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More Shattered Myths About Middle Ear Infections

ear exam


Unless you have a home otoscope and know how to use it, parents are relegated to determine if a child has a possible ear infection based solely on symptoms and signs. Those of us in the clinical trenches know that symptoms and signs are not necessarily predictive of a definitive diagnosis.

A recent two-year study in Finland looked at 469 children, ages 6-35 months, and tested the predictive value of common middle ear infection symptoms: ear-rubbing or pulling, irritability, less playful, excessive crying, poor appetite, restless sleep, runny nose, congestion, vomiting, diarrhea and fever.

The diagnosis of a middle ear infection (otitis media) requires a certain diagnostic criteria:

  • Middle ear fluid detected by pneumatic otoscopy — this is the little bulb syringe attached to the otoscope that puffs air against the eardrum to check for mobility (the normal in and out movement of the eardrum).
  • Abnormal color, opacity, bulging (shape) of the eardrum. Middle ear infections are typically “bulging” and have a distinct red or yellow color, instead of shiny white.

In this study, not one, but three different physicians systematically examined the ears of children strongly suspected by the parents as having a middle ear infection based on symptoms alone.

The results:

  • The duration and severity of the symptoms were NOT predictive of a middle ear infection.
  • Ear-rubbing and pulling, long thought to be predictive of ear pain, was proven to be an invalid sign. It was actually more common in children who did NOT have a middle ear infection.
  • Fever was also NOT a predictive sign.
  • A prior cold was NOT a predictive sign in this study, although statistically most children who get middle ear infection usually do have a cold. Conjunctivitis (pink eye) may be a presumptive sign in some, not all, cases.

The only definitive way to diagnose a child with a middle ear infection is by a careful, systematic medical examination by an experienced clinician using a pneumatic otoscope.

I see these false alarms nearly every day in my clinical practice. Parents believe their children have an ear infection, when in reality, they do not. Many parents will still demand antibiotics “just in case,” or come up with some compelling stories like going out of town tomorrow, a seriously ill grandparent or upcoming air travel in an effort to plead their case. Cursory or incomplete examinations by hurried clinicians tend to over-read ear examination findings, resulting in inaccurate diagnoses. I find this quite often in emergency room or urgent care visits.

Here are 10 facts about ear infection:

1. Not all middle ear infections in children (not including babies under the age of three months) require antibiotics. As a matter of fact, over 90 percent of middle ear infections will self-resolve in a few days… on their own, without any medical intervention. Shocking. It is perfectly fine to wait a few days to see if the body’s immune system orchestrates the cure.

2. Middle ear infections hurt. Regardless of the presence of fever (harmless), a child in pain should be treated with acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) at an appropriate dose for the pain… not the fever.

3. Fever is harmless and does not need to be treated in most cases.

4. Middle ear infections are not emergencies. They really have no place in the emergency room.

5. Not all recurrent ear infection will result in children getting tubes. However, if middle ear fluid is present for more than three months and/or children are having hearing loss, an ENT specialist should be consulted.

6. Children in daycare get more ear infections. The fall and winter months have the highest incidence.

7. Children exposed to ANY secondary cigarette smoke get more ear infections. (If you smoke around your children, you should be arrested.)

8. Children who are breast-fed for at least six months get less ear infections that bottle-fed babies.

9. Children who have a nighttime bottle in the crib or depend on a pacifier tend to have more ear infections.

10. Children do grow out of ear infections. We see a marked reduction after age six, so hang in there.

Now, go buy a home otoscope and start practicing.

Source: Laine MK et al, Pediatrics 125: e1154-e1161, May 2010.

Surprised that ear-pulling isn’t predictive of an ear infection? Have you misdiagnosed your child’s ear infection before? Share your comments with the Ear, Nose and Throat Community.


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