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Middle Ear Disease in Children

Middle ear disorders in children predominantly present in two forms, or a combination of both. Risk factors for middle ear disorders include attendance in day care, the presence of cigarette smoke in the household pacifier use and the child’s going to bed with a bottle.

The first is middle ear infections, a.k.a., acute otitis media. A middle ear infection occurs when the middle ear space, the part of the ear behind the ear drum, becomes filled with infected fluid or pus. Middle ear infections are frequently preceded by a cold or other upper respiratory infection, and cause the ear drum to bulge and the middle ear to become inflamed. A child with a middle ear infection usually presents with any combination of ear pain, fever, irritability and hearing loss (due to the infected fluid dampening the ear drum’s ability to vibrate). Some may exhibit no signs or symptoms at all. Treatment usually consists of oral antibiotics for 10 days, but watchful waiting with close follow-up is acceptable for mild cases. When middle ear infections become very frequent or resistant to treatment with antibiotics, then surgical management with ventilation tubes may be indicated (see below).

Chronic middle ear fluid (a.k.a. serous otitis media or otitis media with effusion) is the most common cause of reversible hearing loss in children, and is a major cause of early speech delay. Middle ear fluid occurs when the normal ventilation (with air) of the middle ear fails to occur. The middle ear is connected to the back of the nose by the Eustachian tubes, which normally open transiently every time we swallow, allowing a small puff of air to enter and make its way up to the middle ear. This is important, because the air that fills the middle ear is constantly being absorbed into the blood vessels of the lining of the middle ear. Failure to replace the absorbed air creates a vacuum effect, which, in turn pulls fluid out of the middle ear lining into the middle ear space. Young children are most prone to developing middle ear fluid because their head growth is immature, resulting in poor functioning of the Eustachian tubes. Medical treatment of chronic middle ear fluid generally consists of giving the fluid adequate time to resolve itself, and 3 months is widely viewed as an adequate trial period. In children age 3 and older, nasal steroid sprays may be used to reduce nasal congestion and antibiotics may be used at the time of diagnosis and may aid in resolution. Of course, if circumstances dictate, ventilation tubes may be indicated sooner.

Middle ear ventilation tubes, a.k.a. ear tubes or pressure-equalizing (PE) tubes, are tiny plastic or silicone tubes that are inserted into an incision in a patient’s ear drums under an operating microscope. A brief general anesthesia in the form of anesthetic gas via face mask (not requiring an intravenous line or breathing tube) is administered during the procedure. Tubes work by allowing air to directly enter the middle ear from the outside, bypassing the nose and Eustachian tubes entirely. Tubes generally remain in place for a year or more, and most commonly come out of the ear drum by themselves. Regular follow up every 3 to 6 months is recommended to follow the progress of the tubes and the health of the ears. Tubes effectively serve to end the cycle of repeated infection (with infrequent exceptions) and return normal middle ear hearing function by preventing the accumulation of middle ear fluid.