We wonder: do elephants get big ear infections?

“An ear infection,” we often hear parents say, “how can that be? I am so careful not to get water into her ear.”

Let us reassure you: parents do not cause ear infections. Germs cause infections. So please: no parent guilt!

When we doctors say “ear infections,” we usually refer to middle ear infections. Where exactly is the middle ear? When we look into the ear we peer down a tunnel called the ear canal. This part of the ear is considered the outer ear. At the end of the tunnel is a sealed door called the “ear drum” The medical term for ear drum is “tympanic membrane.” We’ll stick with “ear drum.” Behind the ear drum is the middle ear. As long as the ear drum (the door) leading into the middle ear is closed, water cannot enter the middle ear. Only if a child has ear tubes, or if the ear drum is ruptured, can water from a pool or bath enter the middle ear.

Now picture yourself opening the door and walking through to the middle ear. When you stand in the middle ear you will see tiny bones which help with hearing. The middle ear is the space that fills with fluid and gives you the uncomfortable sensation of pressure when you have a cold. It is the same space that gives you discomfort when you are descending in an airplane.

In the floor you will see a drain. This drain, called the Eustachian tube, helps drain fluid out of the middle ear. “Popping” your ears by swallowing opens this drain when you are descending on a flight. If fluid (usually from congestion from a cold or from allergies) sits long enough in the middle ear, it can become infected and the resulting pus causes pressure and pain. Sometimes the pressure becomes so great that it causes the ear drum to rupture and the painful infection will then drain out of the ear. Parents are often surprised to learn that this rupturing can occur both in untreated AND treated ear infections.

Beyond the middle ear is the inner ear, which houses nerves needed for hearing. Because children do not tend to get infections here, you may never hear about this part of the ear from your pediatrician (pun absolutely intended).

So, why do people talk about preventing ear infections by preventing water from getting into the ear? There is a type of ear infection called “swimmer’s ear,” formally known as “otitis externa,” which occurs in the outer ear. Swimmer’s ear usually results from a bacteria which grows in a damp environment. The water that causes this damp environment typically comes from a swimming pool, but can also come from lake, ocean, or even bath water. Swimmer’s ear can also be a result of anything that causes ear canal irritation such as eczema, hearing aids, or even beach sand. You can read more about this malady and it’s treatment and prevention here.

To summarize:

Ear infection = middle ear infection
Swimmer’s ear = outer ear infection
Cause of ear infections = germs

So, are you to blame for either type of ear infection? No, but there are associated factors which you can modify.

Wash hands to decrease spread of cold viruses.
Limit exposure to second hand smoke.
Give all vaccines on time – pneumococcal bacteria and the flu virus can cause ear infections–we have vaccines against these germs.
If your child suffers from allergies, talk to your child’s doctor about decreasing triggers in the environment and/or taking medications which might prevent middle ear fluid build-up from allergies.

Some kids who contract a lot of ear infection need help to stop further infections. Ear tubes, or “myringotomy” tubes,  promote middle ear fluid drainage before an infection occurs. Ear, nose, throat doctors (also known as ENTs or otolaryngologists) poke a hole in the ear drum leading to the middle ear and place a small tube in the hole. Through the myringotomy tubes, or “ear tubes,” fluid runs from the middle ear out into the outer ear canal before the fluid becomes infected. This drainage prevents middle ear infections from occurring.

To prevent swimmer’s ear, dry your children’s ears with a towel or blow gently with a hairdryer on cool setting after they are done swimming for the day.

We wrote this post because of the many questions we often hear about ear infections and ear anatomy. Hope the information wasn’t too eerie. Or is that EARie?

Naline Lai, MD and Julie Kardos, MD
©2018 Two Peds in a Pod®, updated from 2013

“MY EAR HURTS!!!”

Most parents  cannot diagnose their child’s source of ear pain, especially in the middle of the night. Even I can’t diagnose my own children at home because my portable otoscope, the instrument used to examine ears, died from overuse several years ago.  However, there are ways to treat ear pain no matter what the cause.

Good pain relievers such as acetaminophen (brand name Tylenol) or ibuprofen (brand names Advil and Motrin) treat pain from any source, including ear pain. Treating pain does not “mask” any physical exam findings so please go ahead and ease your child’s misery before going to your child’s doctor. I cringe when parents tell me, “We didn’t give him any pain medicine because we wanted you to see how much his ear is hurting him.”

Heat, in the form of warm wet compresses or a heating pad, can also help. Prop your child upright. If the pain is from an ear infection, the position will relieve pressure. Distraction such as a 2:00 am Elmo episode can also blunt pain.

Fewer than half of all patients seen in pediatric offices with ear pain, or “otalgia,” actually have a classic middle ear infection. Sometimes kids with cold virus get ear pain that comes and goes, perhaps from the general congestion in their sinuses and nose. Pain can stem from many sources, including the outer part of the ear. Swimmer’s ear, which is an outer ear infection, is treated differently than a middle ear “inside” infection. Nearby body parts can also produce pain. Throat infections (pharyngitis), from strep throat or viruses, often cause pain in the ears. Even pain from jaw joint strain and dental issues can show up as ear pain. Over the years I have sent several children straight from my office to the dentist’s office for treatment of tooth ailments masquerading as ear pain.

No post on ear pain would be complete without addressing “ear tugging.” Many babies by nine months of age discover their ears and then play with them simply because they stick out (I will leave to your imagination what baby boys tug on). Babies often tug on ears when they are tired. Therefore, tugging on ears alone may not indicate an ear infection, especially if not coupled with other symptoms.

Although ear infections are one of the most common ailments of childhood, and most children have at least one ear infection by age three, remember that not all ear pain is caused by ear infections. In the middle of the night, and even in the middle of the day, it IS okay to give some pain relief before seeing your child’s health care provider.

Why ear pain always seems to awaken a child in the middle of the night, I’ll never know.  All I know is that I have to remember to buy a new otoscope for home.

Julie Kardos, MD and Naline Lai, MD
©2015 Two Peds in a Pod®, modified from our 2010 post