Middle Ear Infection: Causes and Symptoms

Inflammation of the middle ear is medically referred to as otitis media. Otitis, or inflammation of the ear, belongs mainly to the care of the ENT doctor, oto-rhino- laryngologist, popularly also a throat doctor.

However, it is often with this disease that a general practitioner comes into contact, whether for adults or children.

The fact is that inflammatory disease of the middle ear occurs most often in childhood. It is reported that up to 60% of children are affected by inflammation at least once. The highest incidence is before the age of 5. It is less common in adulthood.  

This type of otitis is a common complication of upper respiratory tract infection. Mainly as a consequence of pharyngitis, nasopharyngitis, influenza and rhinitis. The consequence is the anatomical placement of the auditory, or Eustachian tube.

The causative agent is a primary viral infection. A viral cause is reported in approximately 25%. Subsequently, bacterial infection is problematic. The latter can occur already during the viral illness, but also after it has subsided. 

FAQs: 
Why does middle ear infection occur and how does it manifest itself in children or adults?
What is chronic inflammation and what triggers it?
Do home remedies help? 

Categorisation of otitis media

Otitis media is divided according to its course into acute, subacute and chronic. While the acute form occurs suddenly, the subacute form persists for more than 2 months. Chronic inflammation is characterized by damage to the eardrum, secretion (discharge) and hearing impairment, lasting for three months or more.

Subsequently, recurrent otitis media, a recurrent infection that recurs 3 or more times over a six-month period, is also known to occur. Abbreviated designations for these forms of inflammation can also be found in various sources, namely:

• OMA - otitis media acuta, i.e. acute otitis media
• OMR - otitis media recidivans, i.e. recurrent otitis media
• OMS - otitis media secretorica, the secretory form
  • OMC, i.e. otitis media chronica - the chronic form

Another method divides otitis according to whether it is purulent or non-purulent. Subsequently, inflammation is divided according to which part it affects. That is, as tubotympanic inflammation, mesotitis or catarrhal inflammation of the auditory tube.

The middle ear at a glance

The middle ear is a cavity that is filled with air. It houses the three auditory ossicles, namely the hammer, the anvil and the stirrup. These ossicles are used to transmit sound waves from the eardrum to the inner ear. The eardrum separates the middle ear from the outer ear.

The middle consists of:

• the drum or the tympanum
• the middle ear cavity itself, the tympanic cavity
• the auditory, or Eustachian tube, connects the nasopharynx and middle ear cavity
• system of cavities 

Why does otitis occur more often in children?

Most commonly, otitis media occurs in children under 5 years of age. It is also interesting to note that up to 2 thirds of children under 2 years of age will develop otitis media. This is due to the fact that in children the auditory tube is shorter in length and thicker.

This anatomical distribution facilitates the penetration of infection into the middle ear cavity. As a result, it is children of preschool and school age who are more often affected by inflammation. In acute inflammation, the inflammation is often bilateral and very painful. 

Although otitis media is a rather unpleasant disease, it is not dangerous. With early treatment, therapy is not difficult and the inflammation can be easily cured. The opposite is complications, which can be serious, especially if treatment is neglected.

The cause of otitis media is infection with a virus or bacteria. Viral inflammation is usually the initial one, followed by bacterial superinfection. The most common origin is upper respiratory tract inflammation. In which there is a complication and thus a passage of the infection through the auditory tube.

Read also the article on rhinitis.

The auditory tube in infants or toddlers is shorter. This predisposes to faster transmission of infection from the upper respiratory to the middle ear cavity. Therefore, up to 2/3 of children will overcome this disease by the age of three.

Maximum infections are up to five years. Subsequently, in adulthood, the frequency decreases. The incidence of the disease is throughout the year. However, from autumn to spring infection occurs more often than in the summer months. 

The development of the disease is influenced by factors such as:

• age up to 5 years.
• anatomical factors, length and width in young children.
• impaired patency of the nasal cavity (enlarged nasal tonsils).
• impaired ventilation and drainage function, i.e. Eustachian tube dysfunction.
• upper respiratory tract disease.
• other diseases such as Down's syndrome, cleft palate.
• damage to the eardrum, e.g. also when injured by a pressure wave or mechanically.
• immunity of the individual.
• the type of invoker.
• method of treatment, neglected or inadequate treatment.
• collective environment (kindergarten).
• allergies, such as hay fever.
• smoking, especially passive smoking.
• genetic factor, and familial predisposition.
• the use of a baby pacifier (all day long).
• drinking milk from a bottle in a supine position, leakage of milk into the auditory tube.
• cold weather and the winter season.

The gateway for the entry of the disease is mainly the auditory tube, and therefore the upper respiratory tract.

Others include, for example:

• outer sonically and damaged eardrum.
• blood, such as measles or scarlet fever.
• through the ear labyrinth, in intracranial infections.

Table: the most common causative agents of otitis media

Chronic inflammation often afflicts people with weakened immunity, cleft defects or young children who often have a full nose due to a runny nose. Sometimes inflammation can also be related to other diseases.

However, it more often arises as a complication after a rhinitis and other upper respiratory tract infection.

With otitis media, it is interesting that the symptoms differ depending on whether the disease is acute or chronic. The symptomatology of acute infection occurs after an incubation period, which is usually 4-7 days after the upper respiratory tract inflammation.

Acute inflammation is characterized by a rapid onset of discomfort. First of all, ear pain occurs, followed by fever, discharge from the ear, which in most cases in bacterial infection is purulent. The person has a sensation of pressure in the ear and throbbing pain, which constantly returns, in each ear differently intense.

Acute inflammation is usually bilateral. In chronic inflammation, the pain is not as intense. In the case of long-term otitis media, there are difficulties such as discharge from the ear, damage to the eardrum, hearing impairment.

A person does not need to have an elevated temperature or fever. In particular, he or she may feel lying down, pressure or crackling in the ear. There may also be burning or itching in the ear. With chronic inflammation, hearing loss and hearing impairment are typical. Headache may occur. 

Table: the main symptoms in otitis media

The problem may be the low age of the child. In young children who cannot yet talk, name and describe pain, it is necessary to note the overall manifestations. Such as mainly tearfulness, restlessness, nervousness or sleep disturbance. Pain can be aggravated especially when blowing the nose, but also when swallowing.

Similarly, the pain is exacerbated when coughing and sneezing.

Generally the intensity of pain fluctuates throughout the day. Even in the case of otitis media, it worsens mainly at night. Subsequently, the pain also shoots into the surroundings. The pain is also aggravated by pressure on the mastoid process (Latin: processus mastoideus), which is part of the temporal, more precisely, the temporal bone.

In the elderly, otitis media can be asymptomatic. Alternatively, there may be only mild symptoms, such as hearing impairment or a pinching in the ears. Of course, even in this case, it is not a good idea to neglect the disease and not treat it.

For the diagnosis of the disease, the person's medical history and clinical course are important. However, it is important to distinguish otitis media from other diseases. Discharge from the ear is also present in otitis externa.

However, the most important way to check the condition is visual examination using an ear mirror. This examination, medically called an otoscopy, is performed by an ENT doctor. Most often, changes in the eardrum are visible, such as redness, increased blood supply, bulging, thickening. Secretion is present after a violation of the eardrum.

Subsequently, hearing tests, or audiological tests, can be performed. Basic tests that can also be carried out by a GP for adults or children include a blood test and CRP. An elevated white blood cell count will also confirm the presence of inflammation.

Alternatively, a swab test of ear discharge is selected.  

The course of the disease can be individual. It also depends on whether it is an acute or chronic form of the disease. The acute form is characterized by a rapid course, practically in a few hours, most often at night and usually as a complication of upper respiratory tract disease.

The course of acute disease is typically in 4 stages

Inflammation of the middle ear in older age proceeds mildly. Often, only lying in the ear or hearing impairment is present. However, this is not a reason re downplaying and neglecting treatment. Of course, treatment is also important to avoid complications.

The chronic form of inflammation is characterized by a slower onset, the absence of temperatures. It lasts approximately 3 months. Typically, it is accompanied by a perforation of the eardrum, prolonged discharge and hearing impairment. The discharge is mucoid, purulent, may smell. In the ear, a murmur is heard, a sensation of shedding fluid.

TIP: article on influenza in childhood and influenza in pregnancy.

Watch out for complications of otitis media

The risk of complications is mainly due to inadequate or no, but also inappropriate treatment of inflammation. A relatively common complication is inflammation of the gluteal process, i.e. acute mastoiditis. A pus-filled cavity develops. This complication is very serious.

Complications of otitis media include:

• mastoiditis
• facial nerve paresis, VII cranial nerve, i.e. nervus facialis
• meningitis
• hearing impairment, hearing loss
• chronic middle ear infection
• recurrent middle ear infection
• chronic middle ear discharge
• changes, damage, necrosis of the eardrum
• cerebral abscess

Prevention of middle ear inflammation is important

How should prevention take place? Measures are aimed at preventing the development of inflammation or its complications. Important measures include:

• limiting the contact of young children with the mass of people at risk periods.
• keep a child with upper respiratory tract infection or flu at home.
• removal of the cause such as in the case of enlarged nasopharyngeal tonsils, tonsillar tonsils.
• monitoring of children with a predisposition to the development of otitis media, with weakened immunity.
• preventing relapse, i.e. the return of the disease.
• vaccination against influenza, Streptococcus pneumoniae, Hemophilus influenzae B.
• immunity support.
• nutritional supplements in the seasonal period.
• a healthy and balanced diet, plenty of vitamins, minerals and fibre.
• sufficient exercise, exercise in nature.
• limiting smoking and children's exercise in smoky environments.
• limiting the use of pacifiers.
• attention to feeding infants on their backs, milk leakage into the auditory tube.
• increased position of the upper half of the body in sleep.
• protection of ears from draughts, wind, cold.
• sufficient hygiene and hand washing.
• cleaning the nasal cavity and maintaining its patency.
  • proper cleaning of the child's nose (not both nostrils at once), not with high pressure.
  • suctioning phlegm to young children.
  • nose drops.