Reflux and Otitis: Does GERD Cause Ear Infections?

The Study

This post will largely be limited to reviewing a single scientific paper, entitled “The Role of Extraesophageal Reflux in Otitis Media in Infants and Children,” by Dr. Robert O’Reilly and the team at DuPont Hospital for Children in Delaware.

This was a significant study, published in 2008 in the journal, Laryngoscope, a premiere journal in the specialty of Otolaryngology.  This study included over 500 children (893 ear samples), looking for evidence of a link between reflux and middle ear infections (otitis media).

The result: there IS a link between reflux and ear infections, larger than many expected!  Read on for the details, and how to use this information.

Reflux from Stomach Travels up Esophagus to Eustachian Tubes

How Can We Tell There is Reflux?

For evidence of reflux affecting the ear, Dr. O’Reilly’s group decided to look for evidence of stomach acid (and other stuff) making it all the way to the middle ear.  The marker that they measured to indicate the presence of gastric contents was pepsin.  Pepsin is a gastric enzyme, present only in the stomach.

They reasoned that the only way for pepsin to get to the middle ear space in a child would be for that child to reflux it up.

Take a look at the figure on the right:  reflux up the esophagus doesn’t need to go very far before it gets to the openings of the Eustachian tubes.  Those are the small tubes that go from the back of the throat / nose area (“nasopharynx”) to behind the ear drum.  They function to equalize the pressure between the middle ear space and surrounding air pressure.

How does that happen?

Well, reflux of stomach contents goes up the esophagus, into the nasopharynx (back of the throat), and up the Eustachian tubes to the ears.  Regurgitation going all the way up into a baby’s ears.  Yuck.

Others have thought of using this marker before, and there have been small, ”pilot” studies suggesting that pepsin can be found in the middle ears of children who have reflux.

Reflux up Eustachian Tubes Linked to Otitis Media

Reflux up Eustachian Tubes Linked to Otitis Media (Ear Infections)

The Challenge

There have been 2 main challenges to getting useful data in the past:

  1. The first has been having appropriate “controls” – that is, children without any significant history of ear infections, who wouldn’t mind if we sample their middle ears for the presence of pepsin.  That is, normal children are not standing in line to be put under general anesthetic so that we can make a small incision in their ear drum to see whether there is any pepsin in there.Dr. O’Reilly’s group found a great solution – a group of children with no history of ear infections who would be undergoing some un-related ear surgery:  kids who were getting electronic ears (cochlear implants) placed.  This group of 64 children comprised their “control” or normal group.
  2. The second challenge has been obtaining a large enough group of samples (from enough children) that the results have real statistical meaning.Dr.  O’Reilly’s group has been the first to collect such a large sample, providing for the first time such statistically significant results.  After all, they had 509 children with chronic ear infections, and 64 children without chronic ear infections.

Reflux, GERD, causes ear infections, otitis media, babies, infants, toddlers, children

Reflux up Eustachian Tubes to Middle Ear: Risk of Ear Infections


Here is what they found:

  • Pepsin was present in the ear of 20% of the children with recurrent and chronic ear infections.
  • Pepsin was present in the ears of only 1.4% of the control children.
  • Children younger than 1 year had a higher rate of purulent (infected with pus) ears and also pepsin in the middle ear.
  • Children with pepsin in their ears were more likely to have fluid in their ears than those children without pepsin.
  • Most interestingly, there was NO correlation between the presence of pepsin and a reported history of reflux, allergies, or asthma.

The differences described were all “statistically significant,” with a p-value < 0.05.


The authors of the study concluded that pepsin in the middle ear was an “independent risk factor” for otitis media. In other words, reflux is linked to ear infections.

They also note that clinical history of reflux – that is, the parents’ or physicians’ ability to diagnose reflux in infants – did not have any bearing on whether these children were found to have pepsin (from reflux) in their middle ears.  This just tells me that we stink at diagnosing reflux in little tykes based simply on clinical history, or asking the parents.

What to Do With This Information?

What we can take away from this study is that we (pediatric boogor docs) should consider treating reflux in our patients with recurrent and chronic ear infections.

If your little boogor head has chronic ear infections and your doc is recommending ear tubes, you might ask about the possible role of reflux and see what they say.  They may already be hip to these results.  You might save your child a surgery.

Learn More About Reflux – A Couple Books I Recommend

The two best books that I have found to help dealing with reflux are: Eating for Acid Reflux: A Handbook and Cookbook for Those With Heartburn,

and Reflux 101: A Parent’s Guide to Gastroesophageal Reflux, both on Amazon (yes, I am an affiliate).


Thanks for visiting, and see you here again.  I appreciate your comments and questions.  Keep ‘em coming.  Please, “be excellent to one another.”

Best of health and success to you and your families.

Until next time, remember … you can pick your friends, and you can pick your nose, but you can’t pick your friend’s nose (unless you’re a boogor doctor :~D)

If this blog is helpful for you, please click here to subscribe for free email updates (did I mention it’s FREE):

Simply type your best email address (the one you actually use) into the orange-outlined box at the upper right of the page, and click the subscribe button. When you receive the confirmation email, click on the link to give your okay to receive weekly email updates.

No advertising, no spam.  It’s easy, it’s convenient, it’s free. You can un-subscribe any time.

Stay informed, stay healthy.

I promise to continue to work hard to provide content that will improve your health and the health of your children. RF


Note that this excellent study was Dr. O’Reilly’s thesis for his induction into the Triological Society, an esteemed professional society that requires a significant scholarly work as part of their requirements for membership:

O’Reilly et al., The Role of Extraesophageal Reflux in Otitis Media in Infants and Children. Laryngoscope, 118 (Suppl. 116): 1-9; 2008.


  1. the eden biodome product review says:

    What’s up to all, how is the whole thing, I think every one is getting more from this web site, and your views are good in support of new visitors.

  2. Joann cooper says:

    I am 75 years old. I have been having chronic ear infections since may of 2014. I suspect acid reflex. 5 different specialist and no doctor can find the cause.

    • Russell A. Faust, PhD, MD says:

      Hi Joann,
      Sorry to hear your frustration. You might consider looking for a Naturopathic Doctor (doctor of naturopathy, or ND) in your area. “Specialists” can have their value (I am one, after all, and hope that I have some value for my patients). However, most of us specialists are so narrowly focused that we don’t see the forest for the trees: we are too focused to see the whole patient. I have found that Naturopaths are “whole-istic” in that they see the whole person.
      Please let me know how this goes for you.

Speak Your Mind