Most children have at least one ear infection before school age, and many have several. The great majority settle without complication, and the more consequential problem is not the acute infection but the fluid that can persist afterwards.
That persistent fluid affects hearing during the years when language is being learned, which is why it matters.
Why Children Get Them
The eustachian tube connects the middle ear to the back of the nose and equalises pressure. In children it is shorter, narrower and more horizontal than in adults, which makes it easier for infection to travel up from the nose and harder for fluid to drain.
Add frequent colds, enlarged adenoids obstructing the tube opening, and creche exposure, and the pattern becomes clear. Most children outgrow the tendency as the tube matures.
Risk is increased by bottle feeding lying flat, dummy use beyond infancy, exposure to household smoke, and attending group childcare.
Acute Ear Infection
Acute otitis media causes ear pain, fever, irritability, and reduced feeding or sleep. In an infant who cannot report pain, pulling at the ear, unusual crying and disturbed sleep are the clues.
Discharge from the ear with sudden relief of pain usually means the eardrum has perforated, which sounds alarming and generally heals well.
Most cases are viral or resolve without antibiotics. Current practice for a child over two with mild symptoms is often watchful waiting for forty eight to seventy two hours with adequate pain relief, prescribing antibiotics if there is no improvement.
Antibiotics are given more readily for children under two, for severe pain or high fever, for both ears affected, and where there is discharge.
Pain Relief Matters More Than Antibiotics
Whatever the decision about antibiotics, pain control is the priority, and it is often underdone.
- Paracetamol or ibuprofen dosed by weight, given regularly rather than as needed for the first day or two
- A warm compress against the ear
- Keeping the child upright, since lying flat increases pressure and pain
- Adequate fluids
Do not put oil, garlic or any other substance into the ear. If the drum is perforated this introduces infection directly into the middle ear, and it is a common cause of complications we see.
Glue Ear and Its Effect on Hearing
Otitis media with effusion, commonly called glue ear, is thick fluid persisting in the middle ear after an infection has settled, or arising without any infection at all.
It causes no pain, which is why it goes unnoticed. What it causes is hearing loss, typically mild to moderate, fluctuating over weeks.
- Not responding when called, particularly from another room
- Turning the television up
- Speaking loudly
- Inattention, often mistaken for a behaviour problem
- Delayed or unclear speech
- Difficulty at school, particularly in a noisy classroom
- Balance problems and clumsiness
Children are frequently labelled as not listening or inattentive when they simply cannot hear well. This is worth considering before behavioural explanations.
How It Is Assessed
Diagnosis needs objective testing rather than an impression.
- Otoscopy: looking at the eardrum, which appears dull, retracted or with visible fluid
- Tympanometry: measures eardrum movement and is the most useful test for fluid. A flat trace indicates fluid
- Audiometry: quantifies the hearing loss, using play audiometry in young children
- Assessment of adenoids, since enlargement contributes
Because glue ear fluctuates, assessment is usually repeated after around three months before deciding on treatment. Many cases resolve spontaneously in that period.
When Grommets Are Recommended
Grommets, or ventilation tubes, are tiny tubes inserted through the eardrum to ventilate the middle ear and allow fluid to drain.
They are considered when fluid persists for three months or more in both ears with a significant hearing loss, when there is speech or language delay, when school performance is affected, when there are recurrent infections despite treatment, or where there are structural changes to the eardrum.
Insertion is a short day case procedure under general anaesthetic, taking around fifteen minutes. Hearing usually improves immediately.
Grommets extrude naturally after six to twelve months as the eardrum heals. Adenoidectomy is often performed at the same time, particularly for repeat procedures, as it reduces recurrence.
Life With Grommets
Aftercare is simpler than most parents expect.
- Swimming is generally permitted, and current evidence does not support routine ear plugs for surface swimming
- Avoid diving deep and submerging in dirty water
- Keep soapy bathwater out of the ears, since soap reduces surface tension and enters more easily than clean water
- Report any discharge, which needs antibiotic ear drops rather than oral antibiotics
- Attend follow up to confirm the grommet is in place and hearing has improved
- Tell the school so the child is seated appropriately
A small hole occasionally persists after the grommet extrudes, which may need repair later. Most heal without any intervention.
Prevention and When to Worry
Several measures reduce the frequency of ear infections.
- Complete elimination of household smoking, which is the strongest modifiable factor
- Breastfeeding, which is protective
- Feeding upright rather than lying flat
- Pneumococcal and influenza vaccination, both part of the immunisation schedule
- Treating allergic rhinitis where present
- Reducing dummy use after the first year
Seek urgent assessment for swelling or redness behind the ear, the ear appearing pushed forward, severe headache with neck stiffness, facial weakness, high fever with drowsiness, or persistent foul smelling discharge. These suggest complications requiring immediate care through our ENT department.
Acute ear infections usually settle with pain relief alone. The problem to watch for is the painless fluid afterwards, which affects hearing at exactly the age language develops. If a child seems inattentive or is behind with speech, have their hearing tested before assuming a behavioural cause.
Our ENT department at T. Nagar provides paediatric hearing assessment and grommet surgery.
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