Acute otitis media (AOM) is a painful infection of the middle ear, the portion of the ear behind the eardrum. (Another form of ear infection, otitis externa or swimmer's ear, is entirely different and is not covered here.)
AOM often follows a cold, sore throat, or other respiratory illness. Although it can affect adults, this occurs primarily in infants and young children. It's estimated that by age 7, up to 95% of all children in the US will have experienced at least one bout of AOM—it's the most common reason parents take a child to the doctor.
When the Eustachian tube connecting the upper part of the throat to the middle ear is blocked by a cold's mucus and swelling, fluids pool behind the eardrum, providing an ideal place for bacteria to grow; an infection may set in, generating even more fluid. The pressure this exerts on the eardrum can be intensely painful. The eardrum turns red and bulges. Children too young to explain their discomfort cry, fuss, and pull at their ears. They might also appear unresponsive because they can't hear well—fluid buildup in the middle ear prevents the eardrum and small bones in the ear from moving, causing temporary hearing loss.
In addition, a complication called secretory otitis media (fluid build-up in the middle ear) may develop and cause continuous hearing loss for months. Other possible, though rare, complications of AOM include mastoiditis (an infection of the bone behind the ear) and spinal meningitis.
Without treatment, most middle ear infections resolve on their own, often through a harmless rupture of the eardrum.1 In the Netherlands, pediatricians take a conservative approach, generally waiting 24 to 72 hours until they are certain an ear infection warrants antibiotics.2,32
US doctors, however, tend to initiate treatment early. This practice has been criticized on several grounds. First, aggressive antibiotic treatment has not been found effective in preventing complications, such as serous otitis,3 pneumococcal meningitis,4 or hearing loss.33
In addition, antibiotic treatment does not even appear to help AOM itself very much. For example, a double-blind, placebo-controlled trial of 240 children ages 6 months to 2 years found so little benefit with antibiotic treatment that the authors recommended physician-supervised watchful waiting rather than immediate treatment.5
In other published reviews, the benefits of antibiotics for AOM have also been found less than impressive. A review of 33 randomized trials involving 5,400 children concluded that antibiotics modestly improved the rate of recovery.6 An evaluation of six randomized, controlled studies concluded that early antibiotic use had only slight benefit, reducing pain and fever in a small percentage of children and helping to prevent the development of infection in the other ear, but not significantly speeding up recovery of hearing.7 Modest benefits were also seen in a more recent trial of 315 children.8 Another study found that children with recurrent ear infections do not appear to benefit from preventive antibiotic treatment.9 A meta-analysis (formal statistical review) concluded that antibiotic treatment may be helpful in children younger than two years old who have infections in both ears, and in children with drainage from the ear, but for other children it may be preferable to delay use of antibiotics.36
However, the claim (often made in alternative medicine circles) that early antibiotic treatment causes an increased rate of ear infection recurrence does not appear to be correct.10
Note: Despite the issues raised above, simply withholding antibiotic treatment can be dangerous. Any child who appears to have an ear infection should be seen by a physician.
When ear infections do reoccur frequently, a physician may insert a tube into the infected ear to drain fluids and relieve pressure, a procedure called tympanostomy. Nearly one million American children undergo this procedure each year; however, its usefulness is somewhat controversial.11-13
Although there is as yet no natural treatment for AOM, there are several promising approaches parents can take that may help prevent children from developing ear infections or reduce symptoms.
A natural sugar found in plums, strawberries, and raspberries, xylitol is used as a sweetener in some "sugarless" gums and candies. One of its advantages is that it inhibits the growth of Streptococcus mutans, a type of bacteria that causes dental cavities.14 Xylitol also inhibits the growth of a related bacteria species, Streptococcus pneumoniae, implicated in ear infections.15 Additionally, xylitol acts against Haemophilus influenza, another bacteria that frequently causes ear infections.16
Based on this evidence, xylitol has been tried as a preventive treatment for middle ear infections with some success. Two well-designed studies enrolling a total of 1,163 children found that when taken 5 times daily throughout a large portion of the cold season, chewing gum and syrup sweetened with xylitol helped prevent middle ear infections. However, xylitol has not proved effective when taken 3 times daily rather than 5 times daily, nor when it is used only after the onset of a respiratory infection.
In one of the positive studies, 857 children were given either placebo or xylitol 5 times daily in the form of chewing gum, syrup, or lozenges.17 Over the next two-month study period, the gum proved distinctly effective, reducing the risk of developing AOM by a full 40%. Xylitol syrup was also effective, but less so. The lozenges didn't prove effective; researchers speculated that children got tired of suckingn the large candies and didn't get the proper dose of xylitol. (In addition, the children were able to distinguish between the xylitol and placebo lozenges by taste, making that portion of the study single-blind.) Similarly positive results had been seen in an earlier three-month, double-blind study by the same researchers, evaluating about 300 children, and again using a dosing schedule requiring use of xylitol 5 times daily.18
Another issue with the studies is that taking xylitol many times throughout the day requires a lot of effort. Because of this, researchers set out to discover whether it would still work if taken only 3 times daily. Unfortunately, in their 3-month, double-blind, placebo-controlled study of 663 children, no benefits were seen.38 Another study, this one enrolling 1,277 children, took a different approach to simplifying the use of xylitol: they used the original dosage schedule, but began treatment only after a respiratory infection had begun, rather than over a period of many months.39 Again, no benefits were seen.
Authors who published a careful review of this evidence did find support for the use of xylitol to prevent ear infections, especially in healthy children attending day care.42 They pointed out, though, the need for more trials from a range of researchers.
For more information, including dosage and safety issues, see the full Xylitol article.
Breastfeeding may help prevent AOM. Numerous studies tracking ear infection frequency in large groups of infants found that the infants who were breastfed exclusively had significantly fewer middle ear infections than those fed formula.19-21 Such observational studies aren't as reliable as placebo-controlled or double-blind designs, but the results do suggest that breastfeeding is a good preventive measure.
Researchers aren't sure how breast milk might protect infants from ear infections. Studies attempting to determine if breast milk inhibits bacteria associated with AOM have yielded mixed results.22,23
Environmental conditions may predispose a child to middle ear infections. A study of 132 daycare students found that the 45 children exposed to cigarette smoke at home had a 38% higher risk of middle ear infections than the 87 children whose parents didn't smoke.24
The herbs mullein and garlic are traditionally combined with other herbs in oily ear drops designed to reduce the pain of ear infections. One study supports this use. Two double-blind trials enrolling a total of more than 250 children with eardrum pain caused by middle ear infection compared the effectiveness of an herbal preparation containing mullein, garlic, St. John’s wort, and calendula against a standard anesthetic ear drop product (ametocaine and phenazone).30,31 The results indicated that the two treatments were equally effective. In addition, one of the studies found that use of the antibiotic amoxicillin did not add additional benefit.
However, due to the strong placebo response in pain conditions, this study would have needed a placebo group to provide truly dependable evidence that the herbs were effective.
Keep in mind that while herbal eardrop products may relieve pain, the actual infection is on the other side of the eardrum, and it is not immediately clear how the herbs can get to where they could do any good. There is some evidence, however, that essential oils of herbs may be able to penetrate the eardrum and reach the other side.35 However, essential oils can be toxic as well as irritating to tissues.
Note: Garlic and its oil are too harsh to instill into the ear. Herbal drops that contain garlic use much milder extracts of the herb.
Allergies may contribute to ear infections, possibly by increasing the amount of fluid in the middle ear. There is some evidence that children allergic to pollens, dust, molds, and foods may be more likely to develop AOM.25-27 Weak evidence suggests that a food allergen elimination diet might help prevent middle ear infections.28,29
Numerous natural products have been proposed for preventing or treating ear infections. These include all herbs and supplements used for colds, including echinacea, probiotics (such as acidophilus), zinc, vitamin C, andrographis, garlic, and ginseng. However, there is no direct evidence that any of these treatments are effective for AOM. In the case of echinacea, at least 2 studies specifically found no benefit.34,40 There is mixed evidence for the effectiveness of probiotics.37,41
This topic is also discussed in the Homeopathy Database, under the chapter name Ear Infections.
1. Rosenfeld RM, Vertrees JE, Carr J, et al. Clinical efficacy of antimicrobial drugs for acute otitis media: metaanalysis of 5400 children from thirty-three randomized trials. J Pediatr. 1994;124:355-367.
2. Rosenfeld RM, Vertrees JE, Carr J, et al. Clinical efficacy of antimicrobial drugs for acute otitis media: metaanalysis of 5400 children from thirty-three randomized trials. J Pediatr. 1994;124:355-367.
3. Kaleida PH, Casselbrant ML, Rockette HE, et al. Amoxicillin or myringotomy or both for acute otitis media: results of a randomized clinical trial. Pediatrics. 1991;87:466-474.
4. Rothrock SG, Harper MB, Green SM, et al. Do oral antibiotics prevent meningitis and serious bacterial infections in children with Streptococcus pneumoniae occult bacteremia? A meta-analysis. Pediatrics. 1997;99:438-444.
5. Damoiseaux RA, van Balen FA, Hoes AW, et al. Primary care based randomized, double blind trial of amoxicillin versus placebo for acute otitis media in children aged under 2 years. BMJ. 2000;320:350-354.
6. Rosenfeld RM, Vertrees JE, Carr J, et al. Clinical efficacy of antimicrobial drugs for acute otitis media: metaanalysis of 5400 children from thirty-three randomized trials. J Pediatr. 1994;124:355-367.
7. Del Mar C, Glasziou P, Hayem M. Are antibiotics indicated as initial treatment for children with acute otitis media? A meta-analysis. BMJ. 1997;314:1526-1529.
8. Little P, Gould C, Williamson I, et al. Pragmatic randomised controlled trial of two prescribing strategies for childhood acut otitis media. BMJ. 2001;322:336-342.
9. Alho O-P, Laara E, Oja H. What is the natural history of recurrent acute otitis media in infancy? J Fam Pract. 1996;43:258-264.
10. Kaleida PH, Casselbrant ML, Rockette HE, et al. Amoxicillin or myringotomy or both for acute otitis media: results of a randomized clinical trial. Pediatrics. 1991;87:466-474.
11. Le CT, Freeman DW, Fireman BH. Evaluation of ventilating tubes and myringotomy in the treatment of recurrent or persistent otitis media. Pediatr Infect Dis J. 1991;10:2-11.
12. Alho O-P, Laara E, Oja H. What is the natural history of recurrent acute otitis media in infancy? J Fam Pract. 1996;43:258-264.
13. Kaleida PH, Casselbrant ML, Rockette HE, et al. Amoxicillin or myringotomy or both for acute otitis media: results of a randomized clinical trial. Pediatrics. 1991;87:466-474.
14. Gales MA, Nguyen TM. Sorbitol compared with xylitol in prevention of dental caries. Ann Pharmacother. 2000;34:98-100.
15. Uhari M, Kontiokari T, Niemela M. A novel use of xylitol sugar in preventing acute otitis media. Pediatrics. 1998;102:879-884.
16. Kontiokari T, Uhari M, Koskela M. Antiadhesive effects of xylitol on otopathogenic bacteria. J Antimicrob Chemother. 1998;41:563-565.
17. Uhari M, Kontiokari T, Niemela M. A novel use of xylitol sugar in preventing acute otitis media. Pediatrics. 1998;102:879-884.
18. Uhari M, Kontiokari T, Koskela M. Xylitol chewing gum in prevention of acute otitis media: double blind randomised trial. BMJ. 1996;313:1180-1184.
19. Duncan B, Ey J, Holberg CJ, et al. Exclusive breast-feeding for at least 4 months protects against otitis media. Pediatrics. 1993;91:867-872.
20. Sassen ML, Brand R, Grote JJ. Breast-feeding and acute otitis media. Am J Otolaryngol. 1994;15:351-357.
21. Aniansson G, Alm B, Andersson B, et al. A prospective cohort study on breast-feeding and otitis media in Swedish infants. Pediatr Infect Dis J. 1994;13:183-188.
22. Kaleida PH, Nativio DG, Chao HP. Prevalence of bacterial respiratory pathogens in the nasopharynx in breastfed versus formula-fed infants. J Clin Microbiol. 1993;31:2674-2678.
23. Rosen IA, Hakansson A, Aniansson G. Antibodies to pneumococcal polysaccharides in human milk: lack of relationship to colonization and acute otitis media. Pediatr Infect Dis J. 1996;15:498-507.
24. Etzel RA, Pattishall EN, Haley NJ, et al. Passive smoking and middle ear effusion among children in day care. Pediatrics. 1992;90:228-232.
25. Hurst DS. Association of otitis media with effusion and allergy as demonstrated by intradermal skin testing and eosinophil cationic protein levels in both middle ear effusions and mucosal biopsies. Laryngoscope. 1996;106:1128-1137.
26. McMahan JT, Calenoff E, Croft DJ, et al. Chronic otitis media with effusion and allergy: modified RAST analysis of 119 cases. Otolaryngol Head Neck Surg. 1981;89:427-431.
27. McGovern JP, Haywood TJ, Fernandez AA. Allergy and secretory otitis media. An analysis of 512 cases. JAMA. 1967;200:134-138.
28. Ruokonen J, Paganus A, Lehti H. Elimination diets in the treatment of secretory otitis media. Int J Pediatr Otorhinolaryngol. 1982;4:39-46.
29. Nsouli TM, Nsouli SM, Linde RE, et al. Role of food allergy in serous otitis media. Ann Allergy. 1994;73:215-219.
30. Sarrell EM, Mandelberg A, Cohen HA. Efficacy of naturopathic extracts in the management of ear pain associated with acute otitis media. Arch Pediatr Adolesc Med. 2001;155:796-799.
31. Sarrell EM, Cohen HA, Kahan E. Naturopathic treatment for ear pain in children. Pediatrics. 2003;111:E574-E579.
32. Pappas DE, Owen Hendley. J Otitis media. A scholarly review of the evidence. Minerva Pediatr. 2003;55:407-414.
33. Butler CC, Van Der Linden MK, MacMillan HL, et al. Should children be screened to undergo early treatment for otitis media with effusion? A systematic review of randomized trials. Child Care Health Dev. 2003;29:425-432.
34. Aldous MB, Wahl R, Worden K, Grant KL. A randomized, controlled trial of cranial osteopathic manipulative treatment and echinacea in children with recurrent otitis media [abstract 1062]. 2003 Pediatric Academic Societies' Annual Meeting; May 3-6, 2003; Seattle, WA.
35. Kristinsson KG, Magnusdottir AB, Petersen H, et al. Effective treatment of experimental acute otitis media by application of volatile fluids into the ear canal. J Infect Dis. 2005;191:1876-1880.
36. Rovers MM, Glasziou P, Appelman CL, et al. Antibiotics for acute otitis media: a meta-analysis with individual patient data. Lancet. 2006;368:1429-1435.
37. Hatakka K, Blomgren K, Pohjavuori S, et al. Treatment of acute otitis media with probiotics in otitis-prone children: a double-blind, placebo-controlled randomised study. Clin Nutr. 2007 Mar 10. [Epub ahead of print]
38. Hautalahti O, Renko M, Tapiainen T, et al. Failure of xylitol given three times a day for preventing acute otitis media. Pediatr Infect Dis J. 2007;26:423-427.
39. Tapiainen T, Luotonen L, Kontiokari T, et al. Xylitol administered only during respiratory infections failed to prevent acute otitis media. Pediatrics. 2002;109:E19.
40. Wahl RA, Aldous MB, Worden KA, et al. Echinacea purpurea and osteopathic manipulative treatment in children with recurrent otitis media: a randomized controlled trial. BMC Complement Altern Med. 2008;8:56.
41. Rautava S, Salminen S, Isolauri E. Specific probiotics in reducing the risk of acute infections in infancy—a randomised, double-blind, placebo-controlled study. Br J Nutr. 2008 Nov 6.
42. Azarpazhooh A, Limeback H, Lawrence HP, Shah PS. Xylitol for preventing acute otitis media in children up to 12 years of age. Cochrane Database Syst Rev. 2011;11:CD007095.
Last reviewed December 2015 by EBSCO CAM Review Board
Last Updated: 12/15/2015
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