The warm, moist environment of the middle ear is exactly the type of place pathogens thrive, and a child’s narrow nasal passages and large adenoids help create just such a space.  Connected to the back of the nose by the Eustachian tube, the middle ear becomes a breeding ground for pathogens when the tube becomes blocked and fluid accumulates, often after a respiratory virus has caused increased secretions and swelling.  Over 2 million children in the United States experience fluid in the middle ear each year but the presence of fluid alone does not mean there is an infection.   For school nurses frequently assessing complaints of otalgia, or earache, it’s important to understand the various types of ear infections and be prepared to provide parents and guardians appropriate guidance and recommendations for follow-up care.

Types Of Ear Infections

• Acute otitis media (AOM) is the most common ear infection and although incidence is most high in very young children, ages 6 to 18 months, it can be extremely common up until age 8. AOM has a sudden onset, typically following a respiratory infection, when fluid trapped behind the eardrum becomes infected, causing swelling/bulging of the eardrum.  Symptoms can include pain, fever, and hearing loss.
• Otitis media with effusion (OME) most often occurs after acute otitis media has run its course and there is no active infection but fluid remains trapped behind the eardrum. It can also be caused by a blocked or dysfunctional eustachian tube, not related to a past acute infection.  Sometimes known as “silent ear infections” due to the lack of symptoms that may be present, signs of OME can include hearing changes, loss of balance, and delayed speech.
• Chronic otitis media with effusion (COME) happens when fluid persistently returns or simply stays in the middle ear. This can cause significant hearing loss and difficulty fighting new infections.

Otoscope Assessment

As part of the focused assessment for a student presenting with otalgia, when there are no signs of redness or pain of the external ear canal, otoscopy may be used.  The National Association of School Nurses recommends first gently inserting the scope into the ear to avoid pushing any foreign bodies further into the ear canal.  Upon insertion, close observation should be taken for impacted cerumen or foreign objects before inspecting the tympanic membrane.  Scarring of the eardrum may indicate chronic otitis media or a prior history of myringotomy tubes.  Acute otitis media may be marked by abnormal light reflex and a bulging, red, and rigid tympanic membrane, while otitis media with effusion is evidenced by clear fluid behind the eardrum without any redness or bulging.

Interventions and Follow-up

While 50% of antibiotics for preschoolers in the United States are prescribed for ear infections, approximately 80% of children with AOM will get better without any antibiotics.  A healthcare provider evaluation is imperative to appropriately diagnose and determine a treatment plan that may or may not include antibiotics.  Pain management is critical as otalgia can disrupt learning and result in academic setbacks and social/emotional disturbances.  If ordered and permitted by policy and consent, analgesics should be administered and dry warmth may be used for further pain relief.

An ear infection that persists and remains untreated may lead to other head infections, permanent hearing loss, and speech and language delays.  Thorough assessment and attentive intervention by the school nurse, along with detailed communication with parents and healthcare providers can support students complaining of otalgia staying in school while also keeping their ears healthy.