Ear Infection

Symptoms

What causes ear infections?

Bacteria cause the vast majority of ear infections. But they are also, less commonly, caused by viruses and fungi.

In the middle ear, inflammation or blockage of the eustachian tube, which normally equalizes pressure, can lead to an accumulation of fluid that creates a favorable environment for bacterial growth. This is often due to upper respiratory infections and seasonal allergies, but can also be the result of a physical blockage from an external mass.

External ear infections, on the other hand, stem from a microscopic trauma to the ear canal tissue combined with either a favorable environment for bacterial growth or direct exposure to bacteria. The micro-trauma can result from direct injury by foreign objects—such as a Q-tip or fingernail-excessive exposure to water, or skin conditions like eczema.

What are common symptoms?

Ear pain is the most common symptom of both otitis media and otitis externa. Other symptoms include decreased hearing and a watery or yellow drainage.

How are ear infections diagnosed?

A middle ear infection is diagnosed by inspecting the tympanic membrane with an otoscope. Typical findings include a bulging tympanic membrane—red or opacified—and either fluid behind the eardrum or decreased tympanic mobility measured by pneumoscopy. A perforated tympanic membrane with or without purulent (pus-filled) fluid drainage is also an indicator.

Diagnosing an external ear infection relies on a history of rapid onset of symptoms along with pain, swelling, or redness of the ear canal. This may or may not include drainage, hearing loss, and swollen lymph nodes.

What are other common causes of ear symptoms that are not an ear infection?

Shingles (herpes zoster) can cause ear pain for days prior to the appearance of the typical rash around the ear.

Conditions involving the nasopharynx (pharyngitis, eustachian tube dysfunction, etc.) can manifest as ear pain in the absence of other signs of ear infection. Recurrent or chronic ear pain with milder signs of infection should be promptly investigated for fungal causes.

Medical Treatment

What’s the best treatment?

Oral antibiotics are the mainstay for middle ear infections in adults to speed recovery and decrease the risk of complications.

Most cases of external ear infections can be treated solely with topical antibiotic preparations with or without added glucocorticoids (anti-inflammatories). More severe cases, however, require both topical and oral antibiotic treatment.

Are antibiotics always necessary?

Although studies suggest watchful waiting in certain cases of children with acute middle ear infections, no research supports the same approach for this type of infection in adults. In milder cases of external ear infection, antibiotics can be avoided, instead using topical acidifying agents (acetic acid, alcohol) with or without glucocorticoids.

What are the risks of not treating an ear infection?

Treating an ear infection with antibiotics not only decreases the discomfort, but also prevents the infection from spreading to and involving structures outside the middle ear and ear canal.

Middle ear infections, for example, can spread to the mastoid bone (behind the ear) and affect the semicircular canals. This can cause vertigo and hearing deficits—as well as affect the facial nerve, leading to facial paralysis.

Untreated infections of the ear canal can lead to malignant otitis media—a rare complication, more common in the elderly and immunocompromised, where the ear infection spreads to the skull and can lead to damage of the cranial nerves, the brain and, in some cases, death.

What are Ear Tubes and when are they used?

On rare occasions when fluid or air pressure in the middle ear space does not drain naturally or equilibrate, an individual becomes a candidate for a procedure called a “myringotomy.” In these cases, the surgeon makes a small opening in the eardrum to allow the fluid to drain or the air pressure to equilibrate.

A tube (tympanostomy tube) can then be placed in this opening to delay the healing of the opening and allow more time for the middle are space to drain. In most instances, however, the tube will fall out and the opening will heal.

Lifestyle Considerations

Does water (swimming/showers) make infections worse?

You should always avoid water in the case of a middle ear infection with a perforated tympanic membrane (eardrum) or if you have an external ear infection.

A perforated tympanic membrane can allow water to enter the middle ear, irritating the mucosal lining and possibly introducing bacteria to the middle ear space.

As for external ear infections, water can dilute or eliminate any topical antibiotic, increase the pH of the canal to favor bacterial growth, and also introduce new bacteria to already injured tissue.

Is it dangerous to fly or travel to higher altitudes when you have an infection?

Frequently, eustachian tube dysfunction, which can be asymptomatic, precedes a middle ear infection. Since the eustachian tube equilibrates the pressure within the middle ear during a flight, changes in cabin pressure can distend or retract an already inflamed and tender tympanic membrane. Most medical experts suggest delaying flying for two weeks, if possible, to allow for the infection and associated eustachian tube dysfunction to resolve.  

Are ear infections contagious?

Ear infections caused by viruses—most commonly seen in children—can be contagious. Bacterial ear infections are not typically thought of as being contagious.  

Do drops or wicking work?

In cases of severe external ear infections, where the swelling of the ear canal will not allow for the penetration of antibiotic drops, a wick (small sponge) is inserted into the canal to assure penetration of the medicine. The wick will, typically, fall out by itself as the swelling resolves or it can be removed by the medical provider at follow-up.

Home remedies such as homeopathic drops should be used with extreme caution, especially when there is not a clear diagnosis. The drops may not be sterile, which can introduce more bacteria into the ear. In addition, some drops can increase the pH of the ear canal, encouraging bacterial growth.

Moreover, because middle ear infections can perforate the tympanic membrane, it’s possible for drops to enter the middle ear space and affect the delicate tissues. Therefore, as a general rule, you should avoid putting anything in the ear, natural or not, without first being evaluated by a healthcare provider.

Prevention

What can people do to avoid getting infections?

There are no proven strategies to decrease the risk for middle ear infections other than minimizing exposure to associated viruses and proper hand washing. Those who have recurrent middle ear infections should consult an otolaryngologist to evaluate any possible underlying predisposing issues.

External ear infections, on the other hand, can be avoided by decreasing prolonged exposure to moisture, as well as by keeping foreign objects out of the ear canal.

People who frequently have water in their ears—such as swimmers or lifeguards—should regularly dry their ear canals with acidifying or alcohol drops or with a blow dryer 12 inches away from the ear set at low power.

Q-tips or other objects should never be used in the ear canal because they can damage delicate skin and allow bacteria to penetrate.

If an individual suffers from a chronically itchy ear, they should consult a medical provider to determine if they have a dermatologic condition, such as eczema or a fungal infection.

Chronic use of ear plugs can also predispose someone to external ear infections by causing microabrasions and over-accumulation of wax and other debris within the ear.

Useful Links

Information about otitis externa (American Family Physician)

The role of an ear wick in treating external ear infections (Medscape)

Air travel recommendations for those with otitis media (American Family Physician)

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