On a busy winter evening at the clinic, I usually will have several parents come in with concerns that their children have ear infections.
This seemingly straightforward diagnosis can cause stress, confusion and frustration for physicians and parents alike. Below, I will clarify how ear infections happen and why it may be tricky to answer the simple question, “Does my child have an ear infection?”
Next to the common cold, ear infections are the most frequent reason for children to see their doctors. By 3 years old, 80 percent of children will have had at least one ear infection. Understanding ear infections is easier once you understand how the ear works.
The ear is made up of three major parts: the outer ear, the middle ear and the inner ear. Sound enters the outer ear, the visible part of the ear, and travels through the ear canal to the middle ear. The middle ear is made up of the eardrum (a thin layer of tissue) and three tiny bones called the ossicles. The eardrum vibrates in response to sound waves travelling through the ear canal. The ossicles amplify the eardrum’s vibrations and carry them to the inner ear. The inner ear transforms the vibrations into electrical signals that the brain interprets as sound.
For this system to work well, the pressure in the middle ear must be equal to the outside air pressure. This is managed by the Eustachian tube, a small passage between the middle ear and the back of the throat behind the nose.
When a child has a bad cold or allergies, the Eustachian tube may malfunction and fail to drain fluid from the middle ear. Instead of air, this space fills with fluid. Bacteria and viruses may become trapped from the malfunctioning tube and grow in the fluid, leading to an ear infection.
Children with ear infections often demonstrate fever, fussiness, pain and poor eating. However, many of these complaints are seen with the common cold and teething, as well. Just the pressure from fluid in the ear, without an infection, also may lead to pain.
Your child’s physician will gather the history and use this information, along with physical exam findings, to make a diagnosis. The exam typically involves inserting an otoscope, a small flashlight with a magnifying glass, into the ear canal to view the eardrum. Ideally, the physician should be able to see the entire eardrum and assess its color, mobility and position to make a diagnosis. Now, add the following complications—a crying, fighting child, wax in the ear canal, and a parent struggling to hold the child still—and this becomes tricky. The eardrum may look red just from a child crying. Removing large amounts of ear wax may further upset an already uncooperative child.
Your child’s physician then will make his or her best recommendation based on how your child looks at the time of the visit, your child’s history, and what is known about the natural course of ear infections. Treatment may involve antibiotics, holding an antibiotic prescription while waiting a couple of days (watchful waiting), or treating with supportive care measures only.
If the doctor cannot see the eardrum well or is concerned that fluid in the ear has a high potential to become infected, you may be asked to bring your child back for a repeat examination in a few days. Even the best assessment cannot predict the child who gets worse or fails to respond to an initial course of antibiotics. Your doctor also can provide guidance on when to call the office for worsening or continued symptoms.
As a parent, you can help your child’s physician make a good assessment about an ear infection. First, provide a clear history of the symptoms. Second, especially for small children, hold on tightly. A parent who gently, but firmly, holds a fighting child for an exam can make a big difference in the physician’s ability to see the eardrum and make an accurate assessment regarding infection.
The good news is that the majority of children fully recover from ear infections. Ear infections tend to become less frequent as children get older and their Eustachian tubes become longer and more vertically placed, improving fluid drainage and reducing the chance of infection. Accurate diagnosis really depends upon a team effort between physicians and parents to answer that seemingly simple question, “Does my child have an ear infection?”
Dr. Deepa Sekhar is a pediatrician at the Penn State Milton S. Hershey Medical Center.
