Persistent Ear Pulling in Infants Without Fever or Illness
In an infant pulling or scratching at their ears for several weeks without fever or other signs of illness, the most likely diagnosis is otitis media with effusion (OME), though normal examination findings are also common and should not be dismissed.
Diagnostic Approach
Most Common Causes in This Clinical Scenario
The three most common findings in infants presenting with persistent ear pulling are 1:
- Normal examination (46.1%) - Most infants referred for ear pulling have completely normal ear examinations 1
- Cerumen impaction (37.2%) - Earwax buildup is the second most common finding 1
- Otitis media with effusion (16.7%) - Fluid behind the eardrum without acute infection 1
Key Distinguishing Features
Timing of symptoms matters significantly 1:
- If ear pulling occurs only when falling asleep, normal examination is most likely 1
- If occurring a few times daily, cerumen is most common 1
- If occurring throughout the day with additional complaints, OME becomes more likely 1
Why OME Occurs Without Fever or Illness
OME develops through two primary mechanisms 2:
- Eustachian tube dysfunction - The fundamental cause allowing fluid accumulation in the middle ear, particularly common in children aged 6 months to 4 years due to immature anatomy 2
- Post-viral inflammation - Following upper respiratory infections, 24% of children aged 6-47 months develop OME, though the acute infection has resolved 2
Critical point: OME is characterized by middle ear fluid without signs of acute infection (no fever, no severe ear pain, no acute illness) 3. This distinguishes it from acute otitis media (AOM), which presents with fever, acute pain, and bulging tympanic membrane 3.
Examination Findings to Assess
For OME diagnosis, look for 3:
- Reduced tympanic membrane mobility on pneumatic otoscopy 3
- Opaque tympanic membrane 3
- Visible air-fluid level behind the tympanic membrane 3
- Reduced mobility on tympanometry 3
The ear examination may be completely normal despite persistent ear pulling, which occurred in nearly half of infants in clinical studies 1.
Management Recommendations
If OME is Diagnosed
Watchful waiting for 3 months is the standard approach 3:
- OME frequently resolves spontaneously, with 90% of children experiencing at least one episode by age 2 years 2
- Re-examine at 3-6 month intervals until effusion resolves 3
- Do NOT use antibiotics, antihistamines, or decongestants - these are ineffective for OME and should not be used 3
Hearing testing is indicated if 3:
- OME persists for 3 months or longer 3
- Language delay or learning problems are suspected at any time 3
- Significant hearing loss is suspected 3
If Examination is Normal
Consider non-otologic causes 1:
- Self-soothing behavior, particularly if only occurring at sleep time 1
- Developmental/behavioral factors - in one study, parental depression was identified in 16% of infants with normal ear examinations and persistent ear pulling 1
- Teething or other sources of referred discomfort 4, 5
If Cerumen is Present
Simple cerumen removal resolves the symptom 1. This is straightforward and should be addressed if identified.
Common Pitfalls to Avoid
Do not assume all ear pulling means acute infection 1:
- The absence of fever, irritability, or acute illness makes AOM unlikely 3
- AOM requires moderate-to-severe tympanic membrane bulging, acute onset (<48 hours) of symptoms, or otorrhea 3
Do not over-refer initially 1:
- Infants referred directly by families have significantly higher rates of normal examinations compared to those referred by physicians 1
- Initial assessment by primary care with pneumatic otoscopy is appropriate 3
Do not prescribe antibiotics for OME 3:
- Antimicrobials do not have long-term efficacy for OME 3
- Prolonged or repetitive antibiotic courses are strongly discouraged 3
When to Escalate Care
Refer to otolaryngology if 3:
- OME persists beyond 3 months with hearing loss 3
- Structural abnormalities of the eardrum or middle ear are suspected 3
- Language delay or developmental concerns emerge 3
Document for referral 3: