Otitis Media (Middle ear infection)

Otitis Media is second only to the common cold as a cause of illness in young children and is the most common reason for a visit to the family doctor.

More than 80% of young children have at least one infection and 46% will have three infections by three years of age.

Middle ear infection may be mis-diagnosed in infants and toddlers because a brief, lusty burst of indignant crying will cause a normal eardrum to appear inflamed for a few minutes to the examining practitioner.

Often the infection is mild with only slight inflammation of the drum and the child is quite well.

There may be a rapid onset of signs and symptoms, the most common being earache or pulling the ear.  Pain is the most pronounced symptom in older children, whilst younger children may have non-specific symptoms such as irritability and fever.  They may appear fussy and agitated or just be ‘not themselves.’

Other possible presentations of middle ear infection include anorexia, vomiting, diarrhoea and discharge from the ear canal.

The highest incidence of middle ear infection occurs between six months to three years of age. Breast feeding has a protective effect and there is a first peak incidence at cessation of breastfeeding.

A second peak incidence occurs at about four years of age at the start of pre-school.

There is a dramatic increase of incidence of ear infection in children in full-time day care.

One Australian study found that 21% of children in full time day care had ventilation tubes (grommets) in situ compared to 3% of children cared for at home.

Various envirronmental and host-related factors affect the incidence of Otitis Media.

• Boys have a higher incidence than girls.
• There is a higher incidence in Aboriginal and Torres Strait Islander than in other Australian children.  Some of these communities have a 50% incidence of acute and chronic ear infection.
• There is a seasonal increase in winter months with increased incidence of all upper respiratory tract infections.
• Prop feeding when the baby is lying flat and the bottle is propped up on a pillow is associated with increased incidence of ear infection.  As is use of a dummy after ten months of age.
• Exposure to cigarette smoke (passive smoking) has been implicated but not conclusively proven.
• Musculo-skeletal problems such as congenital head and neck abnormalities; occipital, cervical and jaw mal-alignments are associated with an increased incidence of ear infection.
• Poor hygiene, poor nutrition and overcrowding are associated with increased incidence of ear infection

The role of allergy (atopy) in middle ear infection is debated by the medical profession.

One Australian E.N.T. surgeon reports historical or clinical features of atopy in more than 75% of children over the age of five years with recurrent ear infections and glue ear.

Significant resolution of glue ear has been reported following an elimination diet.  The worse offender by far is dairy (38%), followed by wheat (33%), egg white (25%), peanut (20%), and soy (17%).  Response to the elimination of foods may take several weeks.

Middle ear infection and Pharmaceuticals

Otitis media (middle ear infection) accounts for the largest number of antibiotic scripts for children.

The treatment of otitis media varies worldwide.  In some countries, the most common approach is observation, rather than antibiotics and decongestants.  

W.H.O. guidelines recommend a waiting period of forty-eight hours, after which antibiotics may be appropriate for severe persistent pain as the natural history of the disease is marked lessening of pain after twelve to twenty-four hours.

The use of antibiotics in Australia, U.S. and U.K. is highest in the world.  Much higher than in countries such as Holland.  Yet the incidence of complications from ear infections in Holland is no higher despite the lower rate of antibiotic prescribing in that country.

Cochrane data base system review 2000 reported that antibiotic use for acute otitis media varies from 31% in the Netherlands to 98% in the USA and Australia.

The trials showed no reduction in pain at twenty-four hours, but a 28% relative reduction in pain at two to seven days.  Since approximately 80% of patients will have settled spontaneously in this time, this equates to an absolute reduction of only 5%.  In other words, seventeen children must be treated with antibiotics to prevent one child having some pain after two days.

There was no beneficial effect of antibiotics on hearing problems.  Nor did antibiotics influence other complications or recurrence.

The review concluded that antibiotics provide a small benefit for acute otitis media in children.  As most cases will resolve spontaneously, this benefit must be weighed against the possible adverse reactions.

A study in B.M.J. 2001 compared immediate and delayed prescribing of antibiotics.  Immediate prescription provided symptomatic relief only after first twenty-four hours when symptoms were already resolving.  A ‘wait and see’ approach was recommended.

J.Ped 1992 published a study of 271 children aged two months to seven years. It showed that the majority of acute ear infections resolve spontaneously without complications and that there is no evidence to support any antibiotic regime.

A study in B.M.J. 1997 asked ‘Are antibiotics indicated as initial treatment for acute ear infections?’   The results showed that 60% of placebo treated children were pain-free within twenty-four hours and that early use of antibiotics provided only modest benefit at two to seven days when only 14% of placebo group still had pain.
Ped Inf Dis J 1997. This study compared the effectiveness of an antibiotic versus placebo in preventing new episodes of acute otitis media.   The conclusion was that there was no benefit of antibiotic over placebo and that, because of the potential of antibiotics to promote bacterial resistance and lack of effectiveness, routine prophylactic use should be discouraged.

B.M.J 1998. A meta analysis of six clinical trials of antibiotic treatment of acute otitis media showed no long term benefit in outcome or recurrence of infection.  The conclusion was that fewer children should be given antibiotics as the condition could be managed without them.

J Otorhinolaryngol Paed 2002 reported that prophylactic use of Penicillin in young children at the time of an upper respiratory tract infection did not prevent otitis media.

Aus.Fam.Phys. 1998 asked ‘Are antibiotics always appropriate in acute otitis media in children?’ It reported that ‘the evidence suggests that, in Western countries the use of antibiotics as initial treatment for children with acute otitis media benefits one out of twenty children by reducing pain in the acute phase.  There is no evident benefit for deafness, recurrent attacks or complications. This suggests that we should use antibiotics less readily.’

Cochrane database review for 2001 reported that although decongestants and antihistamines are frequently recommended for otitis media, studies do not support their use because of lack of clinical benefit and risk of side-effects.

J Fam Pract 1986 reported that decongestants and antihistamines showed no statistically significant benefit in otitis media in terms of resolution of symptoms or prevention of complications.
JAMA 1991 reported that an antibiotic with or without decongestant or antihistamine is not effective for the treatment of persistent middle ear effusions.

Cochrane data base review 2000 showed that in chronic suppurative otitis media, topical treatment to the ear with antibiotics or antiseptic drops was more effective than systemic antibiotics.   Combining topical and systemic was no more effective than topical alone.

Arch Ped Adol Med 2001 looked at the efficacy of naturopathic extracts in acute otitis media.  This study compared local anaesthetic ear drops with an extract of garlic, mullein, calendula and hypericum in olive oil in one hundred children with earache due to acute otitis media.  The herbal formula was found to be as effective as local anaesthetic.

Several hundred clinical trials later, the advantage of antibiotics remains unproven.  What is clear, however, is that accelerated patterns of bacterial resistance mandate decreased use of antibiotics.  Bacteria have an uncanny ability to learn new mechanisms of resistance and a large part of this ‘education’ of bacteria has undoubtedly been fuelled by unnecessary prescriptions.  Repetitive, prolonged, prophylactic use of antibiotics needs to be avoided.