Friday, January 30, 2015

Ear infections/ to treat or not to treat

Please see updated post 6/2016
Ear infections are among the most frequent reasons for a visit to the pediatricians office. It feels like I am long overdue for addressing this issue in a blog post.

As opposed to an otitis externa (also known as swimmer's ear) where the outside of the ear is red and sore, an otitis media (a middle ear infection) is not visible from the outside. One of the biggest challenges is knowing if your child has an ear infection or not. 

Technology is changing, but at present, unless you actually have an instrument at home you will likely need to bring your child in for an exam if you are suspicious.
At the end of this post is some information about CellScope, an app that gives you the ability to check out your child's ears at home.

If they are old enough, they may simply tell you that their ear hurts. Keep in mind that some kids complain about fluid in the ear or pressure; it isn't always an infection.
 If they are still young and non-verbal, they may be extra fussy (especially when going to sleep) feverish or tugging at their ear. Many kids wake up more than usual at night. Most of the time kids are congested. Sometimes vomiting can be associated with ear infections.
Some kids seem like their balance is off. Others seem like they are having trouble hearing (I know, all of our kids can seem deaf when we are telling them something they don't care to hear.)

Other kids don't let you know at all. We have had patients in the office for a well child exam and have been caught by surprise when a routine ear check revealed a raging infection.  I have also seen ear infections go from 'zero to sixty' in no time flat. A child with a perfectly normal ear exam one day can have a horrible ear infection the next.
Most of the time, an infection in the middle ear (the space behind the eardrum) accompanies a common cold, the flu, or other types of respiratory infections. This is because the middle ear is connected to the upper respiratory tract by a tiny channel known as the eustachian tube. Germs that are growing in the nose or sinus cavities can climb up the eustachian tube and enter the middle ear. Children's eustachian tubes are smaller and more level than those of an adult. This means it is harder for them to drain well and easier to get blocked up with even mild swelling. Because of these drainage issues, when kids are congested, they also may have fluid in their ear (serous otitis). This is why I am more suspicious about a possible ear infection in a child who has a cold. What may start out as a virus can turn into something bacterial. That fluid is the perfect medium for bacteria to grow. I compare it to a stagnant pond just waiting for the mosquitoes to breed.

Kids with chronic serous otitis who get one infection after another will usually end up at the ENT doc who may put some tubes in the ear to help them drain. Melissa Wilson, Doctor of Audiology at Sound Speech and Hearing, adds that tubes are also put in to address the hearing loss that often accompanies middle ear fluid. Fluid build-up often causes a hearing loss on the order of 30-40 decibels. Average speech is about 60 decibels. So having fluid is like listening with your fingers plugging up your ears. Everything your child hears is muffled and over time, this can impact their speech and language development, and for the school-aged children this can cause issues with listening in the classroom and academics.

By the way, when kids have goopy eyes, many times they also have an otitis, which is why we may bring them in to check out the eyes and the ears rather than just giving eye drops over the phone.
Just because your child is tugging at their ear does not mean they have an infection. Some kids do it as a habit when they are tired. Others do it when they are teething (especially upper teeth.)  It can be a clue though that is worth paying attention to, especially if it accompanies any other symptoms. I realized after the fact that I had ignored my daughter Lauren's first ear infection for more than a week when she was fairly young. Looking back at videos you can see the poor kid simply grabbing at her ear constantly. This was long, long ago prior to my Noe Valley Pediatrics job. I was working at UCSF with complicated surgical cases and thoughts of an ear infection didn't even cross my mind.

If your child is diagnosed with an ear infection, chances are we will give you a prescription for antibiotics. If your child is miserable and feverish, it makes sense to treat it. If the eardrum is bulging and looks like the membrane may rupture, the doctor will advise you that you should absolutely go ahead with the medication regardless of how your child is acting.
On the other hand, If it is not a severe infection and your child seems consolable, we may suggest that it is perfectly fine to watch and see for a few days. Many ear infections can indeed clear up on their own and of course we all would like to avoid the use of antibiotics if we can.
Some of our parents come in eager to treat even if it is mild and others want to avoid antibiotics at all costs. It is hard finding the balance. We are happy to work with folks who want to do the watching and waiting, but sometimes it does involve multiple trips into the office while we can an eye on things. My main agenda, aside from making the kids more comfortable, is preventing an eardrum from rupturing. This does happen and we can't always stop it, but it is worth trying. If you have an eardrum that ruptures frequently it can cause scarring and this can lead to hearing loss.

When there is a ruptured eardrum, one common scenario is for a child to be quite miserable and suddenly they are much happier. They also have lots of yellow/orange stuff draining out of the ear. The good news is that the pain of the pressure in there is gone, but the tympanic membrane is an important protective barrier from the outside and it is no longer intact. Therefore, if your child does have a ruptured membrane, they do need to be seen and treated even though they are no longer quite as miserable. If there is more than one rupture it is worthwhile getting the hearing tested to make sure there is no lingering hearing loss after the eardrum heals.

If you do opt to treat, make sure that you finish the entire course of medication. I suggest doing probiotics to protect the gut. Do not give them exactly in conjunction with the antibiotics, rather try to space them in between doses. Also please don't forget to brush those teeth. Liquid antibiotics tend to be sticky and sweetened in order to make them more palatable.

It may take  the medication at least a couple of days or before you note a significant improvement. If your child is still super fussy or feverish after a full three days, let's take another look in there to make sure the meds are working. Some kids who are having a really difficult time may end up getting an antibiotic injection. These hurt a bit, but they are usually quite effective.

With or without the use of antibiotics there are several things you can do for comfort. Tylenol and/ or Ibuprofen are useful. There are some prescription ear drops that can numb the ear, but they have some contra indications, so we don't often prescribe those here.

Warmth usually feels good. Try a warm wet washcloth against the ear. You also can put some rice in a sock and heat that up in a microwave. Some folks swear by a warm hair dryer held about a foot away from the ear. Believe it or not though, my favorite remedy is garlic oil.*

Check the ear to make sure there is no reason to suspect a rupture. I don't like to add any drops if I have any suspicion that the eardrum may not be intact.  If there is no odor or drainage (a little wax doesn't count) garlic oil may be  a good option. Saute some cloves of garlic into some olive oil. Let the oil cool until it is warm/not hot. Take a cosmetic square (these are the round or square cotton pads that often come in a stack. I like them better than cotton balls for this.)  Dip one half of the pad into the oil, roll it up like a scroll and stick it in the ear. Do this as often as your child will allow.If it is the middle of the night and your child is screaming, you can try any of these.

*Anecdote: My daughter Alana had her tonsils out a few years ago when she was in her early twenties. She started communicating on message boards with random folk from all over the world who were going through the same ordeal. These strangers bonded over their misery and swapped suggestions for comfort measures. At day three, many of them got earaches. I never paid much attention to this in the past, but with such a wide body of folks communicating, it seems clear that this was a common part of the post tonsillectomy list of woes. I made some garlic oil for Alana and when she put it in her ear she felt almost instant relief. She shared it with the hundreds of new best friends and many of them tried it and thanked her for the suggestion. So there you have it. Garlic oil gives relief.

If you are concerned about hearing loss, either from frequent infections or chronic fluid, Sound Hearing and Speech in Potrero Hillis a great option for getting checked out: (415) 580-7604 Sound Speech and Hearing Clinic  

If you are intrigued by new technology and are interested in the ability to check your child's ears from home, check out cell scope!   click here for the otoHOME site. use the promo code NURSEJUDY for a 20% discount

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