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Ear infections

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of ear infections.

Alternative Names

Otitis media

Diagnosis

The doctor should be sure to ask the parent if the child has had a recent cold, flu, or other respiratory infection. If the child complains of pain or has other symptoms of otitis media, such as redness and inflammation, the doctor should rule out any other causes. These may include, but are not limited to, the following:

• Otitis media with effusion. OME is commonly confused with acute otitis media. It must be ruled out because it does not respond to antibiotics.
• Dental problems (such as teething).
• Infection in the outer ear. Symptoms include pain, redness, itching, and discharge. Infection in the outer ear, however, can be confirmed by wiggling the ears, which will produce pain. (This movement will have no significant effect if the infection is in the middle ear.)
• Foreign objects in the ear. This can be dangerous. A doctor should always check for this first when a small child indicates pain or problems in the ear.
• Viral infection can produce redness and inflammation. Such infections, however, are not treatable with antibiotics and resolve on their own.
• A parent's or child's attempts to remove earwax.
• Intense crying can cause redness and inflammation in the ear.

Physical Examination

Instruments Used for Examining the Ear. An ear examination should be part of any routine physical examination in children, particularly because the problem is so common and may not cause symptoms.

• The doctor first removes any ear wax (called cerumen ) in order to get a clear view of the middle ear.
• The doctor uses a small flashlight-like instrument called an otoscope to view the ear directly. This is the most important diagnostic step. The otoscope can reveal signs of acute otitis media, bulging eardrum, and blisters.

• To determine an ear infection, the doctor should always use a pneumatic otoscope. This device detects any reduction in eardrum motion. It has a rubber bulb attachment that the doctor presses to push air into the ear. Pressing the bulb and observing the action of the air against the eardrum allows the doctor to gauge the eardrum's movement.
• Some doctors may use tympanometry to evaluate the ear. In this case, a small probe is held to the entrance of the ear canal and forms an airtight seal. While the air pressure is varied, a sound with a fixed tone is directed at the eardrum and its energy is measured. This device can detect fluid in the middle air and also obstruction in the Eustachian tube.
• A procedure similar to tympanometry, called reflectometry , also measures reflected sound. It can be used to detect fluid and obstruction, but does not require an airtight seal at the canal.

Neither tympanometry nor reflectometry are substitutes for the pneumatic otoscope, which allows a direct view of the middle ear.

Findings Indicating AOM or OME. A diagnosis of AOM requires all three of the following criteria:

• History of recent sudden symptoms . Symptoms may include fever, pulling on the ear, pain, irritability, or discharge (otorrhea) from the ear.
• Presence of fluid in the middle ear . This may be indicated by fullness or bulging of the eardrum or limited mobility.
• Signs and symptoms of inflammation . These may include redness of the eardrum as well as assessment of the child's discomfort. Ear pain that is severe enough to interfere with sleep may indicate inflammation.

AOM (fluid and infection) is often difficult to differentiate from OME (fluid without infection). It is important for a doctor to make this distinction as OME does not require antibiotic treatment. In patients with OME, an air bubble may be visible and the eardrum is often cloudy and very immobile. A scarred, thick, or opaque eardrum may make it difficult for the doctor to distinguish between acute otitis media and OME.

Severity of AOM : Acute otitis media is characterized as severe or non-severe.

• Non-severe AOM: Mild-to-moderate pain, temperature less than 102.2 degrees F (39 degrees C).
• Severe AOM: Moderate-to-severe pain, temperature of 102.2 degrees F (39 degrees C) or higher.

Home Diagnosis

Parents can also use a sonar-like device, such as the EarCheck Monitor, to determine if there is fluid in their child's middle ear. EarCheck employs acoustic reflectometry technology which bounces sound waves off the eardrum to assess mobility. When fluid is present behind the middle ear ( a symptom of AOM and OME), the eardrum will not be as mobile. The device works like an ear thermometer and is painless. Results indicate the likelihood of the presence of fluid and may help patients decide whether they need to contact their child's doctor.

Tympanocentesis

On rare occasions the doctor may need to draw fluid from the ear using a needle for identifying specific bacteria, a procedure called tympanocentesis . This procedure can also relieve severe ear pain. This is most often performed by an ear, nose, and throat (ENT) specialist, and usually only in severe or recurrent cases. In most cases, tympanocentesis is not necessary in order to obtain an accurate enough diagnosis for effective treatment.

Determining Hearing Problems

Hearing tests performed by an audiologist are usually recommended for children with persistent otitis media with effusion. A hearing loss below 20 decibels usually indicates problems.

Determining Impaired Hearing in Infants and Small Children. Unfortunately, it is very difficult to test children under 2 years old for hearing problems. One way to determine hearing problems in infants is to gauge the baby's language development:

• At 4 - 6 weeks most babies with normal hearing are making cooing sounds.
• By around 5 months the child should be laughing out loud and making one-syllable sounds with both a vowel and consonant.
• Between 6 - 8 months, the infants should be able to make word-like sounds with more than one syllable.
• Usually starting around 7 months the baby babbles (makes many word-like noises) and should be doing this by 10 months.
• Around 10 months, the baby is able to identify and use some term for the parent, dada, baba, or mama.
• The baby speaks his or her first word usually by the end of the first year.

If a child's progress is significantly delayed beyond these times, a parent should suspect possible hearing problems.

Determining Impaired Hearing in Older Children. Hearing loss in older children may be detected by the following behaviors:

• They may not respond to speech spoken beyond 3 feet away
• They may have difficulty following directions
• Their vocabulary may be limited
• They may have social and behavioral problems

• Review Date: 3/6/2007
• Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

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