Ear Infections

Introduction

There are several different types of ear infections depending on what part of the ear is infected. The ear is generally divided into three parts: the external ear, the middle ear, and the inner ear. The external ear includes the visible part of the ear and the ear canal. An infection of the ear canal is called otitis externa, commonly referred to as “swimmer’s ear”. The middle ear is the air-filled space between the eardrum (tympanic membrane) and the inner ear. The middle ear contains the ear bones and the Eustachian tube. Infections of the middle ear are called otitis media. The inner ear is located within the skull. It contains the hearing organ called the cochlea, and balance canals called semicircular canals. Infections of the inner ear are uncommon and are called labyrinthitis, vestibular neuritis, or sudden sensorineural hearing loss, depending on what part of the inner ear becomes infected.

Otitis Media

Otitis media is an infection or inflammation of the middle ear. Ear infections can either be of short duration (acute) or persistent (chronic). When most people refer to an ear infection, they are talking about acute otitis media.

Acute Otitis Media

Acute otitis media is an infection of the middle ear. It most often occurs when a virus or bacteria enters the ear and mucus, or pus build up behind the eardrum. Ear infections usually start with a cold or sinus infection but can occur on their own. The job of the Eustachian tube is to regulate pressure and drain the middle ear. An upper respiratory infection causes swelling of the Eustachian tube and the tissue around it. This prevents the fluid buildup from draining and causes pain and decreased hearing.

Although adults can get ear infections, they are most common in young children. A child's eustachian tubes are narrower, shorter and more horizontally placed than an adults. This makes it easier for fluid to get trapped in the middle ear. In studies, 75% of children get at least one ear infection. They happen most often in the first year of life. By age 1, 60% of children will have had at least one ear infection and 17% will have had 3 or more.

There are two main types: acute otitis media (AOM), and otitis media with effusion (OME). Acute otitis media causes pain, fever, and difficulty hearing. If a child is too young to talk, signs of an ear infection can include crying, irritability, trouble sleeping, and pulling on the ears.

In OME fluid remains trapped in the ear. This leaves clear or straw-colored fluid behind the eardrum. This can result in a sense of the ear being plugged and muffled hearing, but rarely pain.

Risk Factors for Otitis Media

  • Children under 7
  • Daycare attendance
  • Cold, flu or sinus infection.
  • Allergies
  • Exposure to cigarette smoke
  • Family members with a history of frequent ear infections.
  • Using a pacifier.
  • Gastroesophageal reflux disease (GERD).

Treatment

  • If a bacterial infection is present, your doctor may prescribe antibiotics. If your doctor prescribes antibiotics, be sure to give your child all the doses as prescribed. Patients treated with antibiotics can develop vomiting, diarrhea, or a rash. You should contact your prescribing physician for these symptoms.
  • If the eardrum is ruptured (has a hole in it) your doctor may prescribe antibiotic ear drops instead of oral antibiotics. Current recommendations for patients with ear tubes or perforations present are to use antibiotic drops before oral antibiotics.
  • Over the counter pain medications such as Ibuprofen or acetaminophen may be used. Before giving any medication to a child you should talk to your pediatrician.

Most acute ear infections resolve on their own. Antibiotics tend to be overused for treating ear infections. For this reason, children may develop bacteria resistant to antibiotics. The AAP and the American Academy of Family Physicians guidelines recommend taking a wait and see approach for 72 hours if:

  • The child is older than 6 months
  • The patient is otherwise healthy
  • The person has mild symptoms or there is an unclear diagnosis.

Prevention is very important. You can reduce you or your child's risk of ear infections by:

  • NOT exposing your child to secondhand smoke.
  • Always hold your infant in an upright, seated position during bottle feeding.
  • Breastfeeding for at least 6 months can make a child less prone to ear infections.
  • Avoid use of a pacifier.
  • The pneumococcal vaccine (Prevnar) prevents infections such as pneumonia and meningitis, and studies show it slightly reduces the risk of ear infections in children.

Surgery (Myringotomy and Tube Placement)

In patients who have recurring ear infections or those who have fluid that remains in place for months without resolving your ENT physician may suggest putting in tubes. This are sometimes referred to as pressure-equalizing (PE) tubes or tympanostomy tubes. This surgery requires general anesthesia for children but can often be done in the office under local anesthesia for adults. The surgeon makes a small incision in the ear drum and then inserts a small tube into the eardrum. Fluid behind the eardrum can drain out, equalizing the pressure between the middle and the outside environment. The eardrum usually pushes the tubes out on their own over the ensuing 6-18 months.

Chronic Otitis Media (COM)

What is Chronic Otitis Media?

When an ear infection does not completely go away or returns often, it is referred to as chronic. If left untreated, chronic ear infections can lead to a variety of complications including hearing loss, damage to the eardrum, damage to the bones in the middle ear, chronic or recurring drainage from the ear, balance problems, a middle ear cyst called a cholesteatoma, facial paralysis and inflammation of the brain.

How Does Chronic Otitis Media Occur?

If the eustachian tube becomes blocked due to swelling or congestion in the nose, the middle ear cannot equalize pressure properly. Negative pressure then develops. If the eustachian tube blockage is prolonged, fluid or mucus can be drawn into the middle ear. As the blockage persists, the tissue in the middle ear begins to change. First, the mucus become thicker, and less likely to drain. Then the lining itself begins to thicken and become inflamed. The defense mechanisms of the eustachian tube and middle ear become compromised and bacteria normally present in the nose can track into the middle ear and otitis media.

The negative pressure in the middle ear or alternating periods of negative, normal, and positive pressure may deform the eardrum. Over time, the eardrum may become severely distorted, thinned, or even perforated. These changes may cause hearing loss and a sensation of pressure. When there is a hole in the eardrum, the natural protection of the middle ear from the environment is lost. Water and bacteria entering the middle ear from the ear canal can cause repeated inflammation and infection. Drainage from the ear is a common sign of a perforation.

Inflammation and infection in time can cause erosion of ear bones and the walls of the middle and inner ear. This can lead to hearing loss, imbalance, or weakness of facial movement. In rare cases, the infection may extend deeper into the head, causing meningitis or brain abscess.

How is Chronic Otitis Media Treated?

The first step in treating chronic otitis media is a thorough evaluation by an ENT physician. This will include a history and examination of the ear, nose, and throat. Depending on the individual’s unique situation, further testing may include a hearing test, tympanometry (a pressure test of the middle ear), or CT scan.

Treatment depends upon the severity of the disease. In the beginning, the causes of eustachian tube obstruction should be treated to prevent progression of chronic otitis media. Many children and adults with chronic or recurrent ear infections have ventilation tubes inserted in their eardrums to allow normal air exchange in the middle ear until the eustachian tube matures or underlying causes of the eustachian tube dysfunction can be treated.

If the disease has progressed enough to cause damage to the eardrum or ear bones, more intensive treatment is usually needed. Once the active infection is controlled, surgery is usually recommended.

Acute Otitis Externa or Swimmer’s Ear

Acute otitis externa or swimmer’s ear is caused by an infection, inflammation, or irritation of the ear canal. It can affect children and adults. This condition usually result from water getting trapped in the ear (from baths, showers, swimming, sweat) but can also be the result of eczema, excess earwax, use of hearing aids or earbuds, trauma from Q tips or other objects being inserted into the ear canals.

What are the Symptoms of Otitis Externa?

  • Itching inside the ear (common)
  • Pain inside the ear that gets worse when you tug on the outer ear (common)
  • Sensation that the ear is blocked or full
  • Drainage from the ear
  • Decreased hearing
  • Redness or swelling of the skin around the ear

Recurring ear infections (chronic otitis externa) are also possible. Without treatment, infections can continue to occur or persist.

Bone and cartilage damage (malignant otitis externa) are also possible due to untreated swimmer’s ear. If left untreated, ear infections can spread to the base of your skull, brain, or cranial nerves. Diabetics, older adults, and those with conditions that weaken the immune system are at higher risk for such dangerous complications.

How is Otitis Externa treated?

Treatment for the early stages of swimmer’s ear includes careful cleaning of the ear canal and use of eardrops that stop bacterial or fungal growth and reduce inflammation. Before using any drops in the ear, it is important to be sure you do not have a perforated eardrum (an eardrum with a hole in it).

If the ear canal is swollen shut, your doctor may place a sponge or wick in the canal so the antibiotic drops will enter the swollen canal more effectively. Topical antibiotics are effective for infection limited to the ear canal. Oral antibiotics may also be prescribed if the infection goes beyond the skin of the ear canal.

Follow-up appointments are very important to monitor your condition, to clean the ear again, and to replace the ear wick as needed. Your ENT specialist has specific equipment and expertise to effectively clean the ear canal and treat swimmer’s ear. With proper treatment, most infections should clear up in seven to 10 days.

How can Otitis Externa be prevented?

A dry ear is unlikely to become infected, so it is important to keep the ears free of moisture. Prevention tips include:

  • Use ear plugs when swimming.
  • Use a dry towel or hair dryer (from a distance) to dry your ears.
  • Have your ears cleaned periodically by an ENT specialist if you have itchy, flaky or scaly ears, or extensive earwax.
  • Do not use cotton swabs to remove ear wax. They may pack ear wax and dirt deeper into the ear canal, remove the layer of earwax that protects your ear, and irritate the thin skin of the ear canal. This creates an ideal environment for infection.

Inner Ear infections

Infections of the inner ear are uncommon. They usually occur from a virus. Symptoms include sudden onset of hearing loss and/or severe vertigo.

Sudden Sensorineural Hearing Loss

Sudden hearing loss is most often caused by a virus and involves only one ear. You should see an ENT (ear, nose, and throat) specialist urgently for treatment to try and recover some hearing. Symptoms may also include dizziness (spinning sensation, balance problems, or vertigo), ringing in the ear (tinnitus), feeling like your ear needs to pop.

How is Sudden Hearing Loss Diagnosed?

Your doctor will perform a complete ENT exam and review your medical history. A hearing test (audiogram) will be performed to determine if you do have hearing loss, what part of the ear is involved, and how sever the hearing loss is. Routine labs and Xrays are usually not recommended. Less than 1% of the time sudden hearing loss is due to a benign (non-cancerous) tumor on the hearing and balance nerve. Your doctor may order an MRI to look for this tumor.

How is Sudden Hearing Loss Treated?

There are many treatments for SSNHL. Treatment is most successful the earlier it is given. Treatment can include oral steroids or steroids injected directly into the ear (intratympanic steroid injections). If the first treatments do not work, your otolaryngologist should discuss “salvage therapy.” The benefits of treatment may include more quick and complete recovery of hearing, but there are also side effects of steroids that must be considered when choosing from the available options. Side effects of steroids may include sleep problems, anxiety, depression, or mood swings, increased appetite with possible weight gain, dizziness, jitteriness, high blood sugar, and/or high blood pressure. With intratympanic steroids risks include pain, dizziness, residual hole in the ear drum, and infection. In head-to-head comparisons, intratympanic injection of steroids causes much fewer side effects than oral steroids.

Watchful waiting may be recommended. This is because half of patients may get back hearing on their own—these are usually patients with mild to moderate degrees of hearing loss, but healthcare providers do not currently have a way to predict who will get better without treatment.

Will My Hearing Come Back?

Approximately half of patients with SSNHL recover at least some hearing without treatment. Patients have a 75 to 80 percent chance of recovery with steroid therapy given early. The earlier that treatment is begun, the better the chances for recovery. Patients with profound hearing loss, which is a complete or near complete loss of hearing, patients who experience dizziness (vertigo) with their sudden hearing loss, and individuals above age 65 have a much lower chance of getting their hearing back. In those cases, you and your healthcare provider should discuss aggressive treatments to try to bring your hearing back. Hearing can take months to return after treatment is finished.

If you do not experience full hearing recovery, you may want to talk to your otolaryngologist and audiologist about hearing aids or other devices you can use to make hearing easier.

Labyrinthitis

Labyrinthitis is a disorder associated with inflammation of the inner ear. The labyrinth is a fluid-filled compartment that consists of the hearing portion of the inner ear (cochlea) and the balance portion (semicircular canals).

Labyrinthitis has several different causes, and patients of any age and gender may be affected. Patients with labyrinthitis can experience hearing loss in the affected ear, imbalance, dizziness, and nausea.

Labyrinthitis is a self-limiting illness that usually gets better in several weeks. Symptom can begin suddenly and then gradually worsen over the course of hours to days. Failure to seek treatment may put patients at higher risk for permanent hearing loss and imbalance. Although uncommon, it is possible to have some permanent hearing loss despite treatment. While most patients with imbalance and mild dizziness with head movement recover, sometimes it may take months to years to fully recover. Patients with substantial balance issues may benefit from a special type of physical therapy called vestibular physical therapy.

What are the symptoms of labyrinthitis?

  • Hearing loss, often in high frequency pitch range
  • Decreased ability to understand speech
  • Tinnitus, or ringing or buzzing sensation in the ear
  • Imbalance and unsteadiness, falling or swaying to one side while walking
  • Vertigo, or feeling like you are spinning when you are still
  • Involuntary twitching or jerking of the eyeball, called nystagmus
  • Nausea and vomiting

What are the causes of Labyrinthitis?

Viral infections—Viral infections of the inner ear or activation of a virus that is has hibernated within nerve endings are thought to be the most common cause of labyrinthitis. The specific virus that causes this is usually unknown in most cases. A unique type of labyrinthitis may be caused by reactivation of the varicella-zoster virus (Shingles), called Ramsay Hunt syndrome, or herpes zoster oticus. Patients may experience ear pain, facial weakness, and blisters around the ear, ear canal, and/or eardrum in addition to hearing loss and dizziness.

Bacterial infection—A bacterial infection of the middle ear (the space behind the ear drum) can spread to the inner ear and cause bacterial labyrinthitis. Children with inner ear deformities are at a higher risk for bacterial labyrinthitis either from a middle ear infection or from the spread of bacterial meningitis to the inner ear. Severe bacterial labyrinthitis can occur with ear pain, ear infection, drainage of pus from the ear, fevers, or chills. Patients may require hospitalization. This type of infection has a higher risk for permanent hearing loss and may also lead to labyrinthitis ossificans, where there is bone formation in the inner ear after the infection.

Autoimmune—Autoimmune labyrinthitis is a rare cause of labyrinthitis and may come and go. It is often associated with other autoimmune disorders such as systemic lupus erythematosus, inflammatory bowel disease, rheumatoid arthritis, or other autoimmune disorders.

Trauma and surgery—Inner ear trauma puts patients at risk for developing labyrinthitis. Fractures involving the inner ear, concussion of the head and inner ear, or bleeding in the inner ear can cause labyrinthitis.

How is Labyrinthitis Treated?

Treating most cases of labyrinthitis includes observation, bed rest, and hydration. Steroids, such as prednisone, are typically prescribed to minimize inner ear inflammation. In some cases, steroids may be injected through the eardrum into the middle ear space. Severe nausea and vomiting may be treated with anti-nausea medications. Vertigo may be treated with antihistamines or sedatives, such as benzodiazepines, although long-term use can prolong the recovery.

The treatment of bacterial labyrinthitis is to control the primary infection, which is usually a middle ear infection. This may require antibiotics, placement of an ear tube, or more advanced ear surgery. Treatment for autoimmune labyrinthitis addresses the underlying autoimmune condition with steroids or other immune modulating medications usually directed by the rheumatologist.

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