Ear infections are very common, especially in infants and children.
There are three specific types, each with different causes, clinical presentation and management. We will discuss each in detail here. We will also discuss other related issues such as travel considerations when you have an ear infection.
What is an Ear infection?
An ear infection is an inflammation of the inner, middle, or outer ear, caused by a bacterial or viral pathogen. Ear infections can go away on their own in many cases, but if the earache persists for 3 days or there are new symptoms, such as a ear discharge, fever or loss of balance, you should see a doctor immediately.
Types of Ear infections
Based on the part of the ear involved, there are three types of ear infection: Otitis externa, otitis media, and otitis externa.
1. Otitis Externa (OE)
It is described as the infection/inflammation of the external ear. It is also known as the “swimmer’s ear”. Malignant OE affects soft tissue, cartilage, and bone of the external ear.
Causes
Acute otitis externa is typically caused by bacteria, such as Pseudomonas aeruginosa, Proteus vulgaris, Staphylococcus aureus, or Escherichia coli.
Less commonly, it can also be caused by fungi (otomycosis), such as Aspergillus niger or Candida albicans. Furuncles are caused by S. aureus. Malignant OE is caused by Pseudomonas aeruginosa or methicillin-resistant Staphylococcus aureus (MRSA).
Risk Factors
Factors that may lead to OE include injury to the canal (by cotton swabs or other objects), allergies, skin conditions like psoriasis, eczema, seborrheic dermatitis, decreased canal acidity (such as swimming pool water), and irritants (hair spray/dye, etc.).
Malignant OE occurs mainly in elderly patients with diabetes mellitus or in immunocompromised patients.
Symptoms
Patients experience pain, drainage of a foul-smelling discharge, possible hearing loss, extreme tenderness when retracting the pinna or putting pressure over the tragus.
Fungal otitis (otomycosis) is more pruritic, less painful, and accompanied with the feeling of aural fullness.
Furuncles, on the other hand, cause severe pain and may drain sanguineous, purulent material. They can appear as reddened swellings (pimples) as well.
Malignant OE presents with persistent and severe, deep ear pain, foul-smelling purulent ear discharge, and granulation tissue or exposed bone in the ear canal. There may be conductive hearing loss as well.
Diagnosis
The diagnosis is clinical (based on symptomatology). Otoscopic examination is a part of the clinical exam and involves visualization of the ear canal and the external surface of the eardrum.
Due to extreme tenderness, otoscopic examination may be difficult to perform. It shows that the ear canal appears red, swollen, and there is presence of pus, debris and desquamated epithelium.
- Niger otomycosis shows black or yellow dots surrounded by cottonlike fungal hyphae, whereas C. albicans infection contains a thickened, creamy white exudate.
- Malignant OE is diagnosed with high-resolution CT scan of the temporal bone, cultures are done, and the ear canal biopsied.
Treatment
This typically involves debridement, application of topical acetic acid and corticosteroids. In some cases, topical antibiotics are needed.
In mild-to-moderate acute external otitis, topical antibiotics and corticosteroids are effective. The infected debris should be gently and thoroughly removed from the canal with suction or dry cotton swabs but water irrigation of the canal must not be performed.
For moderate OE, an antibacterial solution or suspension, such as ciprofloxacin, ofloxacin, or neomycin/polymyxin needs to be added. A wick wetted with Burow’s solution may also be applied for deeper access into the external canal, especially when the canal is swollen.
It is left in place for 24 to 72 hours. Systemic antibiotics may be needed for severe OE (with cellulitis extending beyond the ear canal), such as cephalexin or ciprofloxacin for 10 days.
A painkiller may also be needed. Fungal OE requires thorough cleaning of the ear canal and application of an antimycotic solution, unless the tympanic membrane is perforated.
Patients are advised to keep the ear dry. A furuncle, if large enough, should be incised and drained.
Oral antistaphylococcal antibiotics should be prescribed. Painkillers may be necessary for pain relief.
For malignant OE, a 6-week intravenous course of a fluoroquinolone and/or piperacillin–tazobactam or piperacillin/aminoglycoside combination is needed.
Mild cases may be treated with a high-dose oral fluoroquinolone on an outpatient basis with close follow-up.
Extensive bone disease may require longer antibiotic therapy. Strict diabetic control is essential. Frequent removal of granulation tissue and purulent discharge is often required.
Prevention
In order to prevent OE, it is important to prevent common colds and other illnesses.
Frequent and thorough hand washing is important.
Children should be taught to cough or sneeze into their arm crook. If possible, limit the time your child spends in group child care or choose one with fewer children.
Also, it is important to keep your child home when ill.
You must avoid secondhand smoke.
Breastfeeding your baby is also important as breast milk contains antibodies that may offer protection from ear infections so it is advisable to breastfeed your baby for at least 6 months.
When If bottle-feeding, hold your baby upright.
Prognosis
OE responds well to treatment, but complications may occur if it is not properly treated.
Individuals with underlying diabetes, weak immune system, or history of radiation therapy to the base of the skull are more likely to develop complications, including malignant OE, chronic OE, necrotizing OE or OE haemorrhagica.
Prevention
You must avoid damaging your ears – do not insert cotton wool buds or other objects into your ears. If earwax buildup becomes a problem, have it removed by a healthcare professional.
Keep your ears dry and clean. Do not let water, soap or shampoo get inside your ears.
If you swim regularly, wear a swimming hat that covers your ears or use ear plugs. You can use acidifying ear drops or spray to help keep your ears clean before and after swimming.
Treat and prevent other skin conditions.
If you have an allergic reaction to any ear apparel, remove it. And use hypoallergenic products.
Complications
If left untreated, the infection may extend inwardly to involve the middle or inner ear, or externally to involve the skin outside.
In extreme cases, it may involve deeper tissue and enter bone, muscle, bloodstream.
Malignant OE spreads along the base of the skull and may cause cranial neuropathies as well as brain infection.
Special considerations for pediatrics and infants
Children may be prone to OE because of foreign body insertions or swimming. The management is the same, with extra precautions for keeping the ear dry.
Home remedies
Some consider these home remedies to cure ear infection, and although their efficacy has not been proven, some of them are quite commonplace.
It is always advised to consult your doctor if the symptoms persist or get concerning.
These home remedies include –
- Olive oil (when warm and put into the ear canal it helps dissolve the impacted earwax)
- Apple cider vinegar (used to irrigate the infected ear as it is known to have antimicrobial properties)
- Salt (can be applied to draw water out and reduce painful swelling in the ear canal)
- Basil (juice made from crushed leaves can be applied on the skin around the ear for its antioxidant properties)
- Tea tree oil (mixed with olive oil and used to irrigate the ear canal for its antimicrobial properties)
- Onion (juice used to irrigate ear canal for its healing properties)
- Ginger (juice/oil dropped in ear canal for its anti-inflammatory features)
- Hydrogen peroxide (cuts through ear wax and help reduce pain)
- Peppermint oil (used for its anti-inflammatory and analgesic properties)
- Mullein flower oil (used for its analgesic properties), radish (to reduce inflammation), etc.
2. Otitis Media (OM)
It is defined as the inflammation of the middle ear caused by a bacterial/viral infection. It can be acute, recurrent or chronic.
Chronic OM is a persistent infection (> 6 weeks) leading to draining, suppurative perforation of the tympanic membrane.
Causes
Acute OM It may be viral or bacterial. Often, viral infections lead to secondary bacterial infection.
In newborns, gram-negative enteric bacilli (Escherichia coli, Staphylococcus aureus) are the main causes.
In children under 14 years of age, the most common organisms are Streptococcus pneumoniae, Moraxella catarrhalis, and nontypeable Haemophilus influenzae.
In patients older than 14 years, S. pneumoniae, group A β-hemolytic streptococci, and S. aureus are most common, followed by H. influenzae.
Chronic OM is often caused by gram-negative bacilli or Staphylococcus aureus.
Risk factors
Smoking in the household is a significant risk factor for acute OM. Others include a strong family history of otitis media, bottle feeding, and attending a day care center.
Chronic OM can result from acute OM, eustachian tube obstruction, mechanical trauma, thermal or chemical burns, blast injuries, or from medical procedures.
Further, patients with craniofacial abnormalities (eg, Down syndrome, cri-du-chat syndrome, cleft lip and/or cleft palate, etc. have an increased risk.
Symptoms
The most typical is earache, often with hearing loss.
Infants may get cranky or have difficulty sleeping.
There is likely fever, nausea, vomiting, and diarrhea (especially in young children).
Otoscopic examination shows a bulging, reddened ear drum with indistinct landmarks and displacement of the light reflex.
Air insufflation (pneumatic otoscopy) shows poor mobility of the eardrum. The eardrum can perforate and cause serous or purulent discharge.
Chronic OM manifests with painless, purulent, sometimes foul-smelling ear discharge for 6 weeks or longer. It also causes conductive hearing loss.
Cholesteatoma presents with white debris in the middle ear, a draining polypoid mass protruding through the eardrum perforation, and an ear canal filled with mucus, pus and granulation tissue.
Hearing loss in children
All children with OM have some degree of hearing loss.
Fluid-filled ears cause a hearing loss of approximately 24 decibels. Thicker fluid in the middle ear can cause up to 45 decibels.
A child experiencing hearing loss due to OM will hear muffled sounds and misunderstand speech. The consequences can be dire. Young patients could permanently lose the ability to understand speech in a noisy environment leading to learning impediment in speech and language skills.
Diagnosis
Diagnosis of OM is clinical, based on symptoms and otoscopic findings.
For chronic OM, drainage is performed and fluid is cultured. When cholesteatoma or other complications are suspected, a CT or MRI is performed.
Treatment
Painkillers (oral or topical) should be provided as needed.
Up to 80% of cases resolve on their own, but antibiotics (amoxicillin, cephalosporins, etc.) are still prescribed to reduce the chance of residual hearing loss and other complications.
However, it is important to keep the issue of antibiotic resistance in mind.
For chronic OM, topical ciprofloxacin solution are instilled in the affected ear. When present, granulation tissue is removed with silver nitrate sticks.
Ciprofloxacin and dexamethasone is then instilled into the ear canal for 7 to 10 days. In severe cases, intravenous antibiotic therapy with amoxicillin or a 3rd-generation cephalosporin is required, with more specific treatment based on culture and sensitivity results.
Tympanoplasty is needed for patients with eardrum perforations or damaged inner ear bones. Cholesteatomas must be removed surgically.
Complications
OM, if left untreated or poorly managed, can spread locally, resulting in acute mastoiditis, petrositis, or labyrinthitis.
Intracranial spread is extremely rare and can cause meningitis, but rarely may cause brain abscess, subdural empyema, epidural abscess, etc.
These complications are more common in patients with a weak immune system.
Persistent chronic OM may result in destructive changes in the middle ear or aural polyps, which are a sign of cholesteatoma.
A cholesteatoma is an epithelial cell growth that forms in the middle ear, mastoid, or epitympanum after chronic otitis media. It can invade and destroy adjacent bone and soft tissue.
Special considerations for pediatric population
Acute OM can occur at any age, but it is most common between ages 3 mo and 3 yr, as at this age, the eustachian tube is structurally and functionally immature making it prone to infections spreading from the upper respiratory tract.
3. Otitis Interna (OI) or Labyrinthitis
It is defined as the inflammation in the inner ear caused by a bacterial or viral infection.
Causes
Purulent labyrinthitis usually occurs when bacteria spread to the inner ear as a complication of severe OM, purulent meningitis, trauma causing a labyrinthine fracture leading to an infection, or an enlarging cholesteatoma.
Symptoms
Symptoms of purulent labyrinthitis include ear pain, fever, severe vertigo, nystagmus, nausea and vomiting, tinnitus (ringing in the ear), and hearing loss.
Symptoms of viral vestibular neuronitis include severe vertigo, with nausea, vomiting and persistent nystagmus toward the affected side, which lasts 7 to 10 days.
The condition resolves over days to weeks after the initial episode. Some patients have residual balance issues.
Diagnosis
CT of the temporal bone is done to identify erosion of the otic capsule bone or other complications of acute otitis media leading OI.
MRI may be done if symptoms of meningitis or brain abscess are noted. In that case, a lumbar puncture and blood cultures also are done.
Patients suspected of having vestibular neuronitis undergo an audiologic assessment, electronystagmography with caloric testing, and contrast-enhanced MRI of the head.
Treatment
Treatment is with IV antibiotics appropriate for meningitis (ceftriaxone or ceftazidime to cover P. aeruginosa).
These are later adjusted according to results of culture and sensitivity testing.
A myringotomy (and sometimes tympanostomy tube placement) is done to drain the middle ear.
In some cases, mastoidectomy may be required. Symptoms of viral labyrinthitis/vestibular neuronitis are symptomatically addressed over the short term with anticholinergics, antiemetics antihistamines or benzodiazepines, and possibly a corticosteroid.
If vomiting is prolonged, IV fluids and electrolytes may be required.
Prognosis
In most cases, OI is a one-time experience that most people fully recover from.
Recovery from acute labyrinthine inflammation generally takes from one to six weeks, but there may be some residual dizziness or balance issues that last for a few of months.
Complications – These include meningitis, brain abscess, mastoiditis, etc.
When to go to Emergency Room for an Ear infection:
You should consider going to emergency room if you experience the following symptoms along with ear pain.
- Stiff neck
- Severe drowsiness
- Nausea and/or vomiting
- High fever.
- A recent blow to the ear or recent head trauma also warrants a visit to the ER.
- For slightly less severe symptoms including minor hearing loss, ringing in ears, and/or dizziness, you should pay a visit to urgent care emergency room as well.
- If there is sticky or bloody discharge coming from the ear or if there is increased pain when wiggling the ear lobe, you should definitely see a doctor.
You should tell your doctor if you have been exposed to loud, prolonged noise or if an object has been inserted in your ear.
Also, if your child’s ear pain is accompanied by a knot or swelling formed under or behind the ear, difficulty moving parts of your face in a normal way, extreme fussiness or lethargy, sudden high fever or seizure, you must seek medical attention right away.
Double ear infection
A double ear infection is when both ears become infected by a bacterial/viral pathogen.
They are not always more serious than single ear infections, but their symptoms are often more pronounced. Treatment options are the same.
Should you go to work if you have Ear infection?
If you have a bad ear pain and you can’t hear well, you likely have an ear infection. In that case, you should see a doctor. You may be prescribed an antibiotic and/or pain medicine.
Ear infections aren’t contagious. But you need rest. Moreover, you could have a cold and you might spread it to someone else during the first few days.
Travel considerations & Preventing Eardrum Rupture
There are special considerations for air travel when you have an ear infection. In order to understand those, let’s look at some basics first.
Eustachian tube is a narrow canal that connects the middle ear to the back of the nose.
It equalizes ear pressure to that outside. Your ears pop when a small bubble of air enters the back of the nose, travels through the Eustachian tube and enters the middle ear.
This air is then absorbed by the middle ear lining, equalizing the pressure.
When the pressure isn’t equalized, flyers experience pain and, sometimes, temporary hearing loss. This experience is even more pronounced in scuba diving.
During an infection, a swollen or blocked Eustachian tube makes it difficult for ears to equalize pressure. This creates a small vacuum that stretches the eardrum.
If the tube remains blocked, fluid collects in an attempt to overcome the vacuum and alleviate pressure. This is known as serous otitis or aero-otitis.
Children have narrower and straighter tubes than adults, which makes it difficult for fluid to drain, making them more prone to have these experiences.
It is for this reason that it’s best to avoid flying when you or your children have an ear infection or a sinus infection.
If the increased pressure on the eardrum is persistent, it can rupture the eardrum. Even short of that, it can be very painful and uncomfortable.
When the eardrum ruptures, there is drainage from the ear, which can be either clear, purulent or bloody. It is accompanied by severe earache or discomfort, ringing in the ears, as well as hearing loss in the affected ear.
It may also be accompanied by dizziness and facial weakness. If this happens, apply a warm compress and take a painkiller for relief.
It often heals on its own within two months, but it’s important to see our ear, nose and throat physicians for a complete evaluation to ensure that there was no permanent damage to your hearing.
It is important to prevent this from happening.
You should first try to avoid flying when you have a full-blown ear infection as much as possible.
If that’s not always possible, then you must see an emergency room physician before you board the flight.
Antibiotics and over-the-counter decongestants may help prevent a ruptured eardrum.
Remember, an ounce of prevention is better than a pound of cure – it is best to prevent a painful condition like a ruptured eardrum if you can.
