Common Questions about Middle Ear Infections

In my clinical practice and on the WebMD Ear Disorders Board, I get many of these same questions every week.

1. Do all middle ear infections need antibiotics?
No, as a matter of fact, the vast majority of middle ear infections will get better on their own without antibiotics. It will take longer, of course, and there will be several days of pain that will need to be addressed. Our own immune system does a pretty good job in curing many infections. Antibiotics should always be used in very young children (under age six months) or in children who have had complications in the past from untreated ear infections. In Europe, it is commonplace to wait up to a week before antibiotics are started, but these children are examined every three days – often not an option for children in the U.S.

2. My child is immune to amoxicillin now. What other choices of antibiotics can be used?
Amoxicillin is still the drug of choice for treating uncomplicated middle ear infections, but that may change soon. Microorganisms are changing, and we are seeing more and more resistant strains. Your child is not likely immune to amoxicillin, but amoxicillin may not be the appropriate drug for the kind of bacteria that is present in your child’s ear. Amoxicillin also has a variable absorption rate and 15% of the population may not be able to absorb it from the gastrointestinal tract. If your child always gets diarrhea or a yeast infection after taking amoxicillin, he may be one of these “non-absorbers”.

3. My child hates taking oral antibiotics. Isn’t there an antibiotic shot that can take care of it?
Yes. Rocephin will kill about 95-98% of the pathogens that can be causing your child’s ear infection, but it isn’t cheap and it also hurts. Usually, it is not just one shot that is needed but three, given every day or every other day. The cost to you (or your insurance company) may be $300 to $600 for treating a simple ear infection. Rocephin should be reserved for the most severe or resistant cases. Using Rocephin for a garden-variety ear infection would be like rabbit hunting using a cannon.

4. My new doctor only gave my child five days of antibiotics. Shouldn’t ear infections be treated for ten days?
Many medical providers use shortened courses – three days, five days, or seven days. Depending on the child’s medical history, age, frequency of ear infections, prevalence of resistant bacterial strains in the area, or day-care attendance (day-care kids tend to have more resistant strains), a shorter course may be quite appropriate. Studies have shown that there are no differences in the outcome.

5. My child is better. Do I really have to complete the full course of the antibiotics? Can’t I save half of it for the next infection?
The number one cause of treatment failures and the development of resistant strains of bacteria stems from not completing the prescribed course. Sure, it can be difficult to remember but it is very important. In one study, only 10-20% of the people took their ten-day course of antibiotics. Saving antibiotics is not wise. First, liquid antibiotics expire quickly and lose their potency (look that expiration date!). If you get another infection a month or so later and only take a few days of your left-over antibiotics, you will seriously compromise your treatment if (and when) this fails.

6. Isn’t there a vaccine to help prevent ear infections?
Yes and no. The pneumococcal vaccine (Prevnar) was really developed to help prevent more serious childhood illnesses, like pneumococcal meningitis. However, the same bugs that cause this form of meningitis is also the strain the causes some (not all) ear infections. This vaccine is given routinely to all children now and has definitely reduced the incidence of certain types of middle ear infections.

7. Zithromax is my favorite medication since you only have to give it once a day for three days. Why doesn’t my doctor use it every time?
Zithromax is an excellent antibiotic and will work for some ear infections. However, recently there has been a shift in the types of bacteria that cause ear infections. Pneumococcus used to be number one, but since the use of the pneumococcal vaccine we are seeing less of this one and more of Haemophilus influenza (not to be confused with the flu). Zithromax will not work for ear infection caused by this organism. Yes, it is convenient. It can even be taken ALL AT ONCE when prescribed that way, but many times Zithromax is not the best choice.

8. Are all middle ear infections painful? My child was perfectly well-appearing and the doctor said he had an otitis media.
Pain is in the mind of the beholder. Some children tolerate discomfort more than others. Yes, an acute middle ear infection can be very painful, especially if there is considerable pressure in the middle ear space. After the immune systems kicks in, along with some pain medication, children can be quite comfortable with a terrible-looking ear. If your doctor sees a bulging, red-yellow eardrum, your child has an ear infection whether he is screaming or not.

9. What is the doctor doing when he puffs air into my child’s ear with a bulb attached to the otoscope?
You have a good medical provider. This is called pneumatic otoscopy and is the standard of care in the diagnosis of a middle ear infections. Eardrums can look red, but your child may not have an infection. However, when the doctor puffs air against the eardrum and it does not move in and out normally, this could indicate fluid or pus behind the eardrum – a sure sign of otitis media. A red or yellow eardrum that is bulging and does not move when air is blown against it is a definite middle ear infection.

10. Can parents buy otoscopes to look in their child’s ear?
Absolutely. I have recommended parents to use home otoscopes for over 25 years, and have personally taught thousands (not an exaggeration) of people how to use this simple and safe instrument. They only cost about $30…certainly less than an office visit. With some practice and the cooperation of your medical provider, a parent can become quite skilled in using an otoscope. You will still need to see your medical provider if you see a potential ear infection, but it certainly reduce those “false alarm” visits.

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