Conditions:
Ear Infections

Related Terms
  • Middle Ear Infection, Otitis Media
Principal Proposed Treatments
  • Xylitol, Breast-Feeding, Avoiding Passive Smoke Inhalation, Herbal Ear Drop Combinations
Other Proposed Treatments
  • Food Allergen Elimination, Echinacea, Zinc, Vitamin C, Andrographis, Arginine, Ginseng, Thymus Extract

Acute otitis media (AOM) is a painful infection of the middle ear, the portion of the ear behind the eardrum. (Another form of ear infection, otitis externa or swimmer's ear, is entirely different, and is not covered here.) AOM often follows a cold, sore throat, or other respiratory illness. Although it can affect adults, this occurs primarily in infants and young children. It's estimated that by age 7, up to 95% of all U.S. children will have experienced at least one bout of AOM—it's the most common reason parents take a child to the doctor.

When the Eustachian tube connecting the upper part of the throat to the middle ear is blocked by a cold's mucus and swelling, fluids pool behind the eardrum, providing an ideal place for bacteria to grow; an infection may set in, generating even more fluid. The pressure this exerts on the eardrum can be intensely painful. The eardrum turns red and bulges. Children too young to explain their discomfort cry, fuss, and pull at their ears. They might also appear unresponsive because they can't hear well—fluid buildup in the middle ear prevents the eardrum and small bones in the ear from moving, causing temporary hearing loss.

Most hearing loss associated with AOM ends when the infection is treated. However, recurring ear infections and their accompanying short-term hearing losses may affect a child's speech and language development. In addition, a complication called secretory otitis media (fluid build-up in the middle ear) may develop and cause continuous hearing loss for months. Other possible complications of AOM include mastoiditis (an infection of the bone behind the ear) and, occasionally, spinal meningitis.

Without treatment, most middle ear infections resolve on their own, often through a harmless rupture of the eardrum.¹ In the Netherlands, pediatricians take a conservative approach, generally waiting 24 to 72 hours until they are certain an ear infection warrants antibiotics.²

However, U.S. doctors tend to initiate treatment early. This practice has been criticized on several grounds. First, antibiotic treatment has not been found effective in preventing complications such as serous otitis³ or pneumococcal meningitis.⁴

In addition, antibiotic treatment does not even appear to help AOM itself very much. For example, a double-blind placebo-controlled trial of 240 children ages 6 months to 2 years found so little benefit with antibiotic treatment that the authors recommended physician-supervised watchful waiting rather than immediate treatment.⁵ In other published reviews, the benefits of antibiotics for AOM have also been found less than impressive. A review of 33 randomized trials involving 5,400 children concluded that antibiotics modestly improved the rate of recovery.⁶ An evaluation of six randomized, controlled studies concluded that early antibiotic use had only slight benefit, reducing pain and fever in a small percentage of children and helping to prevent the development of infection in the other ear, but not significantly speeding up recovery of hearing.⁷ Modest benefits were also seen in a more recent trial of 315 children. ⁸ Finally, children with recurrent ear infections do not appear to benefit from preventive antibiotic treatment.⁹

However, another criticism, that early antibiotic treatment causes an increased rate of ear infection recurrence, does not appear to be correct.¹⁰

Note: Despite the issues raised above, simply withholding antibiotic treatment can be dangerous. Any child who appears to have an ear infection should be seen by a physician.

When ear infections do reoccur frequently, a physician may insert a tube into the infected ear to drain fluids and relieve pressure, a procedure called tympanostomy. Nearly 1 million U.S. children undergo this procedure each year; however, its usefulness is somewhat controversial.^11,12,13

Principal Proposed Treatments for Ear Infections

Although there is as yet no natural treatment for AOM, there are several promising approaches parents can take that may help prevent children from developing ear infections or reduce symptoms.

Xylitol

A natural sugar found in plums, strawberries, and raspberries, xylitol is used as a sweetener in some "sugarless" gums and candies. One of its advantages is that it inhibits the growth of Streptococcus mutans, a type of bacteria that causes dental cavities.¹⁴ Xylitol also inhibits the growth of a related bacteria species, Streptococcus pneumoniae, implicated in ear infections.¹⁵ Additionally, xylitol acts against Haemophilus influenza, another bacteria that frequently causes ear infections.¹⁶

Based on this evidence, xylitol has been tried as a preventive treatment for middle ear infections with some success. Two well-designed studies enrolling a total of 1,163 children found that chewing gum and syrup sweetened with xylitol helped prevent middle ear infections and decreased the need for antibiotics. Although xylitol clearly did not absolutely prevent ear infections, it significantly decreased the rate at which they occurred.

A large double-blind placebo-controlled trial of 857 children investigated how well xylitol (in chewing gum, syrup, and lozenges) could prevent AOM.¹⁷ The gum was most effective, reducing the risk of developing AOM by a full 40%. Xylitol syrup was also effective, but less so. The lozenges weren't effective: researchers speculated that children got tired of sucking on the large candies and didn't get the proper dose of xylitol. (In addition, the children were able to distinguish between the xylitol and placebo lozenges by taste, making that portion of the study single-blind.)

Similarly positive results had been seen in an earlier double-blind study by the same researchers, evaluating about 300 children.¹⁸

For more information, including dosage and safety issues, see the full xylitol article.

Breast-feeding

Breast-feeding may help prevent AOM. Numerous studies tracking ear infection frequency in large groups of infants found that the infants breast-fed exclusively had significantly fewer middle ear infections than those fed formula.^19,20,21 Such observational studies aren't as reliable as placebo-controlled or double-blind designs, but the results do suggest that breast-feeding is a good preventive measure.

Researchers aren't sure how breast milk protects infants from ear infections. Studies attempting to determine if breast milk inhibits bacteria associated with AOM have had mixed results.^22,23

Avoidance of Cigarette Smoke

Environmental conditions may predispose a child to middle ear infections. A study of 132 daycare students found that the 45 children exposed to cigarette smoke at home had a 38% higher risk of middle ear infections than the 87 children whose parents didn't smoke.²⁴

Mullein-Based Herbal Ear Drops

The herbs mullein and garlic are traditionally combined with other herbs in oily ear drops designed to reduce the pain of ear infections. One study supports this use. A randomized, controlled trial of more than 100 children and young adults with eardrum pain caused by middle ear infection compared the effectiveness of an herbal preparation containing mullein, garlic, St. John’s wort, and calendula against a standard anesthetic ear drop product (ametocaine and phenazone).³⁰ The results indicated that the two treatments were equally effective.

However, due to the strong placebo response in pain conditions, this study would have needed a placebo group to provide truly dependable evidence.

Note: While herbal ear products may reduce pain, it is very unlikely that they have any actual effect on the infection because the eardrum is in the way. For more information, including dosage and safety issues, see the full Mullein article.

Other Proposed Treatments for Ear Infections

Allergies

Allergies may contribute to ear infections, possibly by increasing the amount of fluid in the middle ear. There is some evidence that children allergic to pollens, dust, molds, and foods may be more likely to develop AOM.^25,26,27 Weak evidence suggests that a food allergen elimination diet might help prevent middle ear infections.^28,29

Other Herbs and Supplements

Numerous herbs and supplements have been proposed for preventing or treating ear infections. These include all herbs and supplements used for colds, including echinacea, zinc, vitamin C, andrographis, arginine, thymus extract, and ginseng. There is no evidence as yet that they work for AOM, but it is certainly logical to think they might.

Last reviewed June 2002 by Medical Review Board

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