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Ear Infections (Otitis Media) in Children


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

Alternative Names

Otitis Media; Tympanostomy


Acute otitis media (middle ear infection) is most often the result of a combination of factors that increase susceptibility to infections by specific organisms in the middle ear. The infection typically evolves as follows:

  • The primary setting for ear infections is in a child's Eustachian tube, which runs from the middle ear to the nose and upper throat. The Eustachian tubes in all children are shorter and smaller than in adults and therefore more vulnerable to obstruction.
  • Changes in middle ear pressure occur in about two thirds of children with colds, which are typically the first stage in ear infections. Colds are caused by viruses, such as the rhinovirus. Viruses are increasingly viewed as important in many ear infections, although they usually only set the scene for a bacterial infection.
  • Many bacteria normally thrive in the passages of the nose and throat. Most are benign and some can even block harmful bacteria from getting out of control. In addition, a defense system in the airways prevents the harmful bacteria from replicating and infecting deeper passages, such as those in the ear. Such defenses include a mucus layer that traps bacteria and cilia (hair-like structures) that move them out.
  • When a cold occurs, the virus can cause the membranes along the walls of the inner passages to become inflamed, swell, and obstruct the airways. If this inflammation blocks the narrow Eustachian tube so that it cannot drain the middle ear properly, fluid builds up. The defense systems become inefficient, and the fluid becomes a reservoir and breeding ground for bacteria and subsequent infection.

Of note: respiratory viruses may also contribute directly to the infection. Allergens can also produce inflammation and blockage in the Eustachian tube, which creates an environment favorable to bacteria.

Infecting Agents and Triggers

Bacteria. Certain bacteria are the primary causes of acute otitis media (AOM) and are detected in about 60% of cases. The bacteria most commonly causing ear infections are:

  • Streptococcus pneumoniae (also called S. pneumoniae or pneumococcus) is the most common bacterial cause of acute otitis media, causing about 40% to 80% of cases in the US.
  • Haemophilus influenzae is the next most common culprit and is responsible for 20% to 30% of acute infections.
  • Moraxella catarrhalis is also a common infectious agent, responsible for 10% to 20% of infections.
  • Less common bacteria are Streptococcus pyogenes and Staphylococcus aureus.

Of note, about 15% of these bacteria are now believed to be resistant to the first-choice antibiotics.

Viruses. Rhinovirus, a cause of the common cold, is commonly the first player in the process leading to ear infection. It is not the direct infecting agent, however. However other viruses, such as respiratory syncytial virus (RSV -- a common virus in children responsible for respiratory infections) and influenza viruses (Flu), may be actual causes of some ear infections. Evidence is increasing that such viruses may play a greater role than previously believed for either predisposing or even causing ear infections. (Such evidence rests on the significantly lower rates of ear infections in children who have been vaccinated against influenza.)

Allergies. Allergies can cause inflammation in the airways, and contribute to ear infections.

Inborn Conditions that Predispose a Child to Middle Ear Infections

Genetic Factors. Several studies suggest that multiple genetic factors may play a role in making a child susceptible to acute otitis media.

  • Genetic susceptibility to certain bacteria may result in development of persistent and recurrent acute otitis media.
  • Abnormalities in genes that affect the defense systems (cilia and mucus production) and the anatomy of the skull and passages would also increase the risk for ear infections.
  • Abnormalities in genes that regulate a powerful immune factor called interleukin 1 have been identified in some patients with recurrent acute otitis media who did not have any allergic disorders. Interleukin 1 plays a major role in producing inflammation in tissues and cells during heightened immune activity. Abnormalities in interleukin production may possibly result in a persistent inflammatory response.

Researchers are hoping that these findings may encourage primary care physicians to closely monitor children who are offspring or siblings of individuals with a history of unusually frequent or severe upper respiratory tract infections.

Medical or Physical Conditions that Affect the Middle Ear. Any medical or physical condition that reduces the ear's defense system can increase the risk for ear infections. Children with shorter-than-normal and relatively horizontal Eustachian tubes are at particular risk for both initial and recurrent infections. Other examples include inborn structural abnormalities, such as cleft palate, or genetic conditions, such as Kartagener's syndrome, in which the cilia (hair-like structures) in the ear are immobile and cause fluid build up.

Causes of Otitis Media with Effusion (OME)

OME may occur spontaneously following an episode of acute otitis media (AOM). Susceptibility to OME may also be due to an abnormal or malfunctioning Eustachian tube that causes a negative pressure in the middle ear, which, in turn, allows fluid to leak in through capillaries. Problems in the Eustachian tube can be due to viral infections, second-hand smoke, injury, birth defects, such as cleft palate, or genetic diseases that affect the defense systems, such as Kartagener's syndrome.

Causes of Increase in Incidence of Ear Infections and Other Airway Infections and Disorders

Increased diagnosis of other disorders and infections of the upper and lower airways, such as asthma, allergies, and sinusitis, have paralleled the rise in ear infections. For example, the same bacteria are often responsible for both ear infections and sinusitis. In one study, 38% of children with ear infections also had sinusitis, and other studies have reported that nearly half of children with OME have concurrent sinusitis. These studies may have overestimated the extent of clinically important sinus disease, but nonetheless, the association is significant but causal relationships are unclear. Researchers are looking for common risk factors:

  • Increase in Day Care Center Attendance. Although ear infections themselves are not contagious, the respiratory infections that precipitate them can pose a risk for children with close and frequent exposure to other children. Some experts believe, then, that the increase in ear and other infections may be due to the higher attendance of very small children, including infants, in day care centers beginning in the 1970s. For children who had the condition for a long time, however, neither day care attendance nor any other risk factor, including a history of upper respiratory tract infections or family history of OME, appeared to be relevant. Attendance in day care centers, then, may explain part, but not all, of the current increase in ear infections and other upper airway disorders.
  • Increase in Allergies. Some experts believe that the increase in allergies is also partially responsible for the higher number of ear infections, which is unlikely to be related to day care attendance. Studies indicate that 40% to 50% of children over three years old who have chronic otitis media also have allergic rhinitis (hay fever). Allergies are also associated with asthma and sinusitis.

The rise in the rate of acute otitis media, then, is probably due to a combination of factors that are also responsible for the increase in these other airway problems.


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