, answers common questions about ear infections.

Q: What are ear infections, and what causes them?

A: When we talk about ear issues with kids, we’re usually talking about two things: otitis media and otitis media with effusion. Otitis media with effusion is what people commonly refer to as “ear fluid.” Fluid is trapped in the space behind the ear drum. That hollow space should be filled with air. That allows us to hear well and allows us to keep our balance. Whenever it’s filled with fluid, kids can’t hear very well; they can have some balance issues. That can lead to episodes of acute otitis media, or ear infection. The fluid becomes infected. It’s painful, and they can have complications related to the infections, so they need antibiotics.

Q: How common are ear infections, and at what ages are they more prevalent?

A: Ear infections are very common. Otitis media is very, very common. In the United States, 90 percent of kids aged 5 to 6 have had otitis media at some point in their life. Most of those kids never require any type of treatment because it goes away over time.

If you took a sample of any kindergarten classroom in the United States, one in seven of those kids is going to have otitis media at any point. If it resolves on its own within two or three months, and if it isn’t negatively impacting hearing, we’ll just watch those kids. Because of the prevalence of the condition, it accounts for something like 2.2-million doctors’ office visits annually.

Q: What causes the fluid to accumulate behind the eardrum?

A: Otitis media with effusion can be related to a recent upper respiratory infection. The mucosal membranes in our nose, sinuses and ears are secreting mucus all the time. If that middle ear space is not adequately ventilated, and the eustachian tubes don’t work great, then the air can’t ventilate, which forms a negative vacuum. Ultimately, this causes fluid to accumulate, which leads to otitis media.

When you fly on an airplane and your ears pop, or if you’re up in a mountain and your ears are popping, that’s that natural tube opening and closing, allowing air to equalize. Little kids’ heads are not elongated yet, so those eustachian tubes don’t work well. If the eustachian tubes aren’t working effectively, then air can’t ventilate in the hollow space, which forms the negative vacuum behind the eardrum.

Fluid can accumulate because of poor eustachian tube function, because of a bad upper respiratory tract infection that causes the eustachian tube to be swollen and not ventilate well. Those are probably the two most common scenarios where we would see fluid.

Q: How long does the fluid stay in the ear?

 A: A lot of kids will have otitis media for extended periods of time — months on end — and we don’t even know it’s happening if they don’t get an infection. It’s not uncommon for kids to get otitis media with effusion, and it might take up to three months for the fluid to go away. When we see these kids in the office, we don’t know how long the fluid has been present, so many times we just wait and try to educate the family about the issue.

Statistically about 50 percent of kids have cleared that fluid in the middle ear by about a month. Seventy-five percent of those kids have cleared the fluid by two months. And 90-plus percent of the fluid is cleared by three months. If fluid is not cleared by three months, we start talking about what’s next.

Q: Since it is so common, what signs should parents watch for?

A: With otitis media with effusion, the main thing I hear from parents is, “Johnny doesn’t seem to be listening very well.” Well, Johnny can’t hear because he’s got fluid behind his ears. As long as Johnny’s fluid goes away within two- or three-months’ time, we’re not going to worry too much about it. If it doesn’t, then we start talking about putting tubes in kids’ ears.

If kids are getting acute otitis media episodes where the fluid has become infected, the child will be running a fever. It’s painful. The child’s pediatrician will put them on oral antibiotics to treat the infection.

That’s probably what parents see the most. It’s no longer just the fluid-filled middle-ear space that’s impacting the hearing, but now it’s infected. It’s painful.

Q: Is there anything that can help clear up or prevent fluid accumulation?

A: We used to treat otitis media with antibiotics, and sometimes kids are on steroid nasal sprays and oral antihistamines for allergies, but the studies haven’t shown them to resolve the fluid in the middle ear. In our literature they recently released a clinical practice guideline for ENT doctors. They looked at tons of studies on antibiotics and nasal sprays, and they show no statistical benefit to the resolution of otitis media.

That’s not to be confused with acute otitis media with fever. A sick kid will need treatment with antibiotics to cool off the acute infection. And then we’re back to otitis media again, which I typically watch for three months to see if it resolves.

Q: How common are tubes?

A: Tubes are very common. There’s not really an exact number where we say it’s time to put in tubes. A lot of times they’re sent over, with good reason, because their child has had five ear infections in six months. That’s a great time to see an ear, nose and throat (ENT) doctor. But what we’re going to do is watch it for a little while to see if the fluid will clear up and try to avoid surgery.

Q: After you’ve waited, what are the next steps?

A: For the kids where the fluid did not resolve, those who are getting infections or are at a high risk for hearing loss or speech delay because of the fluid, we may be a little more aggressive in recommending tubes. Other medical conditions such as developmental delays, vision issues or cognitive problems may prompt earlier intervention to give those kids the best opportunities.

Q: What happens when a child comes to your office?

A: The doctor is going to look in the ear — it’s called otoscopy. We can typically see if there’s fluid.

And then we’ll do a tympanometry, which is a pressure test that helps confirm that there’s fluid. And then we may do audiogram testing, which is a hearing test that will show if the fluid is negatively impacting the hearing. If it’s negatively impacting hearing and it’s been a few months in duration, that indicates further treatment. That fluid’s not going away, and it’s going to lead to speech issues and developmental problems going forward.

Q: How do you know when to see a specialist?

A: I’d say the majority of kids that we see are sent by their pediatrician or their primary care provider, just because they’re the ones on the front lines seeing these kids with ear infections. However, if they don’t require a referral because of insurance purposes, if the parents are noticing that the child doesn’t seem to be hearing well, then they’ll end up coming to see us for that reason.

Q: If you do make the choice to put tubes in a child’s ears, what should parents know about the process?

A:  When we put tubes in the ear, it’s done in the operating room, with the child under a very brief anesthesia, which is provided through a gas anesthesia mask, not an IV, similar to what you might get with a dental procedure. An anesthesiologist is there making sure everything is safe.

The tube that we put in has a opening of about 1.14 to 1.25 millimeters, depending on which one you use. It’s little bitty. I make a very, very small nick on that eardrum, suction out the fluid, and then insert this little plastic, bobbin-shaped tube. The tube sort of pops into the eardrum and straddles it, creating a small ventilation hole where air can get in without having to go through the eustachian tube. Since it’s a foreign object that your body doesn’t really want in there, it eventually pushes the tube out.

It can range from six months to 24 months, but 97 to 98 percent of the time, they fall out and you don’t see them. Occasionally they’ll just be sitting in the ear, and we’ll take them out in the office, or the parents will find it on the pillow. Things are then back to normal. So, it’s sort of a temporary solution for a temporary problem. And most of the time it gets us through those problem years and works very well.

Problems are typically minor such as drainage from the ear when the child has a bad cold, which we treat that with topical ear drops.

On rare occasions tubes either will not fall out or they’ll fall out and leave a hole. Both of those scenarios require a second procedure to fix the problem. That’s probably the biggest risk, so you’re weighing those risks and benefits.

When the tubes fall out and everything’s healed and back to normal, somewhere between 25 and 50 percent of kids will end up getting a second set of tubes because they still haven’t outgrown the problem.

Q: Is there anything else that parents should know about ear infections or tubes?

 A: Parents should know that otitis media is super common, and ear infections are very common as well. Acute otitis media and otitis media with effusion overlap, but they’re different things. When is it OK to watch and wait, and when do we need to do something? Pediatricians are very good at looking in ears, and they’re very good at keeping track of infections. Eventually, kids get sent to our office, and I feel like my role is to educate parents. Parents often don’t know that it’s OK to wait and watch for a while. They assume that if their child has fluid, they have to have tubes.

There are certainly gray areas where people have complications related to the acute infection or the infections doesn’t resolve with oral antibiotics, or they have complications related to the antibiotics themselves. These are situations that may push us into doing surgery and putting tubes in.