Ear pain in children

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Why does it seem that your toddler is always sick with an ear infection? Like most things in medicine, the answer is not black and white. Let’s look at a few reasons why.

Different Infections

The difference between an outer ear infection (swimmers ear or otitis externa) and a middle ear infection (acute otitis media) is the tympanic membrane (eardrum). The outer ear canal is the part of the ear canal that opens to the outside world. Deeper in the ear canal a thin transparent membrane separates the outer ear from the middle ear.

ear pain, ear infection, ear

During the summer, when children play in the water, the outer ear canal often becomes infected. Bacteria are the main culprit while fungi make up about 10% of outer ear infections. Visible discharge from the ear is common with outer ear infections. Because these infections are exposed to the outside world, topical antibacterial or antifungal ear drops are the treatment of choice.

Middle ear infections are typically bacterial but also may be viral. The infection is contained behind the eardrum giving it a beat red appearance. Therefore there is no discharge in an outer ear infection. Because infections are commonly bacterial, oral antibiotics are the treatment of choice.


As adults, when we become sick with a head cold, we become congested. Congestion is the result of inflammation and mucous build up in our sinuses and middle ear. Head colds are due to viral infections and will resolve with time.

When there is mucous behind the eardrum, it is typically drained into the back of the mouth by way of the eustachian tube. As an adult our eustachian tube is positioned vertically from the middle ear to the back of the throat (nasopharynx). Simple techniques in yawning or pulling on an ear lobe may aid in opening the eustachian tube.

Children have a eustachian tube that is positioned horizontally. Without gravity to assist, mucous and fluid do not drain. Think of a stagnant pond of water vs a flowing river. Like the stagnant pond, the un-drained mucous begins to harbor bacteria.

It’s not an infection

Most parents associate their child’s ear pain with infection. Otitis media with effusion (OME) is not considered an infection but can cause similar ear pain. In short it is a build up of noninfectious fluid or mucous behind the eardrum and does not require an antibiotic.

The causes of OME are not fully understood. Risk factors include bottle feeding, exposure to tobacco smoke and low socioeconomic status. It is associated with allergies and gastroesophageal reflux and commonly presents after an acute otitis media (inner ear infection). Duration of OME may last for months.

More often than not an OME resolves spontaneously without medical intervention. However it can become a chronic problem with recurrence and complications. The most significant complication from OME is hearing loss. Children at risk for speech, language, or learning problems are often considered for tympanostomy tubes (small tubes surgically placed through the eardrum.

No matter the cause, the ear is a sensitive part of the body. The outer canal is lined with sensitive skin and the eardrum does not tolerate pressure from the inside or outside. Unfortunately without an otoscopic exam, the cause of ear pain does not distinguish itself.

Here are some nonspecific symptoms that may be present for different ear problems


Inner ear infection Outer ear infection Otitis media with effusion Ear wax Common cold Pharyngitis
Fever + + +
Pain + + + + +
Discharge + +
Congestion + + +


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