Ear
Infections/Otitis Media
DEFINITION:
An ear infection, or acute otitis media, is defined as the
presence of fluid in the middle ear along with symptoms of
an acute illness
SYMPTOMS:
Ear
pain, fever, throat pain, fussiness, irritability, pulling
at the ears, or no symptoms at all
DIAGNOSIS:
A physician will look into the ear using an otoscope with
an insufflator. If the ear drum is not moving well with insufflation
and the color of the ear drum is red instead of its normal
white, a diagnosis of acute otitis media can be made.
Use of a tympanometer or acoustic meter can also be
used to make a diagnosis.
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The Otoscope
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The Tympanometer
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TREATMENT:
Close observation with good follow-up, antibiotics, pain medications,
tonsillectomy and adenoidectomy, tympanocentesis or, taking
the fluid out of the middle ear through a needle, or tympanostomy
tubes.
CAUSES:
Most ear infections are caused by bacteria, some by viruses,
and some have no identifiable cause. The most common bacteria
are called Streptococcus pneumoniae at 50%, then Haemophilus
influenzae at 30%, Moraxella catarrhalis at 15%, and Streptococcus
pyogenes at 5%. Ear infections are most common in children
from 6 months to 6 years of age. Risk factors which increase
the chance of getting an ear infection include daycare attendance,
exposure to cigarette smoke, winter months, family history
of ear infections, lack of breast feeding, maxillofacial abnormalities
such as cleft palate, bottle propping, and a prior history
of ear infections.
OUTCOME:
Overall, ear infections clear with no problems. There is a
concern about permanent hearing loss with multiple ear infections
or an ear infection that won't go away with proper treatment.
Complications can include mastoiditis, which is an infection
of the bone behind the ear, and meningitis, which is the infection
entering the intracranial space, or the brain and spinal cord.
DISCUSSION:
Ear infections are one of the most common reasons for a child
to visit his or her pediatrician. Most children with an ear
infection experience a lot of pain and discomfort, and parents
want to do anything to make their child feel better. Once
the physician diagnoses an ear infection, a decision can be
made about treatment. Most doctors prefer to treat ear infections
with antibiotics and, if an antibiotic is used, amoxicillin
is the drug of choice.
The reason for this is that amoxicillin will cause the least
amount of bacterial resistance, has few side effects, is inexpensive,
and works as well as any of the more expensive medicines.
If amoxicillin fails, then there are multiple choices for
a second antibiotic. These include cefdinir (Omnicef), cefuroxime
(Ceftin), cefprozil (Cefzil), amoxicillin/clavulanate (Augmentin),
cefpodoxime (Vantin), cefixime (Suprax), ceftibuten (Cedax),
loracarbef (Lorabid), azithromycin (Zithromax), clarithromycin
(Biaxin), trimethoprim /sulfamethoxazole (Bactrim/Septra),
erythromycin/ethylsuccinate (Pediazole), and ceftriaxone (Rocephin),
which is a shot.
In
addition, acetaminophen (Tylenol, Tempra), ibuprofen (Motrin,
Advil), numbing eardrops, and warm compresses can be used.
Another valid option is to avoid antibiotics and let the infection
run its course. Most ear infections will go away without treatment.
This option has both advantages and potential drawbacks. One
advantage is that by avoiding antibiotics you avoid their
potential complications, such as upset stomach, allergic reactions,
yeast infections, trying to force a medication into an unwilling
child's mouth, and creating resistance in your child. Every
time a child takes an antibiotic, all susceptible organisms
are destroyed, giving resistant organisms a chance to grow.
Also, as whole communities use antibiotics, pressure is put
on the organism to mutate, and then it becomes resistant in
order to survive. So, being on an antibiotic may be harmful
to a child and to an entire community by producing and then
perpetuating a resistant organism. Before the days of antibiotics,
children got ear infections and generally did well.
The potential drawbacks come from possible complications of
an untreated ear infection. These include mastoiditis (an
infection of the bone behind the ear), and rarely, meningitis,
where the bacteria invades the intracranial area, the brain.
If antibiotics are withheld, the child should be older than
two years, have no underlying immunodeficiencies, have had
no ear infections in the last three months, and have parents
willing to watch and wait. In addition, these children should
be rechecked in 48 to 72 hours, and acetaminophen, ibuprofen,
eardrops, and compresses may be used to help with the symptoms.
Steroids
are controversial in the treatment of acute otitis media.
Some physicians feel that they lessen the inflammation associated
with ear infections, thereby allowing easier clearing of the
middle ear; others feel they do nothing. Cold medicines, including
antihistamines, decongestants and cough suppressants, seem
to be no help in preventing ear infections. If ear infections
persist despite antibiotic treatment, the next step may be
taken.
If fluid persists behind the eardrum there is the possibility
of hearing loss. To prevent this the fluid can be removed.
This can be done by tympanocentesis, where a needle is put
through the eardrum and fluid is pulled out. The fluid can
then be sent for culture to determine the exact cause of infection.
Also, tympanostomy tubes can be placed in the eardrum. This
is the most common surgical treatment for children. According
to the Agency for Health Care Policy and Research, tubes should
be placed in children who have persistent fluid with hearing
loss from four to six months. Again, the removed fluid can
then be cultured.
The
tube allows fluid to flow out of the ear canal, decreasing
pain and hearing loss. In many cases, children will not get
another ear infection after tube placement. With some children,
in addition to tympanostomy tubes, removal of the adenoids
may allow for fluid drainage from behind the ear, and down
the Eustachian tube to the throat. In rarer instances, removal
of the tonsils along with the adenoids may be of some benefit.
Vaccinations show some promise in preventing acute otitis
media or ear infections. The new pneumococcal
vaccine is estimated to lessen the incidence of ear infections
by 10% to 20% by making children immune to the most common
bacterial cause of ear infections, Streptococcus pneumoniae.
ONE
DOCTOR'S OPINION:
With
the exception of colds, I see ear infections ore than anything
else. I still use antibiotics, and I try to use amoxicillin
whenever possible. I explain to parents that this is still
the best medicine to use first because it causes the least
amount of resistance. Also, higher doses are used now, i.e.,
80 mg. per kg. of body weight, instead of 40 mg. per kg. of
body weight as this seems to work for some of those resistant
bugs.
Something I never do, and which I believe should never be
done, is to have an antibiotic called in over the telephone.
Antibiotics are not over-the-counter medications, nor should
they be. They can be dangerous if used improperly. I can't
tell you how many times a parent wanted an antibiotic called
in, and on examination I find a pebble in the ear, a perforated
ear drum or hole in the ear drum, a more complicated infection
for which oral antibiotics don't work, or a swimmer's ear
requiring ear drops instead of an antibiotic. The best thing
to do when your child has an ear infection is to see your
physician and, until then, use acetaminophen, ibuprofen, numbing
eardrops and warm compresses.
