Paediatric Middle Ear (Otitis)

Why the Middle Ear Causes So Many Problems in Children

The middle ear is an air-filled cavity located just behind the eardrum, where the small ossicles (malleus, incus and stapes) sit. For it to work properly, this cavity must be ventilated regularly; the structure responsible for ventilation is a thin channel called the Eustachian tube, which connects the middle ear to the back of the nasal passage. During swallowing, yawning and chewing, this tube opens briefly, refreshing the pressure and air in the middle ear.

In childhood this system is not yet fully mature. Compared with an adult, the Eustachian tube is shorter, narrower and more horizontal. When these three anatomical features come together, two consequences follow: first, microbes from the nasopharyngeal region are carried easily into the middle ear; and second, fluid that collects in the middle ear during or after an upper respiratory tract infection cannot drain away. For this reason, middle ear infection is the most commonly diagnosed ENT problem of childhood.

An important distinction applies here: “middle ear infection” is not a single condition but the shared name for at least two separate clinical situations. Acute otitis media (AOM) is a bacterial/viral infection of sudden onset, accompanied by fever and severe earache. Otitis media with effusion, or simply middle ear fluid, is the build-up of fluid in the middle ear without infection; this situation is silent, and its only sign is often a reduction in hearing. The two conditions may follow one another, and their treatment approaches differ.

In paediatric ENT, an important part of the middle ear assessment is correctly identifying which condition the child has and measuring the true impact through hearing.

Through the Parent’s Eyes: Symptoms and the Silent Picture

Acute middle ear infection is not silent; it rarely presents without signs. There is usually a typical history:

• Sudden-onset earache following an upper respiratory tract infection of a few days (runny nose, cough)
• High fever (especially 39 degrees and above in young children)
• In infants, pulling at the ear, constant crying, restlessness, shaking the head from side to side
• Reduced feeding; the infant may not want to feed because the change in pressure during sucking increases the pain
• Disturbed sleep; the pain increases especially in the lying position
• Sometimes discharge from the ear (drainage through a small perforation in the eardrum — this often relieves the pain and heals without leaving a scar)
• Temporary balance disturbance, unsteadiness

The effusion picture, by contrast, progresses silently. The child has no pain, no fever and frequently no complaint at all. The signs are only the hearing-related cues that an attentive parent might notice:

• Turning up the volume of the television, raising it again when asked to lower it
• Not turning when called, a sense of “not hearing”
• Frequently asking “what did you say?” during conversation
• Losing concentration in class, missing what the teacher says
• A pause or regression in speech development (especially ages 2–4)
• Speaking loudly, being unable to regulate one’s voice

The most critical distinction is that the acute picture is noisy and the effusion is silent. Even after an acute attack has resolved and the child’s fever and pain have passed, fluid can remain in the middle ear for weeks; during this period the child may appear “recovered” while hearing loss persists.

Causes and Risk Factors

• Child anatomy: The short, narrow and horizontal structure of the Eustachian tube is the principal structural cause of middle ear problems in childhood.
• Enlarged adenoid: The opening of the Eustachian tube into the nose is at the level of the adenoid; an enlarged adenoid can mechanically obstruct this opening.
• Upper respiratory tract infections: Every cold or sore throat is a period of risk for the middle ear.
• Nursery/daycare period: Intense contact with other children increases the frequency of upper respiratory tract infections; middle ear problems increase in parallel.
• Allergy: Allergic rhinitis contributes indirectly through adenoid enlargement and Eustachian tube dysfunction.
• Passive smoke exposure: This is a preventable risk factor that markedly increases the frequency of middle ear fluid.
• Bottle-feeding in the lying position: This increases the risk of milk or fluid passing into the middle ear via the Eustachian tube; for this reason, it is recommended that infants be given the bottle in a semi-upright position.
• Family history: A history of a similar condition in a parent increases the tendency in the child.
• Cleft palate and certain craniofacial syndromes: Special groups that structurally affect Eustachian tube function.

The Diagnostic Process

Middle ear assessment is carried out with a straightforward examination in experienced hands.

1. History: When the complaint began, history of upper respiratory tract infection, the number of previous attacks, and treatments used.
2. Otoscopic examination: The colour, mobility and bulging of the eardrum, and whether there is a fluid/air level behind it, are assessed. In the acute picture the eardrum is red and bulging outward; in effusion a dull, matt appearance with a visible fluid/air boundary inside is typical.
3. Tympanometry: A painless test lasting a few seconds that shows the movement of the eardrum as a graph. It objectively confirms whether there is fluid in the middle ear.
4. Hearing test: Hearing is measured age-appropriately by otoacoustic emissions, behavioural audiometry or pure-tone audiometry. The “true cost” of the effusion to the child becomes clear with this test.
5. Endoscopic adenoid assessment: In recurrent cases the size of the adenoid is directly visualised; in most cases this step shapes the treatment plan.

Treatment Approaches: Medical First, Surgical in Selected Cases

Treatment of the Acute Attack

In some cases, particularly in children over the age of 2 with a mild-to-moderate picture, a 48–72 hour period of watchful waiting with pain relief and close observation may be applied; during this time a significant proportion of attacks resolve on their own. In cases with high fever, a bilateral picture, infancy, or a poor general condition, antibiotic treatment comes directly to the fore. The decision on when and for how long to give antibiotics varies according to the child’s age and the clinical picture; giving antibiotics for every sore throat or cold is not a correct approach.

When pain relievers (paracetamol or ibuprofen) are given at regular intervals, they significantly improve the child’s night-time sleep and daytime comfort; aspirin is not used in children.

Treatment of Middle Ear Fluid

The approach to middle ear fluid that develops after an acute attack or on its own is different. A significant part of the fluid clears on its own within 3 months; for this reason the first step is observation and follow-up. During this period, the following are recommended:

• Treatment of any accompanying allergy
• Management of upper respiratory tract infections
• Avoidance of passive smoke exposure
• Nasal cleaning, and the use of a nasal spray if required

If the fluid persists beyond 3 months, remains bilateral and causes a marked reduction in hearing; or if it begins to affect the child’s speech development, school performance or behaviour, surgical treatment comes onto the agenda.

Surgery: Ventilation Tube (Ear Tube)

The basis of the surgical options is a small ventilation tube placed in the eardrum. The tube is inserted through a tiny opening made in the eardrum and ventilates the middle ear from the outside; the accumulated fluid both drains away and is prevented from re-accumulating. The tube typically separates from the eardrum on its own and falls into the external ear canal within 6–18 months; it performs its function throughout this period.

In the same session the adenoid is often assessed as well, because the most frequent underlying cause of recurrent middle ear fluid is adenoid enlargement. If required, the adenoid is removed under the same anaesthetic; this is an established approach that avoids giving the child anaesthesia twice.

The procedure takes 15–25 minutes; the child receives a short-acting general anaesthetic; discharge is usually on the same day.

The Process and Recovery

After tube treatment the child returns to normal activity within a few hours; pain is minimal compared with adenoid or tonsil surgery.

• First 24–48 hours: Mild restlessness; sometimes slight discharge from the tube may appear for a few days; this is expected and is generally managed with drop treatment.
• First week: Most children can return to class or nursery within a few days.
• Contact with water: As a general rule, dirty and soapy water (bubble bath) is kept from entering the ear with a tube. The matter of swimming pools/the sea is planned according to the physician’s preference; routine contact with clean water causes no problem in most children, but submerging the head to swim and diving are generally managed with the recommendation of an ear plug.
• Follow-up: A check within the first month; thereafter tube position and hearing are followed at 6-month intervals. When the tube falls out on its own, the eardrum closes by itself in the great majority of cases.

Improvement in hearing is often noticed within hours of the tube being placed; the child responds differently to sounds, no longer needs to turn up the television, and turns easily when their name is called.

Effect on School and Development

It is under this heading that we most often see the lasting marks of middle ear problems. Mild-to-moderate hearing reduction caused by fluid can create a serious cost in the 2–4 age window that is critical for speech development. At this age the child learns by repeating sounds; a child whose middle ear is constantly filled with fluid cannot clearly hear soft consonants in particular (s, sh, f, t), and pronounces them incompletely or incorrectly when speaking. In cases recognised late, this situation may require speech therapy; whereas when the cause is removed with early treatment, the child quickly catches up with peers.

In school-age children the picture produces more insidious consequences: the child cannot fully hear what the teacher says in class, appears inattentive, falls behind in lessons, and withdraws from social interaction. These children are sometimes labelled with attention deficit or learning difficulty; whereas the underlying cause is an as-yet-unrecognised middle ear fluid. A hearing test is a critical diagnostic tool in these cases.

In long-standing, untreated cases, more serious conditions such as permanent thinning, calcification or cholesteatoma can develop in the eardrum. This is the structural reason why the approach of “middle ear fluid clears up anyway” is not safe in every case.

Parental Reservations About Tube Treatment

Parents are initially apprehensive about the idea of “having a tube placed in the ear”; this is a natural reaction. In practice, the ventilation tube is the most frequently performed ENT surgery in children worldwide; it is an established, safe and reversible procedure. The tube is not a permanent implant; when the middle ear returns to normal function it is expelled on its own, and the eardrum most likely heals without leaving a mark. The improvement in the child’s sleep quality, hearing and daily comfort generally becomes apparent within days; this helps both the family and the child gain confidence in the decision.

Despite all this, a tube is not an automatic recommendation for every child. Steps such as the 3-month follow-up threshold, the requirement of a notable hearing loss, and assessment of any accompanying adenoid condition are established criteria for preventing unnecessary surgery. When these criteria are exceeded, however, waiting makes the child pay an unnecessary cost in their speech and school years.

When to Consult a Paediatric ENT Specialist

The following situations are reasons for an assessment:

• Acute earache, fever, discharge from the ear
• More than 3 acute otitis attacks within 6 months, or more than 4 within 1 year
• A persistent “ear feels full” complaint that does not pass after an upper respiratory tract infection
• Constantly turning up the television volume, not turning when called
• An unexpected drop in school performance, attention problems
• Speech lagging behind the child’s age, an inability to produce certain sounds
• An infant constantly touching the ear, a restless picture with night-time waking
• Difficulty with feeding, restlessness while sucking
• Temporary balance disturbances, frequent stumbling and falling

In most children a middle ear problem is temporary and follows a favourable course; a simple assessment carried out at the right time often allows the situation to be managed without the need for surgery. In cases that do require surgery, delay can turn into a cost paid in terms of speech and school performance. When in doubt, an examination is a far safer course than the “let’s wait, it will pass” approach.