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Chronic Middle Ear Infection in Children

(Chronic Otitis Media)

By Udayan K. Shah, MD, Professor;Chief, Division of Otolaryngology, Sidney Kimmel Medical College at Thomas Jefferson University;Nemours/A.I. duPont Hospital for Children

Chronic middle ear infection results from recurring infections that damage the eardrum or lead to formation of a cholesteatoma, which in turn promotes more infection.

  • Chronic middle ear infections can be caused by acute middle ear infections, blockage of the eustachian tube, injuries, burns, or placement of tubes through the eardrum.

  • Children usually have hearing loss and ear discharge.

  • A doctor diagnoses chronic middle ear infection based on examination findings.

  • Treatment usually includes antibiotic drops and sometimes antibiotics taken by mouth, insertion of ear tubes, or both.

A Look Inside the Ear

Causes

Chronic middle ear infections can be caused by an acute middle ear infection (usually several), blockage of the eustachian tube (the tube that connects the middle ear with the nasal passages), crushing or penetrating injuries to the ear, thermal or chemical burns, or blast injuries. Additionally, children who have head and face abnormalities resulting from chromosomal disorders, such as Down syndrome or cri du chat syndrome, or who have a cleft palate have an increased risk of chronic middle ear infections.

Chronic middle ear infections may flare up after an infection of the nose and throat, such as the common cold, or after water enters the middle ear while bathing or swimming in children who have a perforated eardrum or tubes. Usually, flare-ups result in a painless discharge of pus from the ear (see Ear Discharge). The pus may have a very foul smell.

Complications

Persistent flare-ups may cause

  • Polyps of the middle ear

  • Destruction of bones in the middle ear

  • Cholesteatoma

Polyps are noncancerous (benign), smooth growths that protrude from the middle ear through the perforation and into the ear canal.

Persistent infection can destroy parts of the small bones in the middle ear that connect the eardrum to the inner ear and conduct sounds from the outer ear to the inner ear (the ossicles), causing hearing loss.

A cholesteatoma is a noncancerous (benign) growth of white skinlike material in the middle ear. A cholesteatoma can destroy nearby bone and soft tissue and can eventually cause complications such as facial paralysis and abscesses in the brain or between the brain and the skull.

Symptoms

Children usually have hearing loss and ear discharge. There is usually no pain unless a complication has occurred. Children who have a cholesteatoma may also have white debris in the ear canal.

Diagnosis

  • A doctor’s examination

  • Cultures

  • Sometimes imaging

A doctor diagnoses chronic middle ear infection based on examination findings (for example, when pus drains out of a hole in the eardrum or skinlike material accumulates in the hole or in a pocket in the eardrum). Samples of the pus are sent to a laboratory where bacteria can be grown (cultured).

If a doctor suspects a cholesteatoma or a complication, imaging studies such as computed tomography (CT) or magnetic resonance imaging (MRI) are done.

Treatment

  • Antibiotic ear drops

  • Sometimes antibiotics taken by mouth

  • Sometimes myringotomy

  • Surgical removal of any cholesteatoma

Doctors may first clean all the debris from the ear. Parents apply ear drops containing an antibiotic and possibly a corticosteroid. Children who have a severe infection are given antibiotics taken by mouth.

If infection lasts or comes back despite the use of antibiotics, doctors may, after a period of time, do a myringotomy with insertion of ventilating (tympanostomy) tubes. If the eardrum is damaged, surgery to repair the eardrum (tympanoplasty) may be done.

A cholesteatoma is removed surgically.

Myringotomy: Treating Recurring Ear Infections

During a myringotomy, doctors make a small opening in the eardrum to allow fluid to drain from the middle ear. Then they place a tiny, hollow plastic or metal tube (tympanostomy tube, or ventilating tube) in the eardrum through the opening. These tubes balance the pressure in the environment with that in the middle ear. Doctors recommend ventilating tubes for some children who have had recurring ear infections (acute otitis media) or recurring or persistent collections of fluid in their middle ears (chronic secretory otitis media).

Placement of ventilating tubes is a common surgical procedure that is done in a hospital or doctor’s office. General anesthesia or sedation is usually required. After the procedure, children usually go home within a few hours. Antibiotic ear drops are sometimes given after the procedure for about a week. The tubes usually come out on their own after about 6 to 12 months, but some types stay in longer. Tubes that do not come out on their own are removed by the doctor, sometimes under general anesthesia or sedation. If the opening does not close on its own, it may need to be closed surgically.

Children with ventilating tubes may wash their hair and go swimming, but some doctors recommend children do not submerge their head in deep water without using earplugs.

Drainage of fluid from the ears indicates an infection, and the doctor should be notified.

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