NASP Communiqué, Vol. 35, #4
Otitis Media (Ear Infections):
Parents and Teachers
By Paul C. McCabe, NCSP & Amy M. Racanello
Brooklyn College, City University of New York
Ear infection or otitis media (OM) is the most frequently diagnosed illness among children in the United
States (Zeisel & Roberts, 2003). The prevalence of OM has grown dramatically in the last 30 years. A U.S.
Department of Health study in 1996 reported a 150% increase in the number of identified ear infections in
preschoolers since 1975 (Feakes, 1996). Frequent ear infections during the first two years of life can have
a deleterious effect on a child’s hearing and may lead to impairment of the child’s developing language and
speech skills. Problems with developing language and speech skills can subsequently lead to academic
problems. It is important that parents and teachers are aware of the features of OM, including prevalence,
current treatment, risk factors and role in later language and learning difficulties.
Otitis media (OM) is the inflammation of the middle ear, which can be accompanied by fluid. OM affects
75% to 95% of the pediatric population. Most episodes occur within the first three years of life with frequency
of episodes most likely to peak between 12 to 18 months. Nearly half of all children experiencing an ear
infection will have had three or more episodes by their third birthday (Cornell Pediatrics, 2003).
In healthy children the middle space behind the eardrum is filled with air. The middle ear is attached to
throat by the Eustachian tube. The Eustachian tube sustains the middle ear airway and protects the middle
ear from secretions. However, when a child is experiencing an upper respiratory tract infection, the upper
respiratory tract (including nose and throat), Eustachian tube, and middle ear are congested with mucous.
When the Eustachian tube is blocked, swollen, irritated or malfunctioning, the child is more likely to retain
or accumulate middle ear fluid that would ordinarily drain into the throat. When the middle ear is filled with
fluid, the eardrum is not able to vibrate properly, which leads to decreased conduction of sound and reduced
hearing. The hearing deficits will persist until the fluid dissipates; often this hearing loss recurs and will vary
When the middle ear is filled with infected fluid, the child’s condition is known as acute otitis media
(AOM), commonly known as an ear infection. Symptoms of AOM include fever, irritability, and pain. Frequently,
the fluid in the ear will not become infected, or if the fluid is infected, often the infection will spontaneously
resolve. The problem, however, is when the fluid will not dissipate. When this occurs the condition
is known as otitis media with effusion (OME). The non-infected fluid may persist for several weeks or even
months. If the fluid remains in the child’s ear for more than three months, then the condition is considered to
be chronic OME.
Multiple factors increase a child’s chance for developing OM, including environmental, developmental,
and biological factors. Environmental risk factors for developing chronic OM include having an episode of
otitis media during the first six months of life, exposure to second-hand smoke, infant feeding practices
(including bottle feeding and position of the bottle during feeding), socioeconomic status, and group daycare
attendance. Regarding the latter, children who participate in group child care are more likely to develop
frequent and recurrent upper respiratory tract infections, which are a major contributor to Eustachian tube
One of the greatest risk factors for developing OME is age. Children who are younger than age three are
at increased risk for OME because their Eustachian tubes are more horizontally aligned than those of older
children. The horizontal position of the tubes makes it more difficult for fluid to drain from the middle ear.
Chronic infection is another risk factor, as children who have had their first episode of OM at an early age
show greater risk for developing repeated and/or chronic episodes.
Other contributory risk factors include heredity, as mothers who themselves have histories of ear infections
are more likely to have children with higher rates of infection. The likelihood of identical twins or triplets
having an ear infection simultaneously is about twice the rate for fraternal twins. Several chromosomal disorders
cause Eustachian tube dysfunction and concomitant OM, such as Down syndrome, Williams syndrome,
Apert syndrome, Fragile X syndrome, Turner syndrome, cleft palate, and autism.
Chronic allergies have been also implicated as a potential risk factor. Allergic rhinitis has been associated
with OME, most likely due to the inflammation of the mucosa of the middle ear. The rhinitis condition can
be attributable to airborne allergens such as pollen, mold, dust, and dander, as well as nonallergic irritants
such as fumes, odors, and smoke. In general, any allergic reaction that leads to mucosa inflammation and
fluid accumulation in the middle ear may lead to OME. Food allergies have been suggested as a possible
contributory source of chronic OM, but this hypothesis has not been supported by rigorous scientific trials
using control samples (e.g., differentiating between children with OME who suffer rhinitis versus those who
have food allergies). The pathogenic role of food allergies in OM is likely unusual and further research is
In contrast, a promising line of recent research suggests that bacterial biofilms may directly contribute
to conditions of chronic ear infections (Hall-Stoodley et al., 2006). Biofilms are colonizations of bacteria that
attach to surfaces and serve as a defensive barrier for the bacteria. Bacterial biofilms are also resistant to
antibiotics. Children with a history of chronic ear infections, including those who were asymptomatic, have
been found to have bacterial biofilms on their middle ear tissue. These results suggest that recurrent OM
may not be due to reinfection, but to persistent biofilms that are metabolically resistant to antibiotics. While
antibiotic therapy is typically effective for those children with acute OM without the presence of biofilms,
those children with chronic OM typically receive little benefit from antibiotic therapy and are better treated by
myringotomy (surgery to insert tubes in the ear canal, see below).
Monitoring Hearing, Speech, and Language Development
Otitis media with effusion is the most frequent cause of acquired hearing loss in children. The link between
OME and speech and language development is related to fluctuating hearing loss that accompanies
OME. In children who have OME, hearing loss can vary from no hearing loss to a loss of up to 50 decibels.
The majority of children with OME experience mild to moderate hearing loss, which is an average of 25 db
(comparable to putting your hands over your ears). The hearing loss may impair the ability to hear certain
speech sounds and subsequently process those sounds. Infants with greater than 20db average hearing
loss from 12 to 18 months of age have a 33% probability of developing subclinical (i.e., emergent) and clinical
speech disorder by three years of age.
One important consideration is that OM does not always present with specific signs or symptoms.
Therefore, when observing a child it is important to consider that the following behaviors may result from
hearing loss: difficulty paying attention, or diminished attention from previous observations; failure to respond
when spoken to; and sitting closer to audio stimuli such as computer speakers or TV. These behaviors
may be indirect symptoms of temporary and fluctuating hearing loss associated with OM. When a child
has a diagnosed ear infection, however, signs of illness will be much more acute. The child will have a fever,
pull on his or her ear, be irritable, and complain of ear pain.
Children with a history of OM and/or risk factors for OM should have their speech and language development
closely monitored, and need a recent hearing assessment. The hearing assessment is in addition to
the hearing screening completed in the pediatrician’s office. The hearing assessment includes a complete
physical examination of the ear, tests of hearing tone or pure-tone audiometry, tests of middle ear function
such as tympanometry and acoustic reflex measurement, and tests of speech audiometry including speech
reception threshold and tests of word recognition.
Prevention and Treatment
Antibiotic therapy. Frequently, children with OME will not be treated unless the fluid becomes infected
or if hearing loss is observed. When treatment is required, antibiotic therapy is the most common treatment
for acute otitis media. In the United States, ten days of antibiotic therapy is the standard prescription for
treatment of an acute ear infection. However, the effectiveness of antibiotic therapy in treating OME is not
conclusive, as antibiotics have a beneficial but limited effect on treating recurrent otitis media and shortterm
OME, but longer-term benefits on OME have not been found (Williams, Chalmers, Stange, Chalmers,
& Bowlin, 1993). This finding is particularly alarming given reports that antibiotic-resistant infections are on
the rise (CDC, 2006). Research indicates that antibiotic use in treating AOM is not always necessary, except
in persistent cases. When parents are counseled about the course of AOM and cautioned against unnecessary
use of antibiotics, the majority of parents opt to not treat their children with antibiotics.
Surgery. In persistent cases clinicians may recommend that surgery be performed to alleviate the
child’s chronic ear infections. The surgery, known as myringotomy, requires that a pressure equalization
tube (i.e., P.E. tubes) be placed in the child’s middle ear. This tube will allow air to enter the middle ear
space. The air will help the lining of the middle ear heal and will prevent future infections. Surgical tubes will
stay in place for six to twelve months and fall out on their own.
Intervention strategies. Parents and teachers can work together to stress several basic intervention
strategies including: 1) promoting a healthy environment, 2) promoting listening, 3) promoting language
learning, and 4) promoting early literacy learning. Promoting a healthy environment may include frequent
hand and toy washing, and minimizing or eliminating exposure to second-hand cigarette smoke. Promoting
listening involves helping children to hear and understand speech and decreasing background noise to
minimize distractions for children when they need to listen. Activities to promote language learning may include
asking simple questions, listening to what the child has to say, and talking about things that the child is
interested in. Finally, promoting literacy learning can be accomplished through interaction with books, songs and games, such as reading stories aloud to children, describing and explaining the pictures, referring to the
child’s own experiences, giving children books and magazines to look at on their own, and reading aloud
signs and labels encountered daily, such as traffic signs, newspaper headlines, and labels on packages.
ASHA (2005). Hearing assessment. Retrieved August 25, 2006 from http://www.asha.org/public/hearing/
CDC (2006). Get smart: Know when antibiotics work. Retrieved August 25, 2006 from http://www.cdc.gov/
Cornell Pediatrics (2003, February). Otitis media (middle ear infection). Retrieved August 25, 2006 from
Feakes, D., (1996, April). Chronic ear infections: the silent deterrent to academic and social success. Paper
presented at the Annual Early Childhood Conference, Menomonie, WI.
Hall-Stoodley, L. H., Fen, Z. H., Gieseke, A., Nistico, L., Nguyen, D., Hayes, J., et al. (2006). Direct detection
of bacterial biofilms on the middle-ear mucosa of children with chronic otitis media. JAMA, 296, 202-211.
Roberts, J. E., & Zeisel, S. A. (2000). Ear infections and language development. (DOE Publication No. ECI-
2000-9008, pp. 1-15). Washington, DC: U.S. Department of Education.
Williams, R. L., Chalmers, T. C., Stange, K. C., Chalmers, F. T., & Bowlin, S. J. (1993). Use of antibiotics in
preventing recurrent acute otitis media and in treatment otitis media with effusion: A meta-analytic attempt
to resolve the brouhaha [Electronic version]. JAMA, 270, 1344-1351.
Zeisel, S., & Roberts, J. (2003). Otitis media in young children with disabilities. Infants and Young Children,
American Speech-Language-Hearing Association (ASHA): 10801 Rockville Pike, Rockville, MD 20825;
(800) 638-8255; www.asha.org
Kids’ Health (Nemours Foundation) — www.kidshealth.org. See page on middle ear infections, http://www.
Medline Plus (National Library of Medicine/National Institutes of Health); www.nlm.nih.gov/medlineplus/;
see page on ear infections at http://www.nlm.nih.gov/medlineplus/earinfections.html
National Institute on Deafness and Other Communication Disorders (NIDCD) Information Clearinghouse: 1
Communication Avenue, Bethesda, MD 20892; (800) 241-1044; www.nih.gov