Ear Infection in Children and Adults: Diagnosis and Treatment in Pokhara
Ear infections are one of the most common reasons parents bring children to medical care in Nepal. They also affect adults, particularly in a region where chronic ear disease following inadequately treated childhood infections is prevalent. Accurate diagnosis — distinguishing the type of ear infection — determines the correct treatment, and incorrect treatment (antibiotics for a viral infection, or inadequate duration for a bacterial one) contributes to antibiotic resistance and treatment failure.
What Is the Difference Between Acute Otitis Media and Otitis Externa?
Acute otitis media (AOM) is an infection of the middle ear — the space behind the eardrum. It most commonly follows an upper respiratory tract infection, when bacteria or viruses ascend via the Eustachian tube into the normally sterile middle ear. The eardrum bulges outward from fluid accumulation and, if untreated or severe, can perforate.
Otitis externa is an infection of the outer ear canal — the passage between the ear opening and the eardrum. It is caused by bacteria (most commonly Pseudomonas aeruginosa or Staphylococcus aureus) or fungi (usually Aspergillus or Candida). It is commonly called swimmer’s ear because water retention in the canal after swimming or bathing predisposes to it. Pain is reproduced by tugging on the outer ear (tragus or pinna) — a distinguishing clinical sign that is absent in otitis media.
The two conditions require different treatments and are distinguished by clinical examination. A&B ENT’s otoscopy allows direct visualisation of the ear canal and eardrum to make this distinction accurately.
How Do Ear Infection Symptoms Differ Between Infants, Children, and Adults?
Infants cannot report pain. Ear infection in infants presents as irritability, crying (particularly when lying flat, which increases middle ear pressure), disturbed sleep, fever, pulling at or batting the ears, and reduced appetite. These signs are non-specific, and diagnosis in infants requires otoscopic examination.
Toddlers and young children may report ear pain directly and often hold or pull at the affected ear. Fever is common. Hearing may be temporarily reduced, noticed as inattention or increased TV volume. Discharge from the ear indicates eardrum perforation — this typically reduces the pain as the pressure is released, but the infection still requires treatment.
Adults typically report ear pain, a sensation of fullness, hearing loss, and possibly discharge. In otitis externa, pain is often intense and worsened by jaw movement. A watery or purulent discharge accompanies both types, though the character and smell can help distinguish them.
When Are Antibiotics Needed Versus Watchful Waiting?
Most acute otitis media in children is caused by viruses and resolves spontaneously. The evidence supports a strategy of watchful waiting — symptom management with paracetamol for pain and fever — for 48–72 hours in children over 2 years of age with non-severe AOM in one ear.
Antibiotics are indicated immediately in children under 6 months, children with AOM in both ears, children with ear discharge (indicating perforation), children with high fever (above 39°C), severe pain, or those who appear unwell. In adults, the threshold for antibiotic treatment is lower than in children.
Amoxicillin is the first-line oral antibiotic for AOM. Amoxicillin-clavulanate is used for treatment failures or where beta-lactamase-producing organisms are suspected. Duration is 10 days in children under 2, 5–7 days in older children and adults.
Antibiotic overuse for viral ear infections contributes to the development of antibiotic-resistant bacteria — a significant problem in Nepal. Appropriate watchful waiting is not inadequate care; it is evidence-based medicine.
What Is Chronic Suppurative Otitis Media and Why Is It So Common in Nepal?
Chronic suppurative otitis media (CSOM) is defined as persistent discharge through a perforated eardrum for more than 2 weeks. It is the most important chronic ear condition in Nepal and the leading cause of preventable hearing loss in the country.
CSOM develops when acute otitis media is inadequately treated — whether due to non-completion of antibiotic courses, inaccessibility of care, or the use of ineffective antibiotics — and the eardrum perforates and fails to heal. The middle ear becomes chronically colonised with bacteria. Repeated episodes of discharge occur, often with each upper respiratory infection.
The hearing loss in CSOM is conductive, arising from both the eardrum perforation and any ossicular chain damage. Left untreated, the degree of hearing loss accumulates. Cholesteatoma — an abnormal proliferation of squamous epithelium into the middle ear — is the most dangerous complication, capable of eroding bone including the ossicles, the bone surrounding the facial nerve, and the barrier between the middle ear and the brain.
What Are the Complications of Untreated Ear Infections?
Complications of untreated or under-treated otitis media include mastoiditis (infection spreading to the mastoid bone behind the ear — causing post-auricular swelling and tenderness), meningitis, cerebral abscess, lateral sinus thrombosis, and facial nerve palsy. These complications, while uncommon, are serious and potentially life-threatening. They represent the cost of inadequate treatment of a condition that is often perceived as trivial.
In resource-limited settings in Nepal, these complications still present, typically in patients who have had prolonged untreated CSOM.
What Is the Surgical Treatment for CSOM?
Myringoplasty closes the eardrum perforation. When the middle ear structures are damaged, tympanoplasty addresses both the eardrum and the ossicular chain. When cholesteatoma is present, mastoidectomy — surgical removal of diseased tissue from the mastoid — is required.
Surgery for CSOM is performed under general anaesthesia and is curative in the majority of cases, arresting progression, eliminating discharge, and restoring hearing to a degree depending on pre-operative damage. Long-term follow-up is important to monitor for recurrence.
What Are Grommets and When Are They Used?
Grommets (ventilation tubes) are small tubes inserted through the eardrum to ventilate the middle ear in otitis media with effusion (glue ear) — a condition where the Eustachian tube fails to equalise middle ear pressure, leading to chronic fluid accumulation and conductive hearing loss.
They are indicated in children with persistent bilateral glue ear causing hearing loss of 25 dB or more for at least 3 months, particularly when it is affecting speech and language development or educational performance. Grommets fall out spontaneously within 6–18 months as the eardrum heals. In the majority of cases, a single set of grommets is sufficient.
A&B International Hospital
Pokhara-02, Bindhyaabasini Way to Sarangkot
Phone: +977 061-412512
Website: abinthospital.com
For ear pain, discharge, or hearing problems in children or adults, an ENT assessment at A&B International Hospital provides accurate diagnosis and appropriate treatment. Do not allow recurrent ear infections to become a source of permanent hearing loss. ECHS polycards accepted.
