What is the middle ear?

The middle ear is an air-filled cavity separated from the ear canal by the paper-thin eardrum. The Eustachian tube is the passageway that connects the middle ear to the back of the nose. This passageway allows air to go into and fluid to drain out of the middle ear space. If the Eustachian tube is not working well, then middle ear problems can develop.

What problems can occur in the middle ear?

  • Middle ear infections (acute otitis media). Bacteria can move from the nose, up the Eustachian tube and into the middle ear. As the bacteria multiply, the middle ear fills with pus causing pain and irritability. Antibiotics should kill the bacteria and improve symptoms within a few days.
  • Persisting middle ear infection (persistent acute otitis media). If the child is getting no improvement in his/her symptoms despite appropriate antibiotics, and the ear exam still shows signs of an infection, persistent acute otitis media is diagnosed.
  • Recurring middle ear infections (recurrent acute otitis media). Some children's symptoms temporarily improve with antibiotics but then recur soon afterwards. Children having more than three symptomatic infections within a six-month period are classified as having recurrent acute otitis media.
  • Middle ear fluid (otitis media with effusion). While antibiotics should kill the bacteria causing an infection within a few days, the middle ear fluid may take weeks to clear. During that time, the non-infected fluid is called otitis media with effusion. Some children, especially older children, develop middle ear fluid without ever having any actual infection.

While the main issue with a middle ear infection is pain and irritability, the main concern with lingering middle ear fluid is hearing. The fluid prevents the eardrum from moving appropriately so sound does not get conducted to the inner ear well. Fortunately, the hearing should return to normal once the fluid resolves.

What are the treatment options for a middle ear infection (acute otitis media)?
Most cases will resolve on their own without any treatment at all. Unfortunately, it cannot be
predicted which episodes will ultimately require medication so the standard treatment for a middle ear infection is a course of antibiotics.

What are the treatment options for persisting middle ear infections (persistent acute otitis media)?
If the doctor determines that there is still an active infection despite a few days of antibiotics, the child is usually switched to a different antibiotic. If there is still no improvement, an incision in the child's eardrum can be performed in the office so that the infected fluid can drain out.

What are the treatment options for recurrent middle ear infections (recurrent acute otitis media)?
One option is to simply continue to treat each individual infection with antibiotics. The vast majority of children will outgrow the problem once the eustachian tube starts functioning better. Until that time, it is reasonable to treat each individual infection as it arises.

What if the child is responding appropriately to antibiotics but the frequency and severity of each infection is excessive? At that point, another option is to use preventative or maintenance antibiotics. A preventative antibiotic refers to using an antibiotic on a daily basis at a lower than usual dose in an attempt to prevent another infection, rather than to treat an infection. Unfortunately, prolonged use of antibiotics, especially at low doses, clearly increases the frequency of developing resistant bacteria. As such, numerous experts now recommend that preventative antibiotics be used on a more selective and limited basis.

The third commonly accepted method of treating recurrent middle ear infections is placing ventilation tubes in the eardrums. (See "Eardrum Tube Placement" handout)

What are the treatment options for middle ear fluid (otitis media with effusion)?
If the fluid has been there for just a short time, one option is to wait and use no medication at all. For the majority of children, the fluid resolves on its own without any treatment in less than two months.

Another choice is antibiotics. Although the fluid is not truly infected, antibiotics help get rid of the fluid in about 15% of cases. Children who have symptoms to suggest nasal allergies, especially if they are over three or four years old, need treatment of their allergies to see if that will help resolve the middle ear fluid.

If the fluid has been present in both ears for three months or longer, then the child should get a hearing test. If the hearing test confirms that the long-standing fluid is causing a hearing loss in both ears, then placing tubes in the eardrums is an appropriate option. Adenoidectomy at the time of tube placement is also a consideration, especially in children over three years old.
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