Middle Ear Conditions

What is Middle Ear?

The middle ear is the air filled space behind the drum with three little bones (ossicles) and a vent pipe (Eustachian tube) to the back of the nose throat (nasopharynx). The ossicles form a bridge between the drum and the inner ear and the configuration of these bones (the malleus, incus and stapes, or commonly known as hammer, anvil and stirrup) create a significant mechanical advantage by concentrating the sound from the eardrum (about 12 mm diameter) to the plate of the stirrup (about 2 mm diameter). This delicate yet robust anatomy gives us the ability to hear softer sounds – without this structure our ability to hear is fundamentally halved.


Middle Ear Structure

Common Middle Ear Conditions

The most common middle ear condition effecting children is otitis media with effusion, which is sometimes called Glue Ear.

There is always fluid made in the middle ear to lubricate the three little bones, and this usually drains down the Eustachian tube to the back of the nose.

Under conditions where the Eustachian tube is blocked, the partial pressure of gasses in the middle ear is altered. There is an increasing carbon dioxide, which often leads to an enlargement of and an increased number of mucous secreting glands. Fluid is secreted in increased quantities, the natural Eustachian tube is blocked and this fluid builds up. The fluid builds up slowly and tends not to be associated with severe pain.

The eardrum tends to look abnormal: in the early stages, it is indrawn due to the negative pressure associated with blocked Eustachian tube and reabsorption of the normal gases in the middle ear cleft. Thereafter, there may be an air fluid interface as the fluid is starting to build up. Thereafter, there is an opaque drum which is often pushed forward, which when you attempt to move it by insufflating ear has got reduced mobility. Because the fluid is not inert, there are sometimes reactive changes on the eardrum, and the eardrum can appear pink with dilatation of blood vessels.

In otitis media with effusion or Glue Ear, the fluid is sterile.

The persistence of fluid for under 3 months is not considered pathological, and is usually treated by observation.

After 3 months, particularly if the fluid is bilateral, is associated with conductive hearing loss, is causing ear pain, behavioral changes, difficulty with speech, language or learning, then an ENT surgeon may recommend myringotomy and insertion of grommets. This involves a minor general anaesthetic, usually using gas, without the child being paralysed or incubated. A little cut is made in the eardrum, the fluid is sucked out and a small bypass tube or grommet is inserted. These grommets usually stay in the eardrum for 6 to 12 months, fall out by themselves and in the vast majority of cases (over 90 percent) the eardrum closes by itself.

Otitis media is a bacterial or viral infection of the middle ear cleft.

The most common cause is viral and follows viral upper respiratory tract infections. There is an acute viral inflammatory response, fluid is secreted into the middle ear cleft and it is often associated with blockage, severe pain, diminished hearing acuity and occasionally a rise in temperature.

A significant number of acute middle ear infections (otitis media) resolve by eardrum rupturing. This is associated with either bloody or snotty fluid running out of the ear canal, often associated with resolution of the pain that has hitherto been present. Most of these infective perforations heal spontaneously.

Primary bacterial infections of the middle ear cleft are thought to be uncommon. For bacterial middle ear infections to occur, it more commonly is a situation where an initial viral infection gets supra-added bacterial secondary infection.

Clinically, it is not possible to tell the difference between a viral and a bacterial infection. The eardrum tends to be red, bulging, there is associated pain and diminished hearing acuity.

There is a little evidence to suggest that the addition of oral antibiotics aids in the resolution either in terms of time, or completeness apropos bacterial otitis media. There is some evidence the addition of oral antibiotics diminishes the pain.

There is some evidence that the evidence of oral antibiotics reduces the possibility of complications of otitis media.

Middle ear infection in children is probably one of the main areas where antibiotics are overprescribed.


If you or your child is suffering from any middle ear conditions, please contact Havas ENT Clinics for help. You can book an appointment either by filling the form on the right or calling our clinic on 02 9387 7360.

If you doubt you have any conditions on outer ear or inner ear, please find the information here: