Ear infection, inner

Otitis media is a build-up of fluid in the middle ear, which is the space between the eardrum and the inner ear.

Usually, the middle ear is filled with air, but sometimes it gets filled with fluid or mucus, for example during a cold. If the mucus gets infected with bacteria it causes an ear infection.

Acute and chronic otitis media

Acute otitis media is a short-term ear infection that often comes on suddenly.

Chronic otitis media is a middle ear infection that lasts for a long time or keeps coming back. As the symptoms are often less severe than those of an acute infection, the infection may go unnoticed and untreated for a long time. This may cause more damage than an acute infection.

Otitis media with effusion (OME), also known as glue ear, is common in young children. It is caused by a build-up of fluid in the middle ear with no symptoms or signs of infection. Otitis media with effusion usually follows an episode of acute otitis media.

Who is affected by otitis media?

Otitis media is most common in young children, with more than 75% of episodes occurring in children under 10 years of age.

Acute otitis media

The main symptoms of acute otitis media include:

  • severe earache (caused by the pressure of mucus on the eardrum)
  • a high temperature (fever) of 38°C (100.4°F) or above
  • flu-like symptoms in children, such as vomiting and lethargy (a lack of energy)
  • slight deafness

Babies with ear infections will be hot and irritable. As babies are unable to communicate the source of their discomfort, it can be difficult to tell what is wrong with them. However, an ear infection is one possibility worth considering if your baby is unsettled in this way.

Other symptoms to look out for in younger children include:

  • pulling, tugging or rubbing their ear
  • a high temperature (fever) of 38°C (100.4°F) or above
  • irritability
  • poor feeding
  • restlessness at night
  • coughing
  • rhinorrhoea (runny nose)
  • unresponsiveness to quiet sounds, or other signs of difficulty hearing, such as sitting too close to the television or being inattentive
  • loss of balance

In rare cases of otitis media, the eardrum will become perforated (a hole will form in it), and pus may run out of the ear. Sometimes, this can help to relieve the pain by releasing the pressure on the eardrum, but it may also lead to re-infection.

Chronic otitis media

Compared with acute otitis media, chronic otitis media often has fewer symptoms or milder versions of them. However, the symptoms last for a long time or keep coming back. In cases of chronic otitis media there is also more likely to be pus or fluid coming out of the ear.

Otitis media with effusion

The symptoms of otitis media with effusion (OME) include:

  • ear discomfort
  • hearing difficulty or hearing loss
  • recurring episodes of acute otitis media
  • recurring upper respiratory tract infections, which are infections that affect the nose, sinuses, throat, pharynx (the area at the back of your throat) and larynx (voice box).    

Glossary

Acute
Acute means occurring suddenly or over a short period of time.
Pain
Pain is an unpleasant physical or emotional feeling that your body produces as a warning sign that it has been damaged.
Fever
A high temperature, also known as a fever, is when someone's body temperature goes above the normal 37°C (98.6°F).
Vomiting
Vomiting is when you bring up the contents of your stomach through your mouth.
Chronic
Chronic usually means a condition that continues for a long time or keeps coming back.

Ear infections are not the cause of all earaches. If there are no symptoms other than the earache itself, it could be due to a different cause. For example, an earache can be caused by a build-up of uninfected mucus after a cold or a toothache.

Useful Links

Otitis media is usually caused by the common cold. The infection spreads from the nose or throat through the Eustachian tube, which is a tube that passes between the throat and the middle ear.

Blocked Eustachian tube

Any fluid in the ear usually runs out through the nose via the Eustachian tube. If the Eustachian tube becomes blocked, otitis media may develop.

Enlarged tonsils or adenoids (small lumps of tissue that are located at the back of the throat, above the tonsils) may block the Eustachian tube. Adenoids and tonsils can be removed if they cause chronic otitis media, which is more common in children than in adults.

Cholesteatoma

Chronic otitis media is sometimes caused by a permanent hole (perforation) in the eardrum, or a tissue growth inside the middle ear, which is known as a cholesteatoma.

Causes of otitis media in children

Otitis media can affect adults, but the condition more commonly occurs in children. There are many reasons why children are more commonly affected by otitis media than adults. Some of these are outlined below.

Weak immune system

Children find it much harder to fight off infection than adults because their immune systems are still developing.

Small Eustachian tubes

A child's Eustachian tube is smaller than an adult's, and is therefore more likely to get blocked if the child has a cold, or if the lining of the tube becomes inflamed. This can cause a build-up of fluid in the middle ear, leading to otitis media.

Large adenoids

As a child's adenoids are much larger than an adult's, they can interfere with the lining of the opening of the Eustachian tube. This makes children more likely to develop otitis media.

Otitis media is also more likely to occur in children because their adenoids may also become infected, and the infection may spread to the Eustachian tube.

See the Health A-Z topic about Adenoids for more information. 

Glue ear

Children with otitis media with effusion (glue ear) whose ears get filled with mucus for periods of several weeks, are more likely to develop an ear infection.

See the Health A-Z topic about Glue ear.

Other causes

Otitis media may also be caused by childhood illnesses, such as measles. The child's immune system is weakened by the illness, making it difficult for them to fight infection when bacteria enter the middle ear. This is known as a secondary infection.

If a child has a perforated eardrum, it may become infected if water enters their ear while bathing or swimming.

Sometimes there is no apparent reason for the infection.

Glossary

Tissue
Body tissue is made up of groups of cells that perform a specific job, such as protecting the body against infection, producing movement or storing fat.  
Immune system
The immune system is the body's defence system, which helps protect it from disease, bacteria and viruses.
Bacteria
Bacteria are tiny, single-celled organisms that live in the body. Some can cause illness and disease and some others are good for you.
Chronic
Chronic usually means a condition that continues for a long time or keeps coming back.

Ear examination

Otitis media is diagnosed from the condition's symptoms and by examining the eardrum with an instrument called an auriscope, or otoscope. An auriscope has a light at one end that is shone into the ear and a magnifying glass so that the doctor can see inside the ear in more detail.

An auriscope cannot be used to see inside the middle ear, but the doctor can use it to see whether there is any fluid leaking into the outer ear. It is also possible to examine the eardrum, which gives some clues as to what is happening inside the ear.

You may be asked to pinch your nose and close your mouth before gently blowing out. Alternatively, an instrument may be used to blow a small puff of air into your ear.

If your Eustachian tube (a tube that passes between your throat and middle ear) is clear, your eardrum will move slightly. However, if it is blocked, your eardrum will remain still. The examination will also show whether your eardrum is perforated (has a hole in it).
 
The eardrum is usually a pink colour. However, if you have otitis media, your eardrum is red or yellow, and may look a little lumpy. It may also be bulging outwards as a result of the pressure of the mucus.

Around 80% of cases of acute otitis media clear up within three or four days without any treatment. Perforated eardrums also usually heal up on their own without treatment.

Antibiotics

While antibiotics may help to treat the short-term symptoms of otitis media, there is no evidence to suggest that they make the condition clear up more quickly, or reduce the chance of complications occurring.

Some bacteria that can cause otitis media have become resistant to some types of antibiotics. This is due to antibiotics being used to treat minor ailments, such as coughs, colds and viral infections.

Relying on antibiotics to treat minor conditions causes the bacteria to become resistant to the medication, making it less effective at treating more serious infections.

For this reason antibiotics are not usually used to treat mild conditions. You are unlikely to be prescribed antibiotics unless you are at high risk of serious complications. People with a high risk of developing serious complications include those with:

  • heart, lung or liver disease
  • neuromuscular conditions, which affect the nerves and muscles 
  • immunosuppression (a weakened immune system)
  • cystic fibrosis (an inherited condition that affects the internal organs by clogging them with mucus)

Young children who are born prematurely also have a higher risk of developing complications.
 
Antibiotics may be prescribed to treat otitis media in cases where the infection is severe, or where it gets worse after two or three days. A long-term course of antibiotics may also help to prevent long-term or recurrent otitis media.

Over-the-counter medication

Over-the-counter (OTC) painkillers, such as paracetamol and ibuprofen may be used to control the symptoms of otitis media (pain and fever). Aspirin should not be given to children who are under 16 years of age.

Nose drops containing decongestants or antihistamines may be used to reduce the swelling of the mucous membranes in the nose and back of the throat. This may help to keep the Eustachian tubes clear, and allow mucus to drain from the middle ear. However, nose drops have not been proven to be an effective treatment for otitis media.

In adults with long-term (chronic) otitis media, drops containing antibiotic medication have been shown to help reduce the amount of pus that comes from the ear.

Tympanostomy tubes (Grommets)

For children with recurrent, severe otitis media, tiny tubes may be inserted through the eardrum to help drain fluid. These tubes are called grommets or tympanostomy tubes.

Tympanostomy tubes are not recommended in all cases, as there is a chance that the grommets may cause other problems. For example, they can become blocked or infected themselves.

Surgical procedures

There are similar risks for an operation called a myringotomy, which is where a small hole is made in the eardrum to allow fluid to drain out.

Removal of the adenoids and tonsils (small lumps of tissue that are located at the back of the throat) may help if they are blocking the entrance to the Eustachian tube.

Otitis media with effusion

Antibiotics, steroids, antihistamines and decongestants are not recommended to treat otitis media with effusion (OME).

If OME has been present for 12 weeks or more, your GP will refer you to an ear, nose and throat (ENT).

Glossary

Chronic
Chronic usually means a condition that continues for a long time or keeps coming back.
Antibiotic
Antibiotics are medicines that can be used to treat infections caused by micro-organisms, usually bacteria or fungi. For example amoxicillin, streptomycin and erythromycin.
Pain
Pain is an unpleasant physical or emotional feeling that your body produces as a warning sign that it has been damaged.
Fever
A high temperature, also known as a fever, is when someone's body temperature goes above the normal 37°C (98.6°F).
Antihistamines
Antihistamine medicine counteracts the action of histamine (a chemical released during an allergic reaction). For example loratadine, hydroxyzine.
Swelling
Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.
Acute
Acute means occurring suddenly or over a short period of time.
Decongestants
Decongestant medicine relieves congestion by reducing the swelling of the lining of the nose and sinuses and drying up the mucus.

Hearing impairment

Left untreated, otitis media can lead to serious complications, such as permanent hearing impairment.

If the infection is not treated, it can spread from the middle ear to other parts of the head, including the brain. A child's hearing can be reduced as a result of the constant build up of fluid in the middle ear.

Hearing impairment that is caused by regular ear infections can affect a child's language and speech development, increasing their risk of developing speech and language difficulties.

Recurrent acute otitis media

If you have three or more episodes of otitis media in a six-month period, or four or more episodes in a year, you may be diagnosed with recurrent acute otitis media.

Recurrent acute otitis media is usually defined as a given number of episodes within a given time frame (as stated above), with an absence of middle ear disease between these episodes.

After an initial episode of acute otitis media, recurrence is more likely within a few weeks. Possible risk factors for recurrent acute otitis media include:

  • early age of first episode of acute otitis media, particularly before six months of age
  • dummy (pacifier) use
  • daycare attendance
  • passive smoking
  • acute otitis media episode lasting for more than 10 days
  • being male
  • craniofacial abnormalities (abnormalities of the head and face)
  • feeding in a supine (lying face upwards) position
  • history of not having been breastfed for at least three months
  • adenoids are present

Treatment for recurrent acute otitis media is similar to that for non-recurrent otitis media. Over-the-counter (OTC) painkilling medication, such as paracetamol or ibuprofen may be used to control the symptoms (pain and fever). Again, aspirin should not be given to children under 16 years of age.

Antibiotics will not be prescribed straight away for recurrent acute otitis media unless you have persistent symptoms or you are likely to be at high risk of developing complications. If your symptoms worsen, your GP may prescribe a course of antibiotics.

Chronic suppurative otitis media

Chronic suppurative otitis media (CSOM) is a rare complication of acute otitis media. In the UK it is estimated that less than 1% of people are affected by CSOM each year.

CSOM is caused by an initial episode of acute otitis media, and its main symptom is a persistent discharge from the middle ear. CSOM may be diagnosed if the discharge from your ear persists for two weeks or more.

If your eardrum becomes perforated, you may experience some hearing loss, although this should resolve once the infection has passed and the perforation heals. However, if the perforation persists, it may lead to permanent hearing loss and problems with language development in children.
 
If CSOM is left untreated, the infection can spread from your ear to other parts of your head, causing:

  • local bone inflammation (mastoiditis)
  • swelling of a part of the brain called the meninges, causing meningitis and cerebral abscess (a pus-filled swelling in the brain tissue)
  • numbing of the face

See the Health A-Z topic about Meningitis for more information about the condition.

CSOM is an infection that is rarely spread to others.

To treat CSOM, you will be referred to an ear, nose and throat (ENT) specialist. They will be able to clean out your ear and provide antibiotics to treat any underlying infection.

To avoid further infection, make sure you keep your ear dry. Take precautions, such as wearing a shower cap when bathing or showering, and ear plugs when swimming.

Glossary

Numbing
Numbness refers to a lack of sensation in a part of the body.
Brain
The brain controls thought, memory and emotion. It sends messages to the body controlling movement, speech and senses.
Swelling
Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.

There is little evidence to suggest that any specific measures prevent otitis media. For example, research has shown that cold and allergy medicines, such as antihistamines and decongestants do not help prevent ear infections.

There are some measures that can be taken to try to prevent otitis media occurring in children. These include:

  • avoiding contact with children who are unwell
  • avoiding exposure to environmental tobacco smoke

If you (or your child) have symptoms of acute otitis media that do not resolve within three to four days, and antibiotics have not been prescribed, you should go back to your GP for a follow-up appointment. Following an assessment, your GP will be able to recommend an appropriate course of treatment. This will help to reduce the likelihood of a chronic (long-term) infection developing.

Vaccination

A vaccination is currently being developed by scientists to help prevent otitis media. However, more clinical research needs to be completed before the vaccination becomes available. 

Xylitol

Some research has shown that syrup or chewing gym that contains xylitol reduces the number of children who develop acute otitis media. Xylitol is a substance that is found in some trees, fruits and vegetables, and is used as a sweetener instead of sugar. It seems to stop bacteria growing in the mouth.

In children who are prone to ear infections, chewing gum containing xylitol may help to prevent further episodes.

Otitis media with effusion

To reduce the risk of your child developing otitis media with effusion (OME) you should ensure that:

  • they avoid secondhand smoke
  • they are breastfed (if possible)
  • you avoid feeding them by breast or bottle when they are lying supine (lying face upwards)
  • they avoid close contact with other children who are known to be infected
  • they avoid being in large groups of children, such as day care centres

Glossary

Acute
Acute means occurring suddenly or over a short period of time.
Bacteria
Bacteria are tiny, single-celled organisms that live in the body. Some can cause illness and disease and some others are good for you.
Chronic
Chronic usually means a condition that continues for a long time or keeps coming back.

Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.

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