Can an ear infection cause vomiting in a child?

Can Ear Infections Cause Vomiting in Children?

Yes, vomiting can be a nonspecific symptom of ear infections in children, though it is not among the most common symptoms. 1

Relationship Between Ear Infections and Vomiting

Ear infections (otitis media) can present with various symptoms beyond the ear-specific ones. According to the Nature Reviews Disease Primers guideline on otitis media:

• Vomiting is listed among the nonspecific symptoms that may accompany acute otitis media (AOM) 1
• While ear pain is the most consistent symptom (present in only 50-60% of children with AOM), nonspecific symptoms like vomiting can occur 1
• Other nonspecific symptoms include fever, irritability, sleep disturbance, and anorexia 1

Types of Ear Infections and Their Symptoms

Acute Otitis Media (AOM)

• Primary symptoms: ear pain, bulging tympanic membrane, recent onset of ear pain, erythema of tympanic membrane 1
• Nonspecific symptoms: fever, vomiting, irritability, sleep disturbance 1
• Severe AOM is defined as having moderate-to-severe ear pain, ear pain for at least 48 hours, or temperature ≥39°C 2

Otitis Media with Effusion (OME)

• Defined as fluid in the middle ear without signs or symptoms of acute infection 1
• May cause hearing problems, subtle symptoms like ear rubbing, clumsiness, disturbed sleep 2
• Less likely to cause vomiting compared to AOM

Diagnostic Considerations

When a child presents with vomiting, ear infection should be considered among the differential diagnoses, but other more common causes should be ruled out first:

• Viral gastroenteritis is the most common cause of acute vomiting in children 3
• Other serious causes of vomiting in children include intestinal obstruction, intussusception, increased intracranial pressure, and metabolic disorders 1
• Bilious vomiting requires immediate attention as it suggests intestinal obstruction 4

When to Suspect Ear Infection as Cause of Vomiting

• When vomiting is accompanied by ear-specific symptoms (pain, tugging)
• When other common causes of vomiting have been ruled out
• When examining a child with vomiting, always check the ears, especially in younger children who cannot verbalize ear pain 1

Diagnostic Approach

1. Otoscopic examination: The primary diagnostic method for ear infections

   • Look for bulging tympanic membrane, which is most useful for diagnosing AOM 1
   • Pneumatic otoscopy is recommended for accurate diagnosis 1

2. Consider symptom severity:

   • Vomiting with ear pain and fever suggests more severe infection
   • Isolated vomiting without ear-specific symptoms is less likely to be from ear infection alone

Management Implications

If vomiting is determined to be related to an ear infection:

1. For AOM with vomiting:

   • Antimicrobial treatment is recommended for children under 2 years 5
   • For children ≥2 years, antibiotics are recommended if temperature ≥39°C, bilateral otitis media, or toxic appearance 5
   • Amoxicillin is the drug of choice 5

2. For children with ear tubes:

   • Topical antibiotic eardrops (ofloxacin or ciprofloxacin-dexamethasone) are the best treatment 1
   • Children with ear tubes who develop infections typically do not have fever 2

When to Seek Immediate Medical Attention

Parents should seek immediate medical attention if their child with suspected ear infection has:

• Persistent vomiting leading to signs of dehydration
• Severe ear pain with vomiting
• Vomiting with neurological symptoms (altered consciousness, severe headache)
• Bilious vomiting 3

Pitfalls and Caveats

1. Don't assume vomiting is always from gastroenteritis

   • Always consider ear examination in a child with unexplained vomiting

2. Don't miss serious causes of vomiting

   • Vomiting can be a symptom of increased intracranial pressure 1
   • Bilious vomiting suggests intestinal obstruction until proven otherwise 4

3. Don't overlook ear infections in preverbal children

   • Young children cannot verbalize ear pain and may present with nonspecific symptoms like vomiting and irritability 1

4. Remember that symptoms alone have poor diagnostic accuracy

   • Physical examination with otoscopy is essential for diagnosis 1