The pediatrician answers > Common diseases in the first months of life: otitis

Otitis is defined as an inflammation, acute or recurrent, of the ear.otitis is defined as an inflammation, acute or recurrent, of the ear.

Mar 5, 2019

What is otitis?

Otitis is defined as an inflammation, acute or recurrent, of the ear. Depending on the characteristics of this inflammation, its development, symptoms, location and the microorganism that produces it, different types can be distinguished:

  • External otitis: Are those in which the external auditory canal is affected.
  • Otitis Media: In which there is an involvement of the middle ear (of the structures located behind the eardrum). These, in turn, can be divided according to their presentation as:
    • Acute otitis media, in which symptoms appear suddenly. They can manifest in a punctual and sporadic way, they can persist having relapses at close intervals, or they can be repeated over several months
    • Serous or exudative otitis media, in which no symptoms appear, or are milder and its evolution is more chronic (lasts longer).

Acute otitis media is one of the most common diseases suffered by children, occurring in 60% of children before completing their first year and up to 90% in the course of the first five years of life.

For this reason, it’s interesting that parents and caregivers become familiar with these pathologies, since their highest incidence occurs in babies from 6 to 12 months, when children cannot transmit clearly where it hurts and what symptoms they notice.

What produces it?

Otitis are infections that can produce different microorganisms:

External otitis is related to an increase in the humidity in the external auditory canal, caused for example by frequent bathing in swimming pools, beaches, etc, appearing for this reason, more frequently in summer. It can also present itself as a superinfection of some lesion or erosion of the mucosa or coating of this duct. Among the microorganisms that most commonly participate in the production of this infection are bacteria, such as Pseudomonas aeruginosa, followed by Staphylococcus aureus. Other pathogens that can cause these infections are fungi, such as Candida albicans, Aspergillus niger, etc.

In the case of acute otitis media, the microorganisms that most commonly produce this infection are bacteria, such as Streptococcus pneumoniae, Haemophilus influenzae or Moraxella catarrhalis. Viruses are microorganisms that favour the appearance of otitis media due to the production of respiratory infections that secondarily result in the appearance of otitis due to the accumulation of mucus that they cause and that affects the ear. Its direct relationship in the production of infection is more controversial

It’s established that there are predisposing factors that favour the appearance of otitis media in children, such as day care, having less than two years of age, being male, having a family history of acute otitis media (parents, siblings), or be exposed to tobacco smoke, for example.

What are the symptoms?

The two main symptoms to suspect that the child suffers from a possible otitis are the pain in the ear and the presence of secretion in it (otorrhea).

In the case of external otitis, it’s common for the child to feel itching in the auditory canal and intense pain when the ear is touched or pulled (auditory pinna) or when the cartilaginous “overhang” is pressed located in the middle and anterior region of the ear (pressure in the swallow or positive swallow sign). It may also appear a purulent secretion.

Acute otitis media is manifested as a sudden pain in the ear, often at night or after sleeping, causing irritability when waking up, a disconsolate crying, accompanied by fever and sometimes vomiting and diarrhoea. Babies usually refuse breastfeeding because of the pain caused by sucking.

These episodes usually occur with the history that the baby has had a cold with a lot of nasal mucus. The communication of the nose with the Eustachian tube (anatomical structure in the form of a tube that goes from the nasal region to the ear), favours the development of the infection, since the mucus accumulates and bacterial superinfection appears.

Sometimes the pressure exerted by the mucus is such that, finally, the tympanic membrane undergoes a rupture or perforation, leaving a purulent mucus towards the external auditory canal. At that time, the child usually notices a decrease in pain due to the decreased pressure, although the hearing gets worse. Parents can see in many cases how the sheets of the crib or bed are stained.

Occasionally there is an accumulation of mucus and obstruction of this Eustachian tube more persistently after a catarrhal process, repeated otitis acute media or an increase in so-called “vegetations” (adenoids). In these cases, the child doesn’t have pain, but it can have a decrease in hearing, which in the case of babies, is sometimes not perceived by the parents. It’s then spoken of otitis media serous or otitis media with exudate or subacute. This type of alterations in the first years of life can cause delays and alterations in the language in the long run.

The two main symptoms of suspected otitis are pain in the ear and discharge from the ear (otolaryngorrhea).

How is the diagnosis?

Otitis diagnostic is basically clinical, that is, the paediatrician, due to the symptoms presented by the child, the previous antecedents and the physical examination performed, can see the presence of this auditory pathology.

In general, in the examination, the doctor will observe in the case of external otitis, how the external auditory canal of the child appears inflamed, with oedema and reddening. The child can show signs of a lot of pain when the paediatrician introduces the otoscope to explore it (diagnostic device for visualization of the interior of the ear canal and the eardrum, which has a handle and a cone-shaped end accompanied by a light). There is secretion present and it can be confirmed that, in this case, the eardrum remains normal. In addition, as we have explained before, the doctor verifies that when tightening the area of the ear (called swallow), the child presents an increase in pain

In the case of acute otitis media, in otoscopy, the external auditory canal is almost normal in this case and the eardrum appears red, bulging and dull. The doctor can see if there has been a perforation and the presence of whitish purulent secretion in the duct.

In exudative or serous otitis, the doctor sees in the examination with the otoscope what he suspects is a secretion behind the eardrum, he may observe posterior bubbles and the dull tympanic membrane.

Which is the treatment?

The treatment of otitis externa is topical, that is, with the application of antibiotics in drops directly in the ear (ciprofloxacin, gentamicin, etc.), or antifungals, in the case that it’s produced by a fungus. In addition, it’s advisable to apply local dry heat and avoid moisture as much as possible (prevent water from entering the ear).

Acute otitis media can be treated with antibiotics taken orally (amoxicillin-clavulanic acid, cefuroxime-axetil, azithromycin…), being most usual in babies, or applied topically in drops (ciprofloxacin, etc). Similarly, the application of local dry heat can relieve pain.

In any case, the doctor is the only one who can indicate adequately if the child needs to take antibiotics or not and which is the most appropriate guideline.

Accompanying the specific treatment of the cause of the infection, the paediatrician usually adds an analgesic – anti-inflammatory treatment (paracetamol, ibuprofen…).

Other treatments may be indicated according to the risk factors that precipitate the onset of otitis and its evolution, for example, transtympanic drainages in the case of chronic otitis, (put a few tubes in the tympanic membrane to drain mucus), or also the extirpation of “vegetations” (adenoidectomy), etc.

Parents and caregivers should be vigilant and, if once the treatment is scheduled by the paediatrician, the symptoms don’t improve considerably in the first 3 – 4 days (persistent severe pain, high fever, etc.), they should consult the doctor again so that he can rule out possible complications.


Regarding the prevention of external otitis, as we have said, one of the factors favouring the appearance of these is constant humidity. For this reason, it’s important that, in the periods when the children bathe most (in the summer in pools, etc), both babies and older children wear bathing caps and dry their ears when leaving the water. It’s also important to pay special attention to the entrance of the external auditory canal. It’s not advisable to use swabs for this purpose or to clean the ear, because they can cause damage to the eardrum and lesions in the mucosa of the external auditory canal, this can cause bacterial infections, or can push cerumen towards the bottom of the canal, favouring the formation of plugs.

In otitis media, it’s advisable to do nasal washes without pressure in the case that the child has catarrhs with a lot of mucus, with the intention of “dragging” that mucus and preventing it from going to the ear. It is also advisable that in these episodes the children are always well hydrated, so that the mucus is more fluid and easier to eliminate.

The pneumococcal vaccination included in the childhood immunization schedule has favoured that the incidence of otitis produced by these agents has decreased

In babies, as in other types of pathologies, the positive relationship of protection of breastfeeding has been seen for the stimulation of the child’s natural defences, especially in the first 6 months of life. In cases where this is not possible and it’s necessary to perform artificial or mixed breastfeeding, it’s advisable to use complete formulas adapted to the baby’s age, which can be enriched with prebiotics to promote the development of the child’s defences, contributing the necessary nutrients.