Ear Infections (Otitis)

Outer ear infection

Infection of the outer ear, also called otitis externa, is inflammation of the lining of the ear canal, and sometimes of the eardrum as well. The commonest causes are fungal and bacterial infection.

The lining of the ear canal is warm and moist, and those conditions suit bacteria and fungi. The infection runs an acute or a long-standing course, and it causes severe ear pain. It follows swimming pools, the sea, dirty water and a build-up of ear wax. It is caused both by cleaning the ear too often and by never cleaning it.

What it feels like

• Itching inside the ear
• Severe throbbing pain in the ear
• Pain that spreads to the neck or the eye
• A blocked feeling
• Pain when the ear is touched
• Pain when you chew
• Swelling of the ear or the ear canal
• Coloured, foul-smelling discharge, usually yellow-green
• Fever from the infection

Treatment

See a specialist to find out how far the infection has gone and how to treat it. Do not buy ear drops and treat yourself.

Treatment starts with cleaning the ear canal, because a drug put into an uncleaned canal cannot work. The doctor carefully cleans out discharge and infected material. Medicine or ear drops follow, chosen for how the illness is running.

The most important factor is early diagnosis. The earlier the infection is caught, the easier and the less painful the recovery. Patients get better within 5 to 10 days.

During treatment

• Keep the ear canal dry at all times. Never let the ear or the canal get wet.
• Stay out of the sea and the pool for a while. Ask your doctor how long.
• Use no medicine or drops other than the ones your doctor gave you.
• Take the medicines as your doctor told you, on time.
• Warm the drops first, in your palm or at room temperature.
• If discharge has come out, clean it carefully before putting the drops in.
• Do not scratch or rub the ear. It makes the infection worse.

People who get outer ear infections often can use ear plugs or a silicone swimming cap to keep water out of the ear in the sea or the pool. If water does get in, dry the ear carefully with a towel.

Middle ear infection (otitis media)

Middle ear infections are infections of the space behind the eardrum. The cause is usually a virus or a bacterium.

They usually follow a recent cold or an allergic problem, which stops the Eustachian tube ventilating the middle ear. One ear or both can be affected.

In small children the middle ear has not finished developing. The Eustachian tube differs in shape and in the way it works, so ear infection is commoner at that age.

Who gets them more often

• Children under five
• Boys
• Babies fed from a bottle
• Children at nursery
• Children in crowded, poorly ventilated places and children exposed to cigarette smoke

Middle ear infections also occur in teenagers and adults, though less often. The two types seen most in children are serous otitis media, which is fluid in the middle ear, and acute otitis media.

Serous otitis media (glue ear)

The eardrum cannot vibrate properly through the fluid, so it cannot carry sound, and the child loses hearing. This mild hearing loss changes the child’s behaviour. If it becomes long-standing, it can delay mental development and the start of speech.

Signs in a child with hearing loss

• Turns the television up loud, or sits very close to it
• Does not answer at once, or takes no notice, because they did not hear
• Pays less attention to the teacher, and starts to fail at school
• Speech problems, especially from not hearing consonants such as “s” and “z”

A child called lazy at school must be checked for middle ear fluid and hearing loss.

Causes

• An adenoid that has grown and filled the back of the nose
• Nose and sinus infections
• Acute middle ear infections
• Allergy and weakness of the immune system
• More rarely, tumours that affect the Eustachian tube

The eardrum looks dull and thickened, with more blood vessels on it. Depending on how long the problem has lasted, the drum can be pulled in, stuck to the middle ear structures, or darkened in colour. The condition usually affects both ears. When only one ear is affected the hearing loss can pass unnoticed, though the balance centre is affected and the child becomes unsteady in sport.

Treatment

Treatment starts with antibiotics. Medicines that reduce the swelling of the lining and thin the mucus can be added. Patients with a diagnosed allergy need anti-allergy treatment as well. Chewing gum and blowing up balloons help the Eustachian tube work.

Children who have repeated acute attacks along with glue ear, and who go to nursery, may need to stay away from that environment for a time. Babies fed from a bottle should be fed half sitting up.

The illness is commoner in autumn and winter, alongside viral infections, so the treatment plan changes with the season. Medical treatment succeeds more often before the summer and less often in winter.

Surgery is chosen when six to eight weeks of treatment has failed and the hearing loss is over 20 to 25 dB. If the eardrum has thinned, collapsed or formed pockets, if nerve-type loss has appeared, or if balance problems have started, surgery can be chosen straight away.

In surgery a ventilation tube is put into the eardrum, and the hearing improves at once. The adenoid, and the tonsils if needed, can be removed at the same time. The tube is placed under general anaesthesia in children. It stays in the eardrum for 6 to 12 months, then falls out on its own or is removed by the doctor. Most patients recover completely with this treatment. Tubes rarely have to be repeated.

Children with a tube in the eardrum can usually swim in the sea where the water is clean, as long as they do not dive deeper than a metre. In swimming pools, and when showering or bathing with soapy water, close the ear canal. Use cotton wool and petroleum jelly, or a proper ear plug. Water then cannot pass through the tube into the middle ear.

Acute middle ear infection

Acute middle ear infections are caused by a bacterium or a virus. In children the Eustachian tube is short, so these agents travel easily from the throat to the middle ear. Once there they settle and multiply, which swells the lining of the middle ear and of the tube. The tube then blocks.

This is an infection that starts and advances quickly in the middle ear. Go to an ear, nose and throat specialist at once if you see ear pain, fever, vomiting, loss of appetite, a blocked ear, discharge, hearing loss, or a baby pulling at their ears. Diagnosing the infection and starting treatment early matters.

On examination in the early stage the eardrum is red, swollen, or bulging like a balloon. The middle ear is full of infected fluid. When the drum thins at one point and bursts, the fluid runs out and becomes a discharge from the ear. Fever and pain then ease, because the pressure is gone. Without proper treatment the illness advances and complications follow.

Causes

• The Eustachian tube not working
• Bacteria multiplying in the middle ear
• Diseases of the nose and the sinuses
• Other upper airway illnesses
• Allergy
• Weakness of the immune system

Children with large tonsils usually have a large adenoid as well, sitting right around the opening of the Eustachian tube into the throat, and it stops the tube working. Germs from the air are also caught there and carried into the middle ear through the tube. The adenoid has a large part in ear infections.

Treatment

Most children have at least one middle ear infection in their first two years. How often the infections come, and how long they stay active, decide the treatment.

Acute otitis needs at least 10 days of antibiotics. With today’s medicines, the complications of the years before antibiotics, facial paralysis, hearing loss and infection inside the skull caused by the infection spreading from the middle ear, have become rare.

Treatment uses a suitable antibiotic together with medicines to bring down fever, relieve pain and reduce the swelling of the lining. Follow the recovery. For most children, medicines and removing the risk factors are enough. Complaints should ease clearly within the first 24 to 48 hours of antibiotics. The fluid drains and hearing returns to normal later than that.

Surgery

If the fluid does not clear despite repeated treatment, and it causes hearing loss or a collapsing eardrum, surgery is needed. For repeated acute infections and for fluid that does not clear, the method used most often is a ventilation tube in the eardrum. The tubes stay in your child’s ear for about 6 to 12 months.

Chronic ear infection

Long-standing middle ear infection has many types. Two are seen most in practice.

A hole in the eardrum. Acute middle ear infections, injury or ear surgery leave a hole that does not close on its own or with simple treatment. Water reaches the middle ear through it, and infection travels up the Eustachian tube from the sinuses, the nose and the back of the nose. The ear then discharges from time to time, and repeated infection makes the hearing worse over the years. This group is seen more often, is relatively easier to treat, and gives better functional results.

Cholesteatoma. The second important chronic disease usually follows a Eustachian tube that has worked poorly since childhood. Poor ventilation creates negative pressure, which pulls the eardrum inwards until it collapses. A pocket forms. The skin of the ear canal then grows through it into the middle ear and, in time, into the mastoid bone behind. There it forms an infected mass called cholesteatoma.

The mass holds shed skin cells and the bacteria multiplying in them. It presses on the surrounding bone and inflames it, so the bone dissolves. The disease then spreads towards neighbouring organs and causes serious complications.

The history is usually of hearing loss that has lasted a long time and is getting worse, with foul-smelling ear discharge that increases from time to time. Patients can arrive at hospital with sudden hearing loss, dizziness or facial paralysis from the ear itself, or with serious complications such as meningitis or a brain abscess caused by the infection spreading inside the skull.

In surgery for chronic infection with cholesteatoma, the first aim is to stop the infection. The hearing results in these patients are generally not as good as in the first group.