Middle Ear Infections

Before I started specialising I worked in a family medicine practice and saw mostly children. When the complaints were “fever, crying, runny nose, lack of appetite” I was almost relieved when I saw a red eardrum because I had something to blame for the symptoms that I could treat! But is it always necessary to treat ear infection with antibiotics? And when should your child get grommets?

Otitis media (middle ear infection) is a viral or bacterial infection of the space behind the eardrum (also called the tympanic membrane). This space contains the little bones that need to vibrate to transfer soundwaves from the eardrum to the inner ear where the soundwaves are changed to impulses that the brain can understand as sound. The pressure in this space needs to be balanced with the pressure in the outer ear channel. This is done via the eustachian tube (a tube connecting the middle ear space with the back of your nose/throat). That is why you can “pop” your ears when yawning/chewing when the pressure changes in an airplane. If the eustachian tube is blocked / swollen (often due to colds/flu) the pressure in the middle ear space drops and this causes pain and a collection of fluid in the space. This fluid is the perfect breeding ground for viruses/bacteria to flourish.

Studies show that 50% of children had a middle ear infection by the age of 1 year, and 80% by 3yrs! The eustachian tube is shorter, narrower and is positioned more horizontally in children, allowing the secretions of the nose/throat to run into the middle ear or to block the eustachian tube.

Other risk factors for otitis media:

  • Attending creche / school (higher exposure to viruses and bacteria)
  • Drinking from bottles while lying on back (due to positioning of eustachian tube)
  • Exposure to smoke (paralyses the fine hair-cells that help to expel secretions from the tube)
  • Allergic rhinitis (increased secretions and inflammation in the nose)

Symptoms of Acute Otits Media:

  • Fever
  • Ear pain
  • Irritability, lack of appetite, nausea, vomiting
  • Fluid draining from the ear
  • Acute loss of hearing (this is due to the eardrum bulging due to the fluid in the middle ear space, preventing it from vibrating)
  • Your doctor might see a red, bulging eardrum, fluid behind the eardrum or even a perforation in the eardrum when looking in the ear with an otoscope.


In babies below 6months your doctor will probably start antibiotics immediately due to the higher risk of bacterial infections in babies. If both ears are affected, or your child is very ill, antibiotics will also be started as these signs are associated more with bacterial infections.

If your child does not fall into one of these categories, it is important to remember that most ear infections are caused by viruses, and antibiotics are not always necessary. Without antibiotic treatment, symptoms improve in 24 hours in 60% of children, and symptoms settle spontaneously within 3 days in 80% of children.

Your child can thus be treated for up to 48hours with anti-inflammatory and pain medication to see if the symptoms will improve. Anti-inflammatory medication will help to decrease the swelling in the eustachian tube, causing drainage of the fluid and normalising of the pressures.  If your child still has fever and pain after 48hours, or if any of the symptoms become worse, antibiotics should be started.

Complications (can happen with and without antibiotic treatment)

  • Perforation of the eardrum (this is not painful, most children feel better after the perforation due to release of the pressure in the middle ear. The eardrum usually heals again within hours to days, but might leave some scarring on the eardrum).
  • Hearing loss due to the fluid behind the ear drum.
  • Glue ear (otitis media with effusion). This is when the infection has cleared up, but the fluid (effusion) remains in the middle ear space, still causing symptoms. Most effusions clear up spontaneously within 3months, if not, your child may need grommets. If your child has any other risk factors for delayed speech or hearing loss, the grommets might need to be inserted earlier.
  • Chronic suppurative otitis media – there is a discharge from the ear for more than 6 weeks. Local antibiotics and cleaning of the external ear channel will be necessary.
  • Acute mastoiditis. This is an emergency! It means that the infection in the middle ear has spread into the bone surrounding the middle ear. Your child will develop redness and tenderness behind the ear, with swelling of the ear lobe. Intravenous antibiotics +- surgery will be necessary to clear it up.


Avoiding exposure to tobacco smoke, breastfeeding, immunizations against Streptococcus pneumonia and Haemophilus influenza, and the surgical placement of grommets could prevent recurrent episodes of otitis media. Recurrent ear infections are defined as more than 3 episodes in 6 months or more than 4 infections in 12months.


Grommets are very small silicone or metal tubes that are inserted into your child’s eardrum after making a small incision into the eardrum. They allow the fluid to drain out of the middle ear space and let air into the middle ear, equalizing the pressure. This allows the hearing to return to normal soon after the grommets are inserted. As the incision in the eardrum heals, it pushes the grommet out, and most tubes will “fall out” after 6-12 months.

Grommets should be considered in children with recurrent otitis media as classified above, or with children with otitis media with effusion (glue ear) that does not clear in 3months. It is a temporary measure to help prevent recurrent ear infections until your child’s eustachian tubes mature. In 30-50% of children who need grommets once, they will need to be reinserted to “buy more time”.

I must admit that I used to give antibiotics to all children with otitis media. In Belgium they have much stricter guidelines for antibiotic use, and I saw first-hand how well the children with middle ear infection do on only analgesia and anti-inflammatory medication. I have even applied my new knowledge on Eran, and he also improved within 48hrs! I hope this information can help you too when your child has their next ear infection!


  • Venekamp RP, Damoiseaux RAMJ, Schilder AGM; “Acute Otitis Media in children”; BMJ Clin Evid. 2014; 2014: 0301.
  • Gaddey HL, Wright MT, Nelson TN; “Otitis Media: Rapid Evidence Review”; Am Fam Physician. 2019 Sep 15;100(6):350-356.
  • http://www.uptodate.com

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