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The Informed Parent

Ear Infections…Outer Ear Versus Inner Ear

by Louis P. Theriot, M.D., F.A.A.P.
Published on Nov. 04, 2013

My first patient of the day was a seven-year-old girl who came in with an ear infection. As she was getting ready for bed last night she started complaining about her ear itching. She fell asleep as usual but around midnight began crying in pain. The temperature indicated there was no fever but she was in tears, keeping everyone up most of the night. She told mom that the whole right side of her face hurt, and it was hard to hear out of the right ear. That was what prompted her to come in.

As I pulled up to the office I saw them standing at the door. Amy was holding a heating pad against the right side of her face. She was still in her pajamas, bathrobe and slippers. The nurse put them in a room and checked her temperature and vital signs. She did not have a fever but was in a fair amount of pain. Mom said, “I know she has an ear infection because she used to get them all the time when she was younger…she almost had to have tubes put in. I hope we are not heading in that direction again!”

With the history obtained I learned that Amy did not have any symptoms until last evening. There were no respiratory symptoms or cold symptoms. She had been perfectly healthy all summer. Then I learned that she participated in junior lifeguards, and was swimming almost every day. The examination showed that the left ear was completely normal--a pearly white ear drum with good landmarks and a shiny light reflex. The oto-scope showed the light reflecting back, creating a “cone of light”. This is because of the way the eardrum is positioned, slightly tilted back and a bit concave like a dish.

To examine the right ear I gently pulled the ear lobe down to insert the oto-scope speculum into the canal. This was obviously uncomfortable for Amy. When I looked into the ear the entire canal was red, inflamed and a bit swollen. There was some wax and debris in the canal as well. The eardrum was also red, but there was a good light reflex. I did a tympanogram which showed that the eardrum moved normally, confirming that there was not a middle ear infection. I told mom that Amy had an outer ear infection, otitis externa or “swimmers ear”. This could easily be treated with eardrops and not an oral antibiotic. Mom was relieved, but Amy less so.  

There are two main types of ear infectons: an outer ear infection, otitis externa,and a middle ear infection, otitis media. Otitis externa is an infection of the ear canal leading up to the eardrum, The canal becomes red and inflamed, and it can be very painful. This is very common in swimmers because the constant moisture in the ear canal causes the skin to become soft and friable. This provides a perfect environment for certain bacteria to take up residence, causing inflammation and a local infection. Rarely is there fever. It is usually painful to pull the lobe or press on the opening. There may also be decreased hearing on the affected side. Otitis externa is very responsive to eardrops which contain an antibiotic and in some cases a steroid to treat the inflammation. We usually keep them out of the pool until the infection has been adequately treated and they have used the drops for around five days.

Otitis media is a middle ear infection, meaning that the infection is in the middle ear space behind the eardrum. The middle ear space is part of the upper respiratory tract and, as such, is susceptible to the same bacteria as the respiratory tract. The middle ear is connected to the back of the throat via the Eustachian tube whose function is to equalize middle ear pressure and allow for drainage of any fluid. If the Eustachian tube is not functioning properly bacteria can get trapped in the middle ear space, setting up the infection. In otitis media, there is inflammation and pus behind the eardrum. This causes pain and decreased hearing. Because it is more of a systemic infection there is often fever and other upper respiratory symptoms. When one examines an ear with a middle ear infection, the eardrum is red and dull with loss of the light reflex. This is because the fluid behind the drum pushed it outward, making it bulge and no longer like a concave dish. As a result the light is not reflected back to the observer and the “cone of light” is lost. It is also common to see fluid (pus) behind the eardrum. With a middle ear infection, because of its location, it does not hurt to pull the ear lobe or press on the outer ear as it does with an outer ear infection. Otitis media is more of a serious and systemic infection. It is usually treated with oral antibiotics for ten days.

Quite often it is not readily obvious if a patient has an otitis media, an otitis externa or BOTH. In otitis externa, there may be so much inflammation of the canal that everything looks red and inflamed, even the eardrum. One of the tools that we have available to sort this out is the tympanogram. This is a machine that has a soft rubber earpiece that fits in the outer ear opening creating an airtight seal. The machine sends out a sound wave that the patient hears as a hum. Then the machine records how well the eardrum moves by measuring the volume of air displaced by the freely moving eardrum as it moves back and forth. A normal, freely moving eardrum will elicit a “bell-shaped curve” which is displayed on graph paper. The entire process takes a few seconds and is totally painless. In the case of a middle ear infection, since there is fluid/pus behind the eardrum, the drum is unable to move freely and the graph will show a flat line. This is a very sensitive and reliable test and is invaluable to us when trying to differentiate between the two types of ear infections. 

In Amy’s case, the eardrum itself was red and did not look entirely normal. However, the tympanogram showed a nice bell-shaped curve, proving that she did not have a middle ear infection. Mom was thrilled the Amy was not going down the path of ear infections and tubes once again. Amy was not so happy. She was invited to a birthday/swim party that same day, and a boy of her interest was going to be there. Oh well, there’s next time.

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