Can ear infections in pediatric patients under 5 years old cause a barky cough?

Ear Infections Do Not Cause Barky Cough in Children

Ear infections (otitis media) do not cause barky cough in pediatric patients under 5 years old. Barky cough is characteristic of croup (laryngotracheobronchitis), which involves inflammation of the upper airway, not the middle ear. While ear infections are extremely common in young children, they present with ear pain, fever, and irritability—not cough 1, 2.

Why This Distinction Matters

Otitis Media Presentation

• Acute otitis media (AOM) presents with rapid onset of ear pain, fever, and a bulging tympanic membrane—not respiratory symptoms like cough 1.
• Otitis media with effusion (OME) may occur during upper respiratory infections but is characterized by fluid in the middle ear without acute infection signs, and does not directly cause cough 1.
• The most common bacterial pathogens in AOM are Streptococcus pneumoniae, nontypable Haemophilus influenzae, and Moraxella catarrhalis—none of which cause barky cough 3.

The Arnold Ear-Cough Reflex: A Rare Exception

• In approximately 2.3% to 4.2% of people, the Arnold ear-cough reflex can be elicited through the auricular branch of the vagus nerve, but this causes chronic cough, not acute barky cough 1.
• This reflex can be triggered by ear canal stimulation from wax impaction or cholesteatoma, but the prevalence in children with chronic cough is similar to healthy children 1.
• This is considered a very rare cause of childhood chronic cough and would not explain acute barky cough 1.

What Actually Causes Barky Cough

Upper Respiratory Tract Infections

• Barky cough is characteristic of viral croup (laryngotracheobronchitis), which affects the larynx and trachea, not the middle ear 4.
• The mean annual incidence of total respiratory illness ranges from 5 to 8 per person-year in children under 4 years of age 1.
• Viral upper respiratory tract infections are the most common cause of acute cough in children, and these may coincidentally occur alongside ear infections but are separate pathologies 1, 4.

Important Clinical Pitfall

• When a child presents with both ear infection and barky cough, these are likely two concurrent but separate conditions—both triggered by the same viral upper respiratory infection 1.
• The ear infection does not cause the cough; rather, both are manifestations of the same viral illness affecting different anatomical sites 1, 2.

Practical Clinical Approach

When You See Both Conditions Together

• Treat the ear infection according to otitis media guidelines (antibiotics for children 6 months to 2 years with purulent discharge or severe symptoms) 5.
• Manage the barky cough as viral croup with supportive care—the two conditions require separate treatment approaches 4.
• Do not attribute the barky cough to the ear infection, as this may delay appropriate diagnosis and management of the upper airway pathology 6.

Red Flags Requiring Further Evaluation

• If barky cough persists beyond 3-4 weeks, this transitions to chronic cough and warrants systematic evaluation using pediatric-specific algorithms 7, 8.
• Respiratory rate >70 breaths/min, difficulty breathing, grunting, or cyanosis require immediate medical attention 8.

Common Misconceptions to Avoid

• Do not use over-the-counter cough medications in children under 2 years—they lack proven efficacy and have significant safety concerns, including reported deaths 8, 4.
• Do not assume common causes of chronic cough in adults (like postnasal drip or GERD) apply to children without specific clinical features 1, 7.
• The concept that ear infections cause cough through drainage or "postnasal drip" lacks scientific validity in pediatric populations 9.