Ear Infections

Ear infections are a relatively common problem that can affect anyone. The term ear infection can refer to a problem in the outer ear or the middle ear. The drawing below demonstrates the anatomy of the ear. The outer ear and middle ear are separated by the eardrum, or tympanic membrane. Thus, an outer ear infection takes place in the skin lined cylinder of the ear canal. A middle ear infection occurs in the space behind the eardrum.

Outer Ear Infection (Otitis Externa)

Infections in the ear canal can be either bacterial or fungal, or sometimes both. These can be caused by moisture trapped in the ear, such as after swimming (thus an outer ear infection is sometimes called Swimmer’s Ear). Diabetes can also predispose patients to outer ear infections, particularly fungal infections. Other triggers include trauma to the ear canal from Q-tips or other objects, or moisture trapping from prolonged hearing aid use. However, it many cases, the infection occurs spontaneously. Symptoms can include pain, drainage, itching, and sometimes hearing loss. The pain can be reproduced by pulling on the ear, or by pushing on the small bump of tissue in front of the ear, called the tragus. The discharge is typically foul smelling. Fungal infections tend to be very itchy.

A mild case of otitis externa can sometimes be managed without any medication. One key is to keep the ear dry. You can use a cotton ball coated with Vaseline to keep water out of the ear when bathing. Avoid wearing a hearing aid in the ear until symptoms resolve. You can treat a mild ear infection with a 50/50 mixture of rubbing alcohol and white vinegar, using 4-5 drops in the ear 2-3 times daily until symptoms resolve. Don’t use this technique if there may be a hole in the ear drum as it will be painful. More significant infections will require visiting an otolaryngologist to clean the ear in the office and treat with appropriate medications. 

If you are predisposed to Swimmer’s Ear, you can decrease the risk by using ear plugs during water activity. After water exposure, you can use the alcohol/vinegar mixture and/or dry the ears using a blow dryer on a low heat setting about one foot away from the ear to dry any moisture.

Middle Ear Infection (Otitis Media)

A middle ear infection is caused by bacteria that grows in fluid trapped behind the eardrum. The middle ear is an air-filled space behind the eardrum. Within this space, there are three small hearing bones which help to transfer soundwaves from the eardrum to the inner ear. More information on the mechanism of hearing can be found here. The small air pocket in the middle ear is connected to the back of the nose by a passageway called the eustachian tube. When you swallow or yawn and feel the ear “pop,” this is due to the eustachian tube opening and equalizing the pressure in the middle ear. If this system doesn’t work properly, abnormal pressure may develop in the middle ear causing fluid to collect. This will initially cause a feeling of stuffiness in the ear along with hearing loss. If bacteria grows in the fluid, a middle ear infection will develop. This will then cause pain in the ear. If too much swelling occurs in the middle ear with an infection, sometimes it will cause the eardrum to break allowing the drainage of the infected fluid into the ear canal. At this point, you make begin to notice a foul-smelling fluid draining from the ear. This process can be quite painful, though after the eardrum ruptures, it may alleviate the pain as the pressure is relieved.

Children can be predisposed to middle ear infections as their eustachian tubes sometimes don’t work well. If a child is suffering from recurrent ear infections, small tubes can be placed through the eardrums to equalize the middle ear pressure. Fortunately, children will often outgrow this problem with age. Abnormal pressure changes such as flying or scuba diving can cause trauma to the middle ear with subsequent accumulation of fluid and possible infection. Middle ear infections can also be the result of swelling in the nose which impairs the function of the eustachian tube opening. Common examples are nasal allergies, chronic sinusitis, and the common cold.

Some middle ear infections can resolve without antibiotics. Over the counter anti-inflammatories such as Ibuprofen can help with swelling and pain. Decongestants such as Sudafed or Afrin nasal spray will help to open the eustachian assisted by “popping” the ears by gently trying to blow out with the nose pinched and lips closed tightly. With more significant symptoms, antibiotics will be prescribed and possibly oral steroids. If otitis media is a recurrent issue, tubes can also be placed in the adult ear to prevent continued infections. 

Tympanic membrane perforations and Cholesteatoma

After the eardrum ruptures, it is often able to spontaneously heal itself. However, if this does not occur, a patient may be left with a hole or perforation in the drum. This can cause persistent hearing loss and predispose the patient to middle ear infections. See here for more information on management of tympanic membrane perforations and surgery to repair them (called tympanoplasty).

Patients with chronic eustachian tubes problems can develop a particular condition called cholesteatoma. In this condition, the eardrum becomes retracted inward due to the chronic negative pressure and can develop a pocket where skin debris begins to accumulate. This can cause recurrent infections in the ear, along with hearing loss. See here for more information on cholesteatoma and surgery to address this condition.