Specialist article children and ears
Middle ear infection in childrenWhy ventilation of the ear matters
Your child has earache again? Here you will learn which warning signs mean you should have it checked by a doctor straight away, how the Eustachian tube ventilates the middle ear when swallowing, what antibiotics and grommets achieve and what role breathing, swallowing and head balance play.
Does this sound familiar?
The ear again, and nobody asks why?
What applies to your child?
Tap whatever applies to you.
If several points apply, it is worth looking at the ventilation of the middle ear. It runs via the Eustachian tube, which opens during swallowing. In our view, how your child breathes, swallows and balances their head is therefore part of the search for reasons.
Warning signs for a doctor’s visitHow the ear is ventilatedThe key points at a glance
- Middle ear infection is one of the most common illnesses in early childhood. As a rule it clears up after a few days, but in some children it keeps coming back.
- The middle ear is ventilated via the Eustachian tube. It opens during swallowing and yawning, pulled by a muscle of the soft palate. If the infections recur, in our view the common starting point usually lies in poor ventilation. The infection is the trigger; negative pressure and fluid in the middle ear prepare the ground for it.
- Antibiotics and grommets have their place. They do not change the pattern of breathing, swallowing and head balance. That is exactly where we start with training the basic functions.
Video
Middle ear infection: correcting causes and fending off inflammation
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Context
Middle ear infection in children: common, persistent in some
Almost all parents know the night when their child wakes up with a fever, grabs at their ear and cannot be calmed.
Behind the eardrum lies a small, air-filled space, the middle ear. In an acute middle ear infection, its mucous membrane becomes inflamed, often following a cold. Typical signs are sudden earache, fever and poorer hearing. Small children often show this differently: they cry, sleep restlessly, touch their ear or do not want to drink.
of children have at least one acute middle ear infection before their third birthday1
of these children experience two or more infections1
is how long an acute middle ear infection usually lasts before it clears up on its own2
For most children it remains at one or two episodes. In others, one infection follows the next, with fluid remaining in the ear in between. This article is about these children, and about the question of why their middle ear is poorly ventilated.
Safety first
Warning signs: when your child should be examined by a doctor straight away
Complications are rare. Nevertheless, some signs should be seen by a doctor without hesitation, on the same day or, in an emergency, via the emergency number.
Swelling behind the ear
Redness, swelling or pain behind the ear, or an outer ear that suddenly sticks out, may indicate mastoiditis, an inflammation of the bone behind the ear2.
Neck stiffness or drowsiness
Very rarely, the inflammation spreads to the meninges2. If your child is barely responsive or has a stiff neck, call the emergency number 112.
Dizziness or vomiting
If your child becomes dizzy or vomits, have them examined on the same day3. This also applies if a corner of the mouth suddenly droops.
High fever, clearly ill
Very high fever, chills or a clearly ill child belong in the practice or the out-of-hours service3.
Fluid from the ear
If pus or fluid runs out of the ear canal, the eardrum may have ruptured3.
Younger than one year
In infants under twelve months, have every suspected middle ear infection seen by a doctor3.
Longer than three days
If the pain does not improve after three days or your child suddenly hears less well, take them back to the doctor3.
Have children with weakened immune defences or diseases of the heart, lungs, kidneys or nervous system examined earlier3. This article does not replace an examination. Training only begins once fever and pain have subsided.
Anatomy
The Eustachian tube: ventilation of the middle ear
The middle ear is a closed air space whose air must be renewed regularly.
The mucous membrane of the middle ear continuously absorbs some air. It is replenished via the Eustachian tube, a narrow passage from the middle ear to the nasopharynx behind the nose. At rest it is closed and opens briefly when swallowing and yawning. This is done by the tensor muscle of the soft palate, a small muscle attached to the wall of the Eustachian tube.
The opening of the Eustachian tube lies on the side wall of the nasopharynx, right next to the adenoids. What happens there also affects the ear: swelling with a cold, large adenoids or a nasopharynx through which hardly any air flows with mouth breathing.
If the Eustachian tube opens too rarely, negative pressure develops in the middle ear. Fluid collects behind the eardrum and provides a breeding ground for germs from the nasopharynx. In children, the Eustachian tube is also shorter and flatter than in adults.
Like a room with only one window
Imagine a cellar room whose only window opens briefly only when someone pulls on it. If it is aired often, the room stays dry. If the window stays shut, moisture condenses. That is how we see the middle ear, and the window is pulled when swallowing.
Mechanics
Swallowing ventilates the ear
A person swallows many hundreds to a thousand times a day, and every swallow is a ventilation process for the middle ear, because the Eustachian tube opens in the process.
The tongue rests against the palate
The swallow begins at the front, at the tongue reference position.
The soft palate lifts and tenses
In doing so, the tensor muscle pulls on the wall of the Eustachian tube.
The Eustachian tube opens
For a moment, the middle ear and nasopharynx are connected.
Air flows in
The pressure equalises, and fluid can drain away.
The middle ear stays ventilated
Repeated throughout the day, the space behind the eardrum stays filled with air.
with healthy ears opened their Eustachian tube by muscle power less well than 92 adults6
showed altered mechanics of the Eustachian tube after the tensor muscle of the soft palate had been paralysed4
of 20 people with a middle ear infection showed less activity of this muscle on the affected side when swallowing5
The evidence has limits: an animal experiment does not replicate a middle ear infection in children, and the measurement from Rome covers only 30 people. Both show, however, that muscle work during swallowing helps determine the opening of the Eustachian tube; in Rome it increased after targeted training5. They do not prove that the swallowing pattern is the cause in a particular child.
How does your child swallow? Take a close look next time they drink from a cup.
Our view
Why the infection keeps coming back in some children
The trigger of the acute infection is an infection of the airways. In our view, whether this repeatedly develops into an ear infection depends on the ventilation between infections.
If the mouth is open, the tongue lies low on the floor of the mouth instead of at its reference point on the palate. The child breathes through the mouth, and hardly any air flows through the nasopharynx any more.
Swallowing also works differently: the lips, cheeks and chin help to seal, and the soft palate works in an altered sequence. In our view, the Eustachian tube then opens less often or less strongly.
The pattern deviates
Mouth breathing, a low-lying tongue and a forward-shifted head balance become everyday.
The body compensates
The lips, cheeks and chin take over tasks of the tongue, and the nervous system stores the sequence.
Ventilation suffers
Negative pressure and fluid remain in the middle ear more often.
The next infection hits an already burdened ear
In many of these children, a cold turns into a middle ear infection again.
In children whose middle ear infections occur repeatedly, in our view the common starting point usually lies in poor ventilation, and that depends on breathing, swallowing and head balance. The infection is the trigger; negative pressure and fluid behind the eardrum are what prepare the ground for it. If you follow this logic, a Eustachian tube that opens reliably during swallowing removes this ground from the infection. Muscles that are not integrated into their function lose tension; when they are used again, they regain tension.
Nursery and siblings
Close contact with other children means more infections2.
Tobacco smoke
Passive smoking increases the risk of infections2.
Adenoids
If it is large, it blocks the nasopharynx right next to the Eustachian tube.
Dummy and bottle
In studies, both are considered risk factors, breastfeeding a protective factor.
Research
Dummy, bottle and breastfeeding: what has been studied
There are few influences with data as clear as those on dummies and breastfeeding. Both concern the pattern of sucking, swallowing and breathing.
In Finland, 14 advice centres for young children were divided up by lot. In one half, parents of children under 18 months were advised to limit the dummy to falling asleep; the other half carried on as before. 272 and 212 children took part. Afterwards, constant sucking on a dummy became less frequent7.
fewer middle ear infections per month were seen in children from the advice centres that gave the dummy advice7
fewer episodes were seen in children who did not use a dummy constantly, compared with children who did7
less often did children exclusively breastfed for six months have a middle ear infection in their first two years of life, analysed across 24 studies8
The studies do not explain why this is so. Our view: a dummy keeps the tongue low and forward for hours, away from the palate. During breastfeeding, the tongue, lips and soft palate work in one sequence together with nasal breathing.
This is not a criticism of parents. Not every child can be breastfed, and a dummy for falling asleep is something different from one used all day. More under FaceFormer for children.
Nose and nasopharynx
Adenoids, snoring, open mouth: the link to enlarged adenoids
When parents hear about “polyps” in a child, it usually means enlarged adenoids. They sit where the Eustachian tube also opens.
Large adenoids block the airway behind the nose; the child breathes through the mouth and often snores. What studies show about adenoid surgery is covered under Adenoids in children. In three- to five-year-olds in Poland, the size of the adenoids was associated with the eardrum findings and with sleeping with the mouth open9.
with night-time snoring or mouth breathing were examined in a Chinese clinic. In those with sleep apnoea, the negative pressure in the middle ear was considerably stronger10
was the proportion with middle ear effusion in children with and without sleep apnoea, not significant10
After surgery that resolved the sleep apnoea, the negative pressure in the middle ear improved considerably10. The retrospective analysis shows an association, not a cause. For us, it fits the picture: where the airway is narrow at night and the mouth is open, the ear suffers too. More under Snoring and sleep apnoea.
The adenoids sit right next to the opening of the Eustachian tube. Whatever puts strain on the nasopharynx also affects the ear.In our view, the nose, nasopharynx and ear belong together and should be considered as a whole, even though different specialties treat them.
Putting treatments into context
Antibiotics and grommets: what they achieve
Treating the acute infection and deciding on grommets is a matter for the paediatric or ENT practice. The body of evidence helps to put things into context.
A child with recurring glue ear is examined, receives antibiotics, receives grommets in the eardrum. Whether they breathe through the mouth and how they swallow is rarely asked. The question belongs in the examination, because the muscle that opens the Eustachian tube is part of the same movement pattern. Antibiotics and grommets treat the infection and the ventilation deficit, but ventilation itself remains the task of the Eustachian tube.
A Cochrane review analysed 13 studies with 3,401 children. After 24 hours, children given an antibiotic were no less likely to have pain than those given a placebo; after two to three days they were slightly less likely. According to the authors, most infections clear up on their own; adequate pain relief is important11.
need to be given an antibiotic for one child to be pain-free after two to three days who otherwise would not be11
treated with an antibiotic result in one child with vomiting, diarrhoea or a rash11
a Canadian review generally recommends an antibiotic; in older children, from a fever of around 39 degrees1
A grommet is a tiny ventilation tube in the eardrum. It ventilates the middle ear from the outside for as long as the Eustachian tube cannot manage this. For recurrent infections, low-quality studies show around one episode fewer in the first six months12. In a large US study (six to 35 months), children with and without grommets had a similar number of infections over two years13.
What a grommet achieves
What it does not change
- The Eustachian tube works the same way as before
- Mouth breathing and the swallowing pattern remain
- The hearing benefit becomes smaller after six to nine months, because many effusions also resolve on their own14
The two are not mutually exclusive. The grommet takes over ventilation for a while; the training focuses on the time afterwards.
Whether your child needs an antibiotic, a grommet or adenoid surgery is something you decide together with the paediatric or ENT practice. Do not stop prescribed medication on your own initiative. The training can be combined with all of these treatments, more under FaceFormer and other treatments.
Active rather than passive
Ventilation from the inside: what active opening shows
A study from English GP practices shows that ventilation via the Eustachian tube can be actively influenced.
In 43 practices, 320 children aged four to eleven with middle ear effusion were allocated by lot. For one to three months, one group inflated a balloon with the nose three times a day, pushing air through the Eustachian tube; the other received usual care15.
of the children with the balloon had normal eardrum findings after three months15
was the figure in the group without the balloon15
of the children were still practising regularly after three months15
The balloon opens the Eustachian tube with pressure; in everyday life, swallowing does this. Our training focuses on this, but it has not been studied for the ear. The randomised Hamburg study with 45 children measured the basic functions: in the FaceFormer group, the tongue lay against the palate more often when swallowing, and lip closure was established more quickly16.
A grommet ventilates the ear from the outside. Swallowing ventilates it from the inside.Not studied does not mean disproven, but not tested. All studies and their limitations are listed under Studies and science.
In our view, the question of ear ventilation does not end with childhood. In adults with ear pressure, sensitivity to noise or tinnitus, it is also worth looking at the swallowing sequence and the Eustachian tube. That early middle ear infections cause such complaints has not been demonstrated; it is our explanatory model. More in the articles Ear pressure and Tinnitus.
Training
Training ventilation: breathing, swallowing and head balance
Reminders like “Close your mouth” rarely last long. A pattern of breathing and swallowing is a stored sequence, and it changes through many identical repetitions. Training the basic functions of breathing, swallowing and head balance creates the conditions for nasal breathing and an orderly swallow to become the norm again.
Breathing
Lips loosely closed, air flows through the nose and the nasopharynx, where the Eustachian tube opens.
Swallowing
The tongue starts the swallow at the palate, the soft palate tenses, the Eustachian tube opens.
Head balance
When the head is balanced over the body, the tongue and soft palate work under good conditions.
The starting point is the tongue reference position: the tip of the tongue rests on the small ridge behind the upper front teeth, the back of the tongue against the palate, and the lips are loosely closed. More under Tongue reference position.
- Day 1 to 14
Getting to know it
Three times a day, 5 basic and 5 pull exercises each with the FaceFormer ZERO, the youngest ones through play.
- Day 15 to 28
Building up
Three times a day, 10 basic and pull exercises each time.
- From week 5
Full programme
Three times a day, 20 basic and pull exercises each time, if your child is keeping up well.
- After a few weeks
At night too
The ZERO is added for night-time use. If it falls out at first, that is normal.
- Over months
The pattern runs by itself
The training allows six to twelve months until the new sequences run on their own, followed by maintenance training.
Children train with the FaceFormer ZERO: softer material, the same size as the ONE, recommended for ages 2 to 10. The basic exercise and pull exercise are part of the plan from the start; the free FaceFormer app guides you and keeps count.
During an acute infection with fever and pain, take a break. If the nose is completely blocked, have this checked beforehand. Children under 4 train with expert support. Otherwise the app and the exercise pages are enough; a practice can tailor the plan to your child.
Everyday life
What you can do in everyday family life
Take pain seriously
In the first few days, pain relief is the priority. Discuss the medication and dose with your practice or pharmacy11.
Keeping the nose clear
With a cold, saline solution helps so that the mouth does not take over for weeks.
Pay attention to hearing after the infection
If your child responds less well when spoken to weeks later, have the ear checked; a middle ear effusion can persist for longer.
Limit the dummy
Ideally only for falling asleep, as in the Finnish study7.
Stay smoke-free
Tobacco smoke in the home and car increases the risk of infection2.
Don’t tape the mouth shut
A plaster closes the lips from the outside but does not change the pattern. We expressly advise against it for children, more under Mouth taping.
Questions
Frequently asked
Why does my child keep getting middle ear infections?
The trigger is usually an infection of the upper airways. Whether this develops into a middle ear infection depends on how well the Eustachian tube ventilates the middle ear. With recurring infections, in our view this is usually where the common starting point lies, together with mouth breathing and an altered swallow. Nursery, tobacco smoke and large adenoids add to this.
When do I need to take my child to the doctor for earache?
Seek help immediately if there is swelling behind the ear, a protruding outer ear, a stiff neck, drowsiness, dizziness, vomiting, a very high fever or fluid coming from the ear. Always have babies under twelve months checked. If the pain does not improve after three days, take your child back to the doctor.
Does every middle ear infection need an antibiotic?
No. According to a Cochrane review, most acute middle ear infections in otherwise healthy children clear up on their own, and on the first day antibiotics do not relieve the pain. In children under two years of age with severe symptoms, they are more likely to be recommended. The practice decides this, and if an antibiotic is prescribed, you give the full course as agreed.
What do grommets achieve?
They ventilate the middle ear from outside as long as they sit in the eardrum. With glue ear, children hear better in the first months; with recurrent infections, the benefit is moderate. They do not change the Eustachian tube itself.
What is the difference between a middle ear infection and glue ear?
An acute middle ear infection starts suddenly with pain and often fever. With glue ear, there is fluid behind the eardrum without acute inflammation. It hardly hurts, but it muffles hearing and sometimes persists for weeks.
Can a dummy make middle ear infections more likely?
Studies suggest so. In Finland, children whose parents were asked to restrict the dummy to falling asleep had 29 per cent fewer middle ear infections. In our view, constant dummy use keeps the tongue away from the palate.
From what age can my child train with the FaceFormer?
Children train with the FaceFormer ZERO, recommended for ages 2 to 10, and under 4 years with expert supervision. Pause during an acute infection. The training can be combined with grommets and other medical treatments. Whether it changes the number of infections has not been studied.
More articles from the knowledge section
Where to go next
Sources
- Leung AKC, Wong AHC (2017). Acute Otitis Media in Children. Recent Patents on Inflammation & Allergy Drug Discovery 11(1):32-40. PMID 28707578. Source
- Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG) (Institute for Quality and Efficiency in Health Care). Mittelohrentzündung. gesundheitsinformation.de, accessed on 28.09.2026. Source
- National Health Service (NHS). Ear infections. nhs.uk, accessed on 28.09.2026. Source
- Ghadiali SN, Swarts JD, Doyle WJ (2003). Effect of tensor veli palatini muscle paralysis on eustachian tube mechanics. Annals of Otology, Rhinology and Laryngology 112(8):704-711. PMID 12940669. Source
- Picciotti PM, Della Marca G, D’Alatri L, Lucidi D, Rigante M, Scarano E (2017). Tensor veli palatini electromyography for monitoring Eustachian tube rehabilitation in otitis media. Journal of Laryngology and Otology 131(5):411-416. PMID 28294083. Source
- Bylander A, Ivarsson A, Tjernström O (1981). Eustachian tube function in normal children and adults. Acta Oto-Laryngologica 92(5-6):481-491. PMID 7315267. Source
- Niemelä M, Pihakari O, Pokka T, Uhari M (2000). Pacifier as a risk factor for acute otitis media: a randomized, controlled trial of parental counseling. Pediatrics 106(3):483-488. PMID 10969091. Source
- Bowatte G, Tham R, Allen KJ et al. (2015). Breastfeeding and childhood acute otitis media: a systematic review and meta-analysis. Acta Paediatrica 104(467):85-95. PMID 26265016. Source
- Zwierz A, Domagalski K, Masna K, Walentowicz P, Burduk P (2023). Impact of Breastfeeding Duration on Adenoid Hypertrophy, Snoring and Acute Otitis Media: A Case-Control Study in Preschool Children. Journal of Clinical Medicine 12(24):7683. PMID 38137751. Source
- Zhang Q, Qiang Y, Xie M et al. (2023). The effect of OSA on the negative pressure and acoustic compliance of middle ear cavity in children. International Journal of Pediatric Otorhinolaryngology 165:111457. PMID 36701819. Source
- Venekamp RP, Sanders SL, Glasziou PP, Rovers MM (2023). Antibiotics for acute otitis media in children. Cochrane Database of Systematic Reviews 11:CD000219. PMID 37965923. Source
- Venekamp RP, Mick P, Schilder AG, Nunez DA (2018). Grommets (ventilation tubes) for recurrent acute otitis media in children. Cochrane Database of Systematic Reviews 5:CD012017. PMID 29741289. Source
- Hoberman A, Preciado D, Paradise JL et al. (2021). Tympanostomy Tubes or Medical Management for Recurrent Acute Otitis Media. New England Journal of Medicine 384(19):1789-1799. PMID 33979487. Source
- Browning GG, Rovers MM, Williamson I, Lous J, Burton MJ (2010). Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children. Cochrane Database of Systematic Reviews 10:CD001801. PMID 20927726. Source
- Williamson I, Vennik J, Harnden A et al. (2015). Effect of nasal balloon autoinflation in children with otitis media with effusion in primary care: an open randomized controlled trial. CMAJ 187(13):961-969. PMID 26216608. Source
- Korbmacher HM, Schwan M, Berndsen S, Bull J, Kahl-Nieke B (2004). Evaluation of a new concept of myofunctional therapy in children. International Journal of Orofacial Myology 30:39-52. PMID 15832861. Source
Get started
Ready for the training?
The free FaceFormer app guides you through the basic exercises, counts along and reminds you of your sessions. If you wish, a practice from the practitioner directory can support you.
FaceFormer ZERO + ONE
Both material hardnesses for getting started, day and night. The set for adults.
FaceFormer ZERO
The softer FaceFormer for getting started, for children and for the night.
FaceFormer ZERO Children’s Set
ZERO with hygiene box, plush bag and success book with stamp.
FaceFormer training aims to restore the physiological setting of the basic functions of breathing, swallowing and head balance, with lip closure and the tongue reference position, thereby creating the conditions under which symptoms can improve. It does not replace a medical assessment. You can find practitioners near you in the practitioner directory.
