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What’s Up With Ear Infections and Antibiotics

ear infection viral or bacterial

It’s cold and flu season is here and I’m already hearing that familiar refrain in my office: “I wanted to bring him in just to make sure he didn’t have an ear infection.” Ah yes, the dreaded ear infection.

Ear infections are no fun if you’re an adult, and many of us remember the pain we experienced when we had one as a child. As a result Ear pain is one of the most common concerns that parents have. If you had an ear infection as a child you remember how painful and uncomfortable it was. Parents often bring their children in to be checked for an ear infection if they’re waking at night, pulling on their ears, coughing, having a fever or actually complaining of ear pain.

The good news is that the vast majority of the time, kids and babies who are pulling on their ears but who are not otherwise sick, do not have an infection.  This is usually true even if the child has recently had a cold.

But when kids do get an ear infection, it hurts! So what are parents supposed to do if they suspect their child has an ear infection? It’s time to talk about all things ear infections with resident ear nose and throat doctor, Dr. Matthew Brigger.

What is an ear infection actually?
There are lots of issues that can affect the ears, especially when a child has a cold, flu or other illness. Many of these illnesses can mimic the symptoms of an ear infection, which leaves many parents frustrated when their child is sick, experiencing ear pain and a doctor, like myself or Dr. Brigger, check out their child’s ears and discovers no signs of an infection.

Ear infections are infections similar to a pimple or any other cut or abrasion that gets infected. Dr. Brigger explains that in a true ear infection, “bacteria grows behind the eardrum leading to a collection of pus.” Pus is a thick fluid consisting of dead white blood cells that your immune system sends to fight the infection.  Your ear structure is actually pretty small, and there’s no place for that accumulated pus to go, which causes the “pressure, pain and temporary hearing loss” Dr. Brigger says we’re all familiar with.

With that said, there’s another kind of “ear infection,” one that isn’t caused by bacteria and pus. If an ear infection is caused by a virus there can be inflammation and eardrum pain or have clear fluid behind the eardrum, but the key is the lack of pus behind the eardrum.

Both types of ear infections can cause similar symptoms. Usually for your doctor to consider an ear infection as a differential diagnosis, we look for signs that the child is sick or is suffering from allergies (more on that later). Generally speaking, if your child is sick and experience the following symptoms, they may have an ear infection:

  • Ear pain, especially when lying down (in babies and non-verbal children this can include increased irritability, crying or fussiness);
  • Tugging or pulling at an ear
  • Difficulty sleeping
  • Difficulty hearing or responding to sounds
  • Loss of balance
  • Fever of 100 F (38 C) or higher
  • Drainage of fluid from the ear
  • Headache

Why do kids get ear infections?
We most often see ear infections in kids who are already sick with colds. As an adult, you likely remember how much an ear infection hurt as a child, but you probably haven’t had one as an adult. There’s actually a really good reason for both of these things.

Dr. Brigger explains this has to do with the structure of our ears as we mature. “The space behind the eardrum, also known as the middle ear, is filled with air which comes from the nose. The air is delivered through a small internal connection known as the Eustachian tube.  By having air in the middle ear, our eardrum can vibrate properly.”  That’s how we hear. How our ears developed this way is actually ingenious evolutionarily, but it also leaves them vulnerable to infections.

This ingenious bit of evolution can go haywire when the Eustachian tube is closed off by congestion during a cold, or allergies.  “When the Eustachian tube closes off, the ear can fill with fluid which then becomes infected.  Due to the small size and immature nature of the Eustachian tube in children, they are more likely to get ear infections than adults.”

Unfortunately for children, it can be normal for fluid to persist in the middle ear after an infection or be present during a cold, but this is “non-infected ear fluid which may remain [behind the ear drum] up to several months”.

How are ear infections treated?
Our treatment of ear infections has evolved tremendously. If you had an ear infection as a child in the 70s, 80s or 90s you likely remember being prescribed a liquid antibiotic that tasted like bananas. If your child has had an ear infection in the past few years, you’ve likely noticed that antibiotics for ear infections are no longer our first line of defense.

“Most ear infections are relatively minor and some do not even require antibiotics,” Dr. Brigger says. This is because not all ear infections are caused by bacteria, some are caused by viruses. If the infection is caused by a virus, antibiotics will not help the infection resolve. A bacterial ear infection (the kind we discussed above) is caused when the pus collection causes bulging of the eardrum, as well as signs of inflammation like pain and fever.

Our current guidelines allow for pain control for 24-48 hours prior to starting antibiotics in children over 2 years of age, who do not have a history of ear problems and who are otherwise well.  “In general, antibiotics will lead to resolution of [an] acute [bacterial] infection relatively quickly,” Dr. Brigger says, but he cautions the correct antibiotic needs to be used. In recent years, increasingly more people have experimented with alternative antibiotics or even using fish antibiotics for human dosage, but this is not advisable for infants.

What are the complications of ear infections?
While most ear infections are benign and will resolve on their own, some ear infections can result in complications or can reoccur multiple times. When that happens it’s usually when your pediatrician will call-in an ear nose and throat specialist like Dr. Brigger.

“Untreated ear infections can lead to rupture and scarring of the eardrum.  Occasionally, repeated ear infections can lead to permanent hearing loss,” Dr. Brigger cautions. But that’s not all, “in rare instances, ear infections can lead to more serious bacterial infections, including infection of the skull bones or the brain.  Rarely ear infections can cause damage to the nerve that controls facial movement.”  Those are pretty big, but rare, risks. Therefore, if your child is still having pain or physical signs of an ear infection 24-48 hours after diagnosis, it’s good to follow-up with your pediatrician and see if treatment with antibiotics would be beneficial.

When does a child need ear tubes? (And really, what are ear tubes?)
Some kids have dysfunction of their Eustachian tubes that causes increased pressure in the middle ear even when they aren’t sick with a cold.  That can also lead to an infection and considerable pain. So when should parents consider ear tubes for children with recurrent ear infections?

“Ear tubes should be considered when a child has frequent ear infections. In general, when children have 3 infections in 6 months or 4 infections in a year, ear tubes may be indicated,” Dr. Brigger says. “Ear tubes are also known as pressure equalization tubes and are placed through a surgical procedure that creates a hole in the eardrum to allow fluid to drain but more importantly allows the space behind the eardrum to fill with air and equalize the pressure on both sides of the eardrum. Ear tubes are small approximately 1mm rings with flanges that hold the ring in the eardrum. Ear tubes generally last approximately 8-10 months and then fall out on their own at which point the eardrum generally heals. The small size of the ear tube still allows the eardrum to vibrate and allow normal hearing.”

While having ear tubes placed is considered a surgery, Dr. Brigger says recovery is usually uncomplicated. “Recovery from surgery is generally quite easy with most children resuming their normal routines the following day. Ear tubes do not prevent children from swimming as earplugs are no longer recommended when in the water.”

So in a nutshell, if you are worried about your child’s ears, have him/her checked.  Follow your doctor’s advice and if antibiotics are prescribed, finish the entire prescription.  If your child is getting frequent ear infections, a referral to the Ear, Nose and Throat doctor may be needed.

Author: Dr. Jaime Friedman. A pediatrician in San Diego, CA.

Originally posted at

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