Pediatric Ear Infections: Q&A

Ear infections are one of the most common medical problems among infants and young children. The following Q&A addresses the basic types of ear infections and their treatments.

What are the different types of ear infections in children?

Ear infections in children are primarily characterized by where they are located in the ear. 

An outer ear infection, known as otitis externa or “swimmer’s ear,” is confined to the ear canal, which extends from the outer ear to the eardrum. Symptoms of an outer ear infection typically include pain and drainage from the ear canal. The two most common causes of otitis externa are excess moisture and trauma to the ear canal. Local abrasion to the canal, often caused by the excessive use of Q-tips, can introduce bacteria. The most common bacteria that cause otitis externa are staphylococcus and pseudomonas. In addition to bacteria, fungus can develop in the moist environment of the ear canal. Swelling of the ear canal can occur in advanced cases, along with hearing loss due to the collection of fungal debris or bacterial fluid. 

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Middle ear infections, also called otitis media, occur behind the eardrum, in the middle ear space. Children who have acute otitis media are often irritable, will tug at their ears and have fevers. The bacteria that most commonly cause middle ear infections are streptococcus, hemophilus and moraxella.  


Classic appearance of the ear drum in a patient with acute otitis media. The white color behind the eardrum is a collection of pus in the middle ear.

Do all ear infections require the use of oral antibiotics?

No. Outer ear infections should be treated with a topical antibiotic only as an initial treatment. Antibiotic ear drops are effective because they treat the problem at the source. The ear must be kept dry during treatment, as the introduction of foreign matter, dirty water or bacteria prolongs the infection. Outer ear infections related to fungus require cleaning of the ear under a microscope by an otolaryngologist. The ear is treated with an acidifying agent such as acetic acid. 

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Treatment of a middle ear infection with antibiotics depends on the severity of symptoms. A child with a fever of 101 or less who does not have significant ear pain or discomfort can be observed by his or her parent. If symptoms worsen, the child should be evaluated by a physician. 


Which children should be treated with an antibiotic? 

A child with a fever of 102 or higher and severe ear pain, or with ear infections in both ears should be offered Amoxicillin as a first-line antibiotic. Children who have taken Amoxicillin within the 30-day period prior to the infection should instead be offered an antibiotic that treats resistant bacteria. The most common antibiotic prescribed in these cases is Augmentin.
All children treated with an antibiotic should be re-evaluated by the provider within 48-72 hours to ensure improvement in the child’s clinical condition. Antibiotics should not be prescribed as a preventative measure in any child with recurrent ear infections.


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Otitis media with effusion presents with a clear to yellow colored fluid behind the ear drum. 

What does it mean when the doctor says there is “fluid” in the ears?

Fluid in the ears means the presence of an effusion, a collection of liquid behind the eardrum that is typically the remnant of a recent middle ear infection. After an acute episode of otitis media, children may continue to have an effusion that lingers for weeks to months. The presence of non-infected liquid behind the eardrum, within the middle ear space, is called otitis media with effusion. Chronic otitis media with effusion is defined as the presence of fluid for more than three months. Otitis media with effusion limits the ability of the eardrum to conduct sound, and can result in mild to moderate hearing loss.


When does my child need surgery for ear infections and what types of surgery can be helpful?

Acute otitis media is one of the most common medical problems seen by pediatricians in the United States. The child with recurring otitis media, as defined by the presence of at least three infections in six months (or four in a year), should be evaluated by an otolaryngologist. 

A child with chronic otitis media with effusion should be evaluated as well, and should have an audiogram (hearing test) performed to identify the presence or absence of hearing loss. Due to the frequency of otitis media, long-term research has been completed demonstrating the benefit of surgical intervention. Below are the recommended surgical guidelines.

The most common intervention is the placement of tympanostomy tubes by an otolaryngologist. These are very small tubes that equalize pressure between the environment and the middle ear. Aeration of the middle ear allows for drainage of fluid out of middle ear space. A child with recurrent otitis media who presents with effusions at the time of the doctor visit should be offered tympanostomy tubes. A child with otitis media with effusion in both ears and documented hearing loss over a three-month period should be offered tubes as well. Any child presenting with hearing loss and effusion who is deemed “at risk” (exhibiting a known cognitive or speech delay) should be considered for tube placement within three months after the effusion is first identified. 


What are the long-term benefits of tympanostomy tubes?

The child with recurrent otitis media will, on average, have between two and three fewer ear infections each year after placement of tubes. The child with hearing loss due to chronic otitis media with effusion will typically have a complete return of hearing almost immediately after placement of tubes.

About the Author

Salvatore Taliercio, MD, is an otolaryngologist/head and neck surgeon with ENT and Allergy Associates, LLC in Sleepy Hollow, NY. He completed his surgical residency at Eastern Virginia Medical School, where his training focused on the treatment of head and neck cancer and sinus surgery, as well as common pediatric concerns such as recurrent ear infections.
He then completed a fellowship in laryngology at the NYU Voice Center, providing medical and surgical care for individuals with voice limitations, chronic cough and difficulty swallowing. 

Dr. Taliercio provides in-depth evaluation for children with recurrent ear infections, including audiograms (hearing tests) for children with potential hearing loss related to these infections. He has tertiary subspecialty training in laryngology, the study of voice and swallowing, and performs in-office stroboscopy, an evaluation of the movement of the vocal cords. To schedule an appointment with Dr. Taliercio, call 914-631-3053. 

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