Parent’s
Ear Infection
Cookbook
• • • •
Medical Recipes
For
Avoiding Surgery
• • • •
Howard G. Smith M.D.
Copyright 2011 Howard G. Smith, M.D.
PENTA Medical Publishing
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Cover design and illustration by Michael Jonathan.
2 -- A Roadmap For Success: Understanding the Big Picture
Where is the site of common ear infections?
What is a middle ear infection?
What are the patterns of ear infections?
What causes ear infections to occur?
What causes ear infections to persist?
How to treat ear infections.
How to prevent ear infections.
3 -- Recipes for Recurring Acute Otitis Media
Meet Mikey
Mikey’s First Visit
The VIP Program for Recurrent Otitis Media
Ventilation
Cleansing
Decongestion
Infection Prevention
Eradicating infection with continuous antibiotic prophylaxis
Mikey returns
Preventing new infections with episodic antibiotic prophylaxis (SAADD)
Mikey almost “crashes”
About ambush or “guerilla otitis” episodes
Mikey “graduates”
VIP Program for Recurrent Otitis Media at a Glance
4 -- Recipes for Persisting Otitis Media
Meet Michele
Michele’s First Visit
The SuperVIP Program for Persistent Otitis Media
SuperVentilation or Steroid Ventilation
Infection Processing
Michele returns
Michele “graduates”
VIP Program for Persisting Otitis Media at a Glance
5 -- Recipes for Clearing Middle Ear Fluid
Meet David
David’s First Visit
The VIP Program for Middle Ear Fluid
Ventilation
Infection Prevention
David returns
David’s maintenance regimen
David “graduates”
David’s Fluid VIP Program at a Glance
6 -- Recipes for Treating “Colds”
Meet Greg
Greg’s first visit
The SADD ventilation recipe for managing “colds”
Greg returns
Greg’s maintenance regimen
Greg “graduates”
Greg “Cold” Management Program at a Glance
7 – Recipe for Air Humidification
Why do you need air humidification?
What is the ideal relative humidity?
How can you measure relative humidity?
When should you use a humidifier?
Which is the best type of humidifier?
Which brands of warm mist humidifiers are best?
What else can I do to achieve the healthiest air possible?
What causes allergies?
How do environmental allergies cause ear disease?
How do you diagnose the existence of nasal and throat allergies?
When is a professional allergy evaluation worthwhile?
What are the recipes for preventing allergies?
What is the recipe for treating allergies?
Meet Lawson
What types of surgery help middle ear problems?
What is “tube” surgery?
When should you consider this surgery for your child?
What are the benefits of this surgery?
What are the potential complication and risks of this surgery?
What follow up is necessary after this surgery?
Will my child require more than one set of “tubes?”
What are the details about the operative procedure to insert “tubes?”
What is “adenoid” surgery?
When should you consider this surgery for your child?
What are the benefits of this surgery?
What are the risks of this surgery?
What are the details of this surgery?
Appendix A: Determining the dose of over-the-counter medications
Appendix B: Determining the dose of over-the-counter medications
Appendix C: Classification of Antibiotics for Treatment of Ear Infections
This book is dedicated to those professionals, patients, and parents who first taught me medicine and surgery and then helped me perfect the strategies contained in this book. I first thank the late Francis D. Moore, M.D., former Moseley Professor of Surgery at Harvard Medical School and former Surgeon-in-chief at Boston’s Peter Bent Brigham Hospital, who introduced me to the science of surgery and taught me the skill of careful clinical observation. The late Harold F. Schuknecht, M.D., former Walter Augustus Lecompte Professor of Otology and Laryngology at Harvard and Chief of Otolaryngology at the Massachusetts Eye and Ear Infirmary, taught me how to medically as well as surgically correct ear disease and how to humanely as well as effectively care for the patient with those diseased ears. The late William W. Montgomery, M.D., the former Merriam Professor of Laryngology at Harvard, showed me that conscientious medical and surgical innovations make good therapy. The late Daniel Miller, M.D., former Clinical Professor of Otolaryngology at Harvard and Director of the Dana Farber Head and Neck Cancer Clinic, although a internationally renowned cancer surgeon, shared with me a wealth of good old fashioned medical otolaryngology “tips and tricks” as well as some clinical wisdom never taught to most of our younger physicians. Finally, I am most indebted to my mentor and colleague Gerald B. Healy, M.D., the former Healy Professor of Pediatric Otolaryngology at Harvard and the former Otolaryngologist-in-Chief at the Boston Children’s Hospital, for teaching me the art and science of caring for children and their families and for encouraging my efforts to create innovative therapeutic approaches to children’s ear, nose, and throat problems.
Over the past 35 years, I have had the privilege of caring for thousands of children and their families in Boston, Southern California, and Central Connecticut. The lessons that I have learned helping them hear, speak, and breathe better have led to the “recipes” in this book. I thank them all for adhering to the treatment plans and keeping their follow up appointments allowing me to determine the effectiveness of therapy. I am also indebted to their pediatricians for inviting me to collaborate with them in the care of their patients and families.
This book would not have been possible without the love and support of my parents Hilary and Lester Smith. They consistently encouraged me to direct my interests in science toward human biology and medicine. They also gifted me with both the intellect and the financial resources to pursue a career in medicine and surgery.
Special mega-thanks go to my partner in life and in medical practice, my wife Judy Goldstein Smith. A former speech-language pathologist, she has branched into medical office management, and she keeps our practice, Pediatric Ear, Nose & Throat Associates, humming and our patients pampered as well as satisfied. Her office design has created a healing environment second to none, and her love and understanding has given me the inspiration and freedom to continue perfecting these treatment techniques. I dedicate this book to her and to our children Michele, Greg, Michael, and David, for their love, support, and patience. May our first grandchild Lawson as well as thousands of children and grandchildren be the beneficiaries of these recipes.
Howard G. Smith, M.D.
West Hartford, Connecticut
August, 2011
You are likely reading this book because your child or grandchild has developed ear infections of the type that either recur or that will not clear. You are naturally concerned about the numbers and the amounts of medications, especially antibiotics, consumed. You are concerned that your child is often too ill to play or to attend day care, preschool or school. You are especially concerned about the ill effects of all this on your child’s hearing and speech development. These issues are real and your concerns are appropriate.
My first piece of advice to you is to trust your intuition. Parents and grandparents know their infants and children best. If you have questions or worries, speak up and raise them with your child’s doctors. One important goal of this book is to provide you with the information that will empower you as an advocate for your child.
Ear infections are common during infancy and childhood. They are the most common reasons for non-routine pediatrician visits. Most children will have fewer than three ear infections in a six-month period or four infections during a single calendar year. Most children will clear each infection quickly with the use of a single antibiotic at most. Most children will recover normal hearing within weeks following treatment of their ear infection. But your infant or child has proven to be different.
As a pediatric ear, nose, and throat specialist treating children and their ear infections for more than 30 years, I have learned what works as medical treatment and, most importantly, as prevention for ear infections. I have learned that most parents will do anything to help their kids get better once they understand the problem and its possible solutions. I have definitely learned that parents do not want their children to use excessive medication. Above all, parents wish to avoid surgery as part of the treatment for ear infections unless there are no other options. Despite that desire, artificial ventilation of the ears using tympanostomy tubes remains the most common surgical procedure performed on children in the United States today.
Our goal, yours and mine, is not to include your child in that statistic. We will succeed by preventing and managing your child’s ear infections using the intelligent and timely application of medical therapy and medical therapy alone. We will succeed if you understand in common sense terms the causes of ear infections and how to help your child deftly sidestep them.
Good medical therapy is based on evidence from scientific studies. Unfortunately, the available data in the published literature does not offer us sufficient guidance for every aspect of treatment in every child. Like most clinicians, I use the observations and conclusions of published, controlled studies to modify and “fine tune” my own protocols which I have developed over years of clinical practice.
I urge you to read this material, follow its recommendations, and work with your own doctors who will provide the necessary clinical observations as outcome measures to determine the success of my recommended “recipes.” Your own doctors will also provide the necessary prescription medications, including antibiotics, which are critical to the success of my regimens.
This is a cookbook with time-tested recipes for success. Each recipe includes necessary ingredients in the form of over-the-counter medications and prescription medications. Like most recipes, these will often work with alternate ingredients, and, like any good cook, you must discover which combinations of ingredients work best for your child and for you. Experiment, experiment, experiment! Keep notes on your calendars, PDAs, and iPhones about how much of which “ingredients” you used and what worked for your child.
In medicine, practice makes perfect, and I would love to hear from you about your own successful variations. Drop me a line at earinfectioncookbook@gmail.com. I will review your observations, try your suggestion myself, and likely add your recipe variations, your “better mousetraps,” to future editions of my “cookbook.”
Thank you for reading.
2 -- A Road Map For Success: Understanding the Big Picture
Where is the site of common ear infections?
What is a middle ear infection?
What are the patterns of ear infections?
What causes ear infections to occur?
What causes ear infections to persist?
How to treat ear infections
How to prevent ear infections
Where is the site of common “ear infections?”
The most common ear infections during infancy and childhood are middle ear infections, in medical lingo termed otitis media. They occur in the so-called middle ear, the space located down the ear canal behind the eardrum. In contrast, another type of ear infection you have heard about, best known as “swimmers’ ear” or otitis externa and more common in older children, adolescents, and adults, occurs in the ear canal itself or on the outer ear.
I already hear you asking, “Where are and what are all of these parts of the ear?” Well, it is important that you have a good understanding of how the ear is put together in order to understand how it gets infected. So let me first give you a mind’s eye map of the ear. Also look at the illustrated simple “map” of the ear to get your bearings.
Figure A – cross section of the ear.
(Courtesy of the National Institutes of Health)
The part of the ear, which you see on the outside, is called the auricle or pinna. It captures and funnels sound down the ear canal toward the eardrum or tympanic membrane. Think of the eardrum as a thin but watertight as well as airtight curtain forming the outer wall of a tiny air-filled room in the side of the head called the middle ear space. Sound waves hit the eardrum and cause it to vibrate. Attached to the curtain and connecting it to the far wall of the middle ear space is a chain of three tiny bones or ossicles. When sounds shake the eardrum, this attached chain freely rattles and shakes a little window on the wall separating the middle ear from the inner ear. This so-called oval window is a membrane sealing a porthole between the middle ear space and the inner ear’s labyrinth of fluid-filled circular channels called the cochlea. When the eardrum and the attached ossicles rattle the oval window, the motion creates fluid waves in the cochlea that wash up against tiny hair-topped cells. These cells convert motion into electrical impulses which stream down the nerve of hearing to the brain and create the sense of sound.
Another part of the fluid-filled inner ear is the balance system. This ensemble of three semi-circular channels and a central lobby, the vestibule, connecting them responds to spinning or up-and-down head motions by creating fluid waves which wash up against sets of cells which also generate electrical impulses. These sensors in the semi-circular canals tell the brain the position of the head and the body. The balance system may be upset by the presence of ear infection or middle ear fluid, and a moderate proportion of children with middle ear problems become clumsy, experience falling episodes, or complain of dizziness.
The major focus of our efforts, yours and mine, is to keep your child’s middle ear space filled with air and free of multiplying viruses and bacteria. This air-filled and infection-free middle ear status is necessary in order for your child to hear with normal sensitivity and full fidelity.
The middle ear space is closed except for a single ventilation route. The only way air or, for that matter, anything including agents of disease, can enter the middle ear chamber is through a narrow channel called the eustachian tube. This narrow passageway travels along the bottom of the skull and connects the front wall of the middle ear space to the back of the nose. The eustachian tube opens and closes as we breathe and swallow allowing air to flow from the back of the nose into the middle ear. When this air flows freely, it permits the pressure in the middle ear space to equal that in the ear canal and in your child’s environment.
The air in the middle ear space must be consistently replaced since the oxygen within it is constantly being utilized by the living cells which compose the linings covering the middle ear walls, the ossicles, and the inside of the eardrum. If fresh air fails to travel up the eustachian tube into the middle ear and replace that which is used, the air pressure inside the middle ear “room” drops. Big trouble is just around the corner.
What is a middle ear infection?
A middle ear infection, better known as otitis media, is a process of rapid, uncontrolled turnover of bacteria or viruses within the middle ear space. The “germs” which trigger the infection may be forced up the eustachian tube by a sneeze, a cough, or nose blowing. Once they begin to multiply, they release some chemical substances and trigger the body to release others in defense, all of which cause the middle ear lining cells to become swollen and sometimes damaged. The swelling of the middle ear, eardrum, and eustachian tube linings then prevents fresh air from traveling up the eustachian tube and reaching the middle ear. When that occurs, air pressure within the middle ear space drops and a vacuum forms. This negative pressure draws more fluids, likely infected ones, up into the ear from the back of the nose. The negative pressure itself as well as tissue damage resulting from bacterial and viral activity also causes fluid to form in the normally air-filled middle ear space. This fluid, called a middle ear effusion, makes an ideal culture medium for additional bacterial growth. Think of a middle ear infection, an otitis media, as a downward spiral. Infection causes tissue swelling, eustachian tube blockage, a drop in middle ear pressure, fluid formation, and more infection. And so it goes…
Once the infection is rolling, your child may develop any number of possible symptoms and signs or none at all. Commonly, ongoing otitis media causes ear pain that may be worse when lying down, general irritability, wakefulness, loss of appetite, temporary hearing diminution, and balance problems.
As your child’s immune system fights the infection and kills off the viruses and bacteria, the middle ear and eustachian tube lining swelling gradually diminishes allowing air to once again enter the middle ear space. As this occurs, the middle ear fluid dries up and the ear returns to its normal, healthy state.
On the other hand, in the worst-case scenario, the body may not be able to stop the growth of the viruses and bacteria. Their continued proliferation leads to tremendous swelling and the build-up of pressure in the middle ear space and the development of a “pop off valve,” a perforation, in the eardrum. The latter usually heals quickly, but its occurrence signals a severe ear infection.
Sometimes, unrelieved middle ear pressure may drive back flow of infected fluid back into the mastoid chamber, an air-filled cavity located behind the middle ear space, thus creating a nasty infection called acute mastoiditis. The pus may also be pushed out of the mastoid cavity proper into the adjacent fluid-filled space around the brain causing meningitis. The two m’s, mastoiditis and meningitis, are two complications of middle ear disease which are most feared. Since the introduction of antibiotic treatment for otitis media, these complications have been all but eliminated. In fact, their prevention is the chief reason for treating ear infections with antibiotics at all.
During ear infections and the recovery periods that follow them, your child’s hearing will be diminished. The hearing loss is caused by the poor conduction of sound from the surface of the eardrum to the inner ear. The negative pressure in the middle ear and fluid within the middle ear space both prevent the eardrum from moving properly. Hearing impairment also occurs due to tissue swelling of the eardrum and the linings around the chain of bones conducting the vibrations. During these times, the hearing is muffled. Usually, both the volume level of sound a child hears and the fidelity of the sound are reduced. This type of hearing deterioration interferes with efficient speech-language development. The good news is that the hearing loss is temporary. One caveat: the longer it takes for your child’s ear tissues to return to normal, the longer your child will experience suboptimal hearing, both in terms of loudness and fidelity and clarity.
What are the patterns of ear infections?
Acute and recurrent is the most common pattern of troublesome ear infection in infants. Typically, this pattern is characterized by the occurrence of acute ear infections in one or both ears in association with upper respiratory infections such as run of the mill “colds.” Each infection resolves quickly and completely after initiation of therapy. Acute and persistent infections are symptomatic episodes that require multiple antibiotics for effective treatment or fail to respond to a succession of ever stronger and more competent antibiotics. Subacute and persistent ear infections are associated with milder inflammatory changes of the eardrum and middle ear tissues compared with acute infections, and many are asymptomatic or only mildly symptomatic infections. These bouts, despite their low intensity, continue despite the use of strong antibiotic treatments. Chronic and recurrent ear infection bouts are repetitive episodes during which middle ear fluid and hearing loss predominate in contrast to acutely painful inflammation and infection. For children with chronic and persistent ear infections, middle ear inflammation, middle ear fluid and hearing losses persist over many weeks and months without the occurrence of an acute ear infection.
What causes acute middle ear infections to occur?
The answer to this question is simple: AN INFECTION IN THE NOSE AND UPPER THROAT. Since the only way in and out of the middle ear is through the eustachian tube channel, all contamination of the middle ear is caused by germs passing from the back of the nose and upper throat, technically called the nasopharynx, into the middle ear space.
The most common culprit is the common cold, a viral infection of the nasal linings. The virus is usually picked up on the hands, passed from hand to mouth, mouth to mid-throat, mid-throat to upper throat, upper throat to the back of the nose, and from the back of the nose up through the eustachian tube into the middle ear and forward through the nasal cavities into the sinuses. Nose blowing, sneezing, and coughing will all accelerate viral passage into the middle ear and nose. Once the viruses set up housekeeping in either the middle ear space or within the nasal or sinus cavities, the body’s immune system begins to quickly eliminate them, but the secondary tissue swelling in these zones may then permit bacteria, which are also present, to multiply and create a secondary infection.
Sometimes, a bacterial middle ear infection may develop without a preexisting viral infection of the nasal linings if nasal bacteria are “blown” up into the middle ear. This may occur during the latter phases of “colds” or bronchial infections. This problem may be avoided with proper precautions, and I will discuss in detail how to manage “colds” in a later chapter.
Another common scenario that may trigger a middle ear infection is the development of eustachian tube swelling at its nasal end. This swelling is caused by one or more of the following problems: post-nasal drainage from nasal and sinus infections; nasal allergic reactions such as the seasonal spring “rose fever,” the autumn “hay fever.” or year round allergies; physical irritation of the nasal and throat linings by passive smoke from sources such as cigarettes, cigars, fireplaces, and wood-burning stoves; or the “backwash” of irritating liquids such as milk, formula, juice, and stomach acid, so-called reflux, into the upper throat. My recipes also cover solutions to these problems.
Sometimes, otitis media occurs, or I should say recurs, because the middle ear fluid and tissue reaction from a previous bout have not completely resolved. Bacteria and other infectious organisms may persist in a thin film called a biofilm, which then coats the linings of the middle ear spaces and eustachian tubes. A slight and temporary drop in a child’s immune strength is then all that is needed for these germs to reactivate and trigger an ear infection.
What causes ear infections to persist?
A middle ear infection persists for two reasons. ONE: your child’s body cannot eliminate the viruses or bacteria that caused it. TWO: the middle ear lining swelling fails to resolve due to the inability of the eustachian tube to open and readmit a sufficient quantity of air.
It is rare that a pure viral infection will persist in the middle ear, since your child’s immune system makes such a vigorous reaction to it. More commonly, a bacterial infection, which follows the viral infection, persists due to the presence of one or more bacteria that are resistant to the antibiotic used. Unfortunately, over the past ten years, bacteria commonly found in the ears, noses, and throats of infants and children have become increasingly resistant to many frequently prescribed antibiotics. These very resistant bacteria are commonly found in children attending day care and pre-school, and, as a result, such children are more prone to infections, which resist all but the stronger antibiotics.
Bacteria have become more resistant to antibiotics due to the overuse of these medications, particularly in low doses for longer periods of time. In order to stop this process and to avoid arriving at a time when some if not many bacteria will be resistant to all antibiotics, we must become “smarter” about our use these “miracle drugs.” We must use them more selectively and employ treatment strategies that kill the bacteria rather than select out resistant strains.
Reopening the middle ear to a “breath of fresh air” may be quite challenging, and failure to do so with medical therapy alone is the most common reason for resorting to surgery. The only natural route for that “fresh air” to enter the ear is through the eustachian tube ventilation ports at the back of your child’s nose. If that nose is running faster than Niagara Falls and smells like a toxic waste dump, you won’t be surprised to hear that the nasal entrances to your child’s eustachian tubes will remain blocked to air passage or will admit contaminated material into the middle ear. If the eustachian tubes do open and attempt to let air in, the swollen and contaminated middle ear linings tend to remain that way as swelling begets infection and infection leads to swelling. Turning the tide may be like dredging the Everglades.
How to treat ear infections.
Ear infections resolve when your child’s immune system eliminates the viruses and, with the help of antibiotics, the bacteria which cause them and when air reenters your child’s middle ear spaces to help thin their linings. All measures which enhance the function of your child’s immune system help this process including: good nutrition, sufficient sleep, and avoidance of other drains on immune system energy. You help your child’s immune system work in high gear by arranging for your child to avoid other children who are actively sick and by steering your child clear of nasal and throat irritants such as smoke, chemicals, and, if your child is sensitive, airborne allergens such as pollens, dust, and mold.
The use of antibiotics helps your child’s immune system prevent bacterial growth, but antibiotics are not a panacea. To fight increasingly more resistant bacteria, we continue to develop stronger and stronger antibiotics and better recipes for combining them in order to kill even the most devious bacteria. This is a moving target, however, and the medications, which work during this month or this year, may be relatively ineffective in the future.
The most important measures involve re-ventilating the middle ear spaces by driving air up from the nose into the ear through the eustachian tubes. These include eliminating nasal infections and nasal allergic reactions along with the nasal lining swelling which accompanies them. We accomplish this with the use of nasal cleansing and decongestion regimens and with the use of anti-allergic and anti-inflammatory medications.
You have undoubtedly read that pediatricians, family physicians, and ear, nose and throat specialists are now recommending that we all attempt to minimize the use of antibiotic therapy. The latest recommendations suggest taking a wait-and-see (WAS) attitude toward the treatment of acute ear infections delaying the start of antibiotics for several days while treating any symptoms such as pain and fever with over-the-counter drugs such as the aspirin substitutes Tylenol™, Advil™, or Motrin™. If a child’s symptoms persist or escalate in the absence of antibiotic therapy, it is then begun on a delayed basis.
This WAS strategy is suggested for infants above the age of 6 months and children with a normal number and severity of ear infections. If you are reading this book, chances are excellent that your child does not fall into this category. For infants and children with increased natural tendencies to develop ear infections, a delay initiating appropriate antibiotic therapy may permit their infections to advance more rapidly creating tissue changes with will serve to prolong their recovery from the infection and which will make subsequent infections more probable.
How to prevent middle ear infections.
Most ear infections are triggered by “colds” and other upper respiratory infections such as sore throats and bronchitis. Preventing as many of these as possible will prevent the majority of middle ear infections. Do this by keeping your child away from other children who have “colds,” and thereby preventing transmission of “colds” from child to child. Much has been written in parents’ magazines about how to do this, but my list is headed by preventive measures including hand washing, cleaning of shared toys, avoiding pacifier use, humidification, and nasal cleansing. We will discuss much more about all of this later.
How many ear infections are too many?
Since all children have ear infections, when should you as a parent become concerned? The following scenarios should trigger concern and suggest the need for more intense preventive therapy and treatment including the care of a specialist:
• 4 or more acute middle ear infections in a 12-month period;
• 3 or more acute middle ear infections in a 6-month period;
• 2 or more acute middle ear infections associated with a perforation;
• 1 acute middle ear infection per month for more than 3 months;
• 1 acute middle ear infection that persists for longer than 3 to 4 weeks, especially if the child is very irritable, wakeful, feverish and clearly ill;
• Fluid observed in both ears for more than two months if your child seems to be experiencing hearing and/or speech difficulties;
• Fluid observed in both ears for more than three months even if your child seems to be hearing appropriately;
• Fluid observed in one ear for more than three months if your child seems to be experiencing hearing and/or speech difficulties.
If any of these situations arise in your child, ask for a conference with your child’s pediatrician. Indicate your concerns, and ask the pediatrician to make a list of your child’s ear infections, the circumstances in which they arose, and their treatment. This objective look at your child’s clinical history, the “rap sheet” of otitis media, often suggests a pattern and an approach to treatment.
Once you and your pediatrician review your child’s ear infection history, you should be able to jointly arrive at a strategy for managing this problem going forward. The recipes in this book provide a framework for maximal medical management. Your pediatrician may wish to implement them or variations on them directly. More likely, your pediatrician will suggest that you take your child to an ear, nose, and throat specialist for a consultation. Following that visit, your pediatrician will work closely with that specialist to provide an effective treatment program.
Remember that referral to a specialist should not automatically guarantee a trip to the operating room. Otolaryngologists are in the best position to help your pediatrician craft treatment programs and to provide serial clinical monitoring to assess the success or failure of such programs. If your pediatrician tells you that the specialist referral is merely for a preoperative examination, ask for an explanation. If, after reading this book and other literature available to you, that explanation is unsatisfying, request a referral to a specialist who will fairly and evenhandedly review your child’s history, his or her current clinical status, and recommend comprehensive medical management before resorting to surgery. You want a specialist who will not merely rubber-stamp another physician’s opinion but one who will apply creative problem-solving and suggest a treatment plan which tilts the benefit-risk “see-saw” in your child’s favor.
3 -- Recipes for Recurring Acute Otitis Media
Meet Mikey, a child with recurrent otitis media
Mikey’s First Visit
The VIP Program for Recurrent Otitis Media
Ventilation
Cleansing
Decongestion
Infection Prevention
Eradicating infection with continuous antibiotic prophylaxis
Mikey returns
Preventing new infections with episodic antibiotic prophylaxis
Mikey almost “crashes”
About ambush or “guerilla otitis” episodes
Mikey “graduates”
VIP Program for Recurrent Otitis Media at a Glance
Meet Mikey
To understand the issues surrounding recurrent otitis media, let’s look at a typical infant suffering from this type of ear disease. Let me introduce you to Mikey, a sweet and mellow little fellow, whom I first met at 15 months of age. He is the first child of two committed and doting first time parents, George and Lori. George is a software engineer and Lori teaches fourth grade. She took maternity leave for the remainder of the school year following his birth, and she was nursing him. Then, in late August, at 5 months of age, Mikey began attending the KiddieCare day care center as Lori headed back to her classroom. By late September, he experienced his first “cold.” Three days after his nose began to run, his lovely disposition disappeared and he began to cry and whine incessantly, refuse his bottle, shriek when positioned on his back for diaper changes, refuse to fall asleep, and awaken repeatedly. Mom and dad carted him off to see Dr. Brown, his pediatrician, who diagnosed his first set of ear infections.
Mikey cleared quickly on one course of the antibiotic amoxicillin, and, although he experienced one minor “cold,” he remained free of ear infections for two months. Then just after Thanksgiving, he developed another “cold” followed rapidly by a left-sided ear infection. At his two-week follow up visit, the course of amoxicillin had helped to erase the inflammation in his left eardrum, but he did have a fluid collection in his middle ear space. This cleared by the time he came in for his 9-month well-child exam.
His “Happy New Year” celebration was anything but happy. Instead of watching the Big Apple’s crystal ball drop while basking in the flickering light of the family wood-burning stove, he and his folks spent the night at the Children’s Hospital emergency room (ER) for evaluation and treatment of fever and irritability. The ER docs ruled out meningitis, but they diagnosed Mikey with bilateral ear infections. This third episode of infection was treated with a stronger antibiotic, cefdinir or Omnicef. The infection cleared quickly, but diminishing amounts of fluid were seen in each ear for weeks after. What then followed was a run of three additional ear infections occurring 3 to 4 weeks apart, each with a “cold,” and many requiring more than one antibiotic to control.
His last ear infection was so fierce that he developed a perforated left eardrum. Treatment for this monster otitis media event included amoxicillin 600 mg + potassium clavulanate, better known as Augmentin ES (Extra Strength) and ofloxacin (Floxin) eardrops, a topical antibiotic drop. After this sixth infection resolved in early April, Dr. Brown recommended that Mikey remain on a two-month low dose course of the amoxicillin. This regimen worked like a charm for about 6 weeks. Then, in late May, his entire day care was attacked by “cold-zilla.” Despite the “protective” course of amoxicillin, he developed a seventh episode of otitis media in each ear and a nasty sinus infection. By the time I first met him as a patient in mid-June, these infections had survived courses of broad-spectrum antibiotics including azithromycin or Zithromax, cefuroxime axetil or Ceftin, and Augmentin ES, which he was just finishing.
Mikey’s case illustrates common features of recurring otitis media during infancy. As I review it with you, I will give you a “cooking demonstration.” You will peek in on his visits with me, and I will review the recipes that I used to successfully stop his and many other children’s cycles of recurrent otitis media.
Mikey’s First Visit
By the time of his first visit with me in mid-June, Mikey had just finished his course of Augmentin ES as treatment for his seventh otitis media and a sinus infection. When I first met his parents, George and Lori, they were understandably upset and frightened. Every new otitis media brought sleepless nights and crabby days. Even his customary bottle before bed failed to completely calm him, and he was drinking another in the middle of the night. He was so irritable that he craved his pacifier constantly.
Though he seemed to hear well enough and loved listening to his bedtime stories, his vocabulary was no longer growing. Babbling constantly in the months leading up to his first birthday, he had 3 words by the time of his birthday celebration and 8 words the following month. His word acquisition was now stalled, and the words he did use were no longer clearly recognizable.
His folks told me that each of them had ear infections as infants and toddlers. Dad had tubes inserted, and mom eventually underwent tonsillectomy and adenoidectomy. Mom and dad both tend to experience seasonal congestion but neither of them carries an official diagnosis of allergic rhinitis.
After reviewing Mikey’s history with his parents and after combing through his pediatrician’s records, my exam began. As I examined Mikey’s ears with a handheld ear microscope, I found that his eardrums were thickened but not inflamed. This indicated that the antibiotics had done their jobs and helped to eliminate the infection. His middle ear spaces appeared filled with air. My sonar ear probe, the instrument known as a tympanometer, confirmed that air was present in Mikey’s middle ear spaces but that the air pressure in each ear was lower than desirable. This situation occurs because the thickened linings of his eustachian tubes and middle ear spaces prevent the amount of air necessary to maintain normal middle ear pressures from entering the middle ear with each swallow or yawn. After any ear infection and particularly after a run of them, it takes time for the lining thickening to disappear. While the linings remain thickened, Mikey’s chances of redeveloping another ear infection remain elevated.
My examination of Mikey’s nasal cavities provided a clue to his problem. His nasal linings were moderately thickened and he had substantial amounts of mucus within each nasal cavity, particularly at the back of each nasal cavity. His mouth and throat exam were normal, except that he was teething.
Mikey’s history and clinical presentation at exam is fairly typical of infants with recurrent otitis media. First of all, little boys in general and children whose parents have a history of otitis media are more likely to develop their own problem with ear infections. Most infants are protected from usual childhood infections for their first six months of life by maternal antibodies transferred through the placenta during the gestational period. Breast-feeding definitely helps accentuate this natural immunity by providing additional maternal antibodies through breast milk. In many cases such as Mikey’s, breast-feeding may improve the situation but it does not prevent recurrent ear infections.
A cascade of events has led to Mikey’s current ear infection issues. His exposure in day care has driven a series of upper respiratory infections. These, in turn, triggered the ear infections. Successive bouts of otitis media then led to chronic swelling of the eardrum, middle ear linings, and eustachian tube linings. The swelling makes it difficult for air to reach his middle ear spaces and drive their return to normal after an infection has resolved. This same pattern has also occurred in Mikey’s nasal cavities and sinuses.
The VIP Program for Recurrent Otitis Media
My master recipe for Mikey’s woes is the VIP program, well titled since your children and my patients are VIPs. This acronym stands for Ventilation and Infection Prevention.
This VIP recipe is two individual but interrelated recipes, one for ventilation and the other for infection prevention. The rationale behind this blend of recipes is the fact that, for the ears, as well as for the nasal cavities and the sinuses, lining swelling leads to infection and infection leads to lining swelling. Since ear infections produce tissue swelling and that swelling, in turn, leads to the recurrence and persistence of infection and middle ear fluid, a major blast of “fresh air” is necessary to clean the swamp!
Ventilation
The goal of my ventilation recipe is to direct air into Mikey’s middle ear spaces, nasal passages, and sinus cavities. The air allows his linings in both the ears and nose to return to normal and, in so doing, makes it less likely for future infections to occur and more likely for high fidelity sound transmissions to occur.
Ventilation occurs by cleansing and decongesting the nasal linings. I am always concerned about the state of a child’s nasal linings, even if sinusitis has not been an issue, because the nasal passages are the conduits for air into the ear and they may be a repository for infection. The only natural air vent for the middle ear space is the eustachian tube, located at the back of each nasal cavity.
CLEANSING
My cleansing routine begins with an emphasis on maintaining clean and moist linings within the nose, throat, and, of most importance, within the eustachian tubes and middle ear spaces. It consists of saline mist irrigations for the nose and humidification as well as cleansing of the air your child breathes.
Saline mist irrigation:
The linings of our throat, noses, eustachian tubes and ears are so called mucous membranes, and they must remain moist in order for them to function normally. Think of these mucous membrane linings as miniature conveyor belts with a blanket of mobile mucus lying on a layer of cells with tiny moving hairs on top of them called cilia. It is these cilia that “motorize” the mucus and allow it to perform its natural cleansing process. Without this cleansing and emptying process, bacteria, molds, virus-laden mucus, and allergens will stall, accumulate, and foster localized infection. Dryness also creates direct damage to the ciliated membranes in the same way as it does to the skin. This damage allows germs to enter the body and trigger infection.
To provide this necessary moisturization, I recommend instillation of over-the-counter saline sprays, available as Simply Saline, Ocean, or Little Noses Saline mist in an aerosol sprayer. I prefer the use of either the aerosol or manual pump packaging as one-way valves in these prevent the back flow of nasal mucus from the tip back into the container, thus avoiding contamination of the remainder of the saline. Most squeeze bottles do not have one-way valves in the spray tip. The aerosol packaging method is also advantageous since the solution is delivered from a pressurized, sealed container, eliminating the need for squeezing the bottle and the need for preservatives. These chemical preservatives can irritate the sensitive linings of infants and children. The aerosol packing also includes a removable tip, which permits the nozzle to be cleaned after use. I recommend warming the saline can or bottle to body temperature by keeping the container in a parental shirt pocket prior to use.
Spray two sprays in each nostril three times a day, and use even more often during “colds.” Allow the mist to cover the intranasal linings, mix with mucus, and then wend its way to the back of the nose. Do not suction the saline back out the front of the nose with the little bulb syringe that was a part of your newborn kit. This maneuver may pull contaminated material from the back of the nasal cavity and the adenoidal mass into the “cleaner” environment of the middle and anterior nasal cavity.
I instructed Mikey’s parents to instill the saline mist in the morning before he departed for day care, when he returned from day care, and just before he went to sleep at night. Mikey, like most infants, did not initially “love” the nasal sprays. After the successive saline spraying led to healthier nasal linings, Mikey instinctively realized that his nose was feeling better as the result of the saline, and he began to look for it. Of course, he continued to look for the reward as well.
The regular use of saline mist irrigation “flushes” away infecting organisms entering the back of the nose and thereby reduces the incidence of viral “colds,” allergic nasal inflammation, and secondary bacterial infections of the ears, nasal cavities, and sinuses. The saline also restores a normal consistency to nasal mucus that has “sludged” as the result of your child breathing dry air. Nasal and throat mucus must be thin enough to move in the proper direction in order to maintain clean nasal cavities, eustachian tube entrances, and nasal sinuses. The saline also flushes away overabundant mucus, and, in so doing, acts as a decongestant.
Humidification:
Nasal and throat linings swell more readily when they are dry. Consistent use of a humidifier to maintain the relative humidity in your child’s room between 40 to 45% is critical in order to maintain sufficiently moist and healthy linings in the nose, throat, eustachian tubes, and, most importantly, in the middle ear. I recommend that you keep an inexpensive humidity gauge, a hygrometer, in your child’s room. Such gauges are available at hardware stores, with mechanical versions priced under $10 and electronic versions in the $10 to $30 range.
Once you know the humidity level in your child’s room, you will likely need to increase it, particularly during the cooler seasons when your home furnace is blazing. For this task, I recommend the use of a warm mist humidifier such as a model manufactured by Honeywell or Vicks. Currently, most of the warm mist humidifiers are made by the same company, Kaz. Look for a model with a 2 or more gallon capacity, a humidistat which controls the vapor production to prevent the room from becoming too humid, and, ideally, a safety fan to mix the pure water vapor with room air. Many of the newer models lack a fan, and, if you purchase one of those, I suggest that you purchase an external safety fan with soft rubber blades. Position it to blow room air over the hot air outlet of the humidifier. This effectively mixes the hot vapors from the humidifier with the cooler room air and circulates the humidified air around the room.
Use the humidity gauge to set the humidifier to the desired level by tuning the humidifier on and turning its humidistat all the way up to initially maximize vapor production. Dial back the humidistat to stop the vapor production once the humidity gauge indicates that the relative humidity in the room is between 40 and 45 percent.
Mikey’s folks told me that they had several old humidifiers around the house. One was a cold mist model and the other was an ultrasound model. I told them to throw both out in the garbage after cutting off the cords so that an unsuspecting garbage can scavenger with a child would not be tempted to use them. To find out why these types of humidifiers are downright dangerous, see the chapter A Recipe for Air Humidification.
Air cleansing:
Keep your child away from dirty air. Do not smoke in the house or, preferably, at all. Cigarette, cigar, and pipe smoke sticks to everything, and it easily enters your home and your child’s respiratory system on your clothes. Clean the rooms in your home often and try to keep your child out of rooms where you are dusting, vacuuming, woodworking, or using strong and smelly solvents. Avoid the use of wood-burning stoves or fireplaces. If your home seems unusually dusty, consider purchasing an air cleaner. Consult consumer information sources such as reviews on the internet via Google searches for reviews of current models.
Fortunately, neither of Mikey’s parents smoke, but the family does have a wood-burning stove. They discontinued its use.
Preventing stomach reflux:
We have long known that milk or other foods easily pass up from the mouth and upper throat into the back of the nose when infants and toddlers feed lying down. For this reason, pediatricians and ear, nose, and throat specialists have long recommended feeding infants and toddlers in the upright position. Recent research now also indicates that food recently ingested and retained in the stomach as well as the stomach acid it produces often comes back up into the upper airway and throat if an infant or toddler lies down to sleep or nap too soon after eating. These irritating fluids may rise high enough to bathe the back of the nose, the eustachian tube inlets, and the adenoids. This so-called extra esophageal reflux produces nasal congestion, inflammation of the adenoids, eustachian tube dysfunction, and, ultimately, the formation of middle ear fluid.
Since the stomach may require as long as 90 minutes to empty following a meal, avoid feeding your child just before bedtime or a nap. Try to compartmentalize feeding to other parts of the day. If you want to give a “security nightcap,” give water in the bottle or cup. If you must feed just before bed or nap, maintain your child in an upright position as sleep comes on by placing your infant or toddler in a swing or car seat. After 60 to 90 minutes, transfer the child to the crib. It is also sometimes helpful to elevate the head of the crib or bed using a pillow or two under the mattress or by using blocks under the legs at the head of the crib.
Some children have other evidence of gastroesophageal reflux disease and extra-esophageal reflux disease. Footprints of these problems include not only the obvious regurgitation of food, but also more subtle symptoms such as nighttime and morning cough, throat pain, and hoarseness. When such symptoms coexist with ear infection problems, diagnostic efforts should be made to verify the occurrence of reflux. Once confirmed, reflux should be initially managed with acid suppression therapy using agents such as ranitidine (Zantac) or lansoprazole (Prevacid).
Mikey’s parents will move his bedtime bottle back several hours and give him a cup of water just before bed or nap time. They have a wind up swing and will use it or use his car seat if necessary. He has no symptoms to suggest significant gastroesophageal reflux disease or extra-esophageal reflux disease.
Consider allergies:
Many infants and toddlers begin to show evidence of seasonal or year-round allergies as they grow. Keep your index of suspicion high while looking for nasal, throat, airway, or eye irritation as the result of exposures at home and out of doors. Look for reactions when you are dusting and cleaning the house, exposing your child to cats and dogs, or spending time out of doors near flowers or freshly cut grass. This risk of allergy in your child is significantly higher if one or if both parents have or had allergies themselves.
If your child only experiences characteristic nasal congestion and nasal drainage at certain times of the year, in certain environments, or after very specific exposures, the diagnosis is nearly made. A formal allergy evaluation may be useful, but it is not mandatory since your pediatrician or ear, nose, and throat specialist will suggest and prescribe a treatment program. On the other hand, if there is evidence of allergic reactions for more than 4 months of the year, ask your pediatrician or specialist about an allergy consultation. Read more about my treatment for allergies in the chapter Recipes for Allergies.
Mikey’s parents both have a history of seasonal allergies, and that fact significantly increases his chances of developing allergies. They have not noticed any tendency for him to have chronic nasal congestion or symptoms of post-nasal drainage at those times of the year when they are affected. He makes no reactions to his grandmother’s dog and cat. They will continue to observe him closely.
DECONGESTION
The goal of my decongestion recipe is to maintain a child’s nasal and throat linings in their normal, non-swollen state. By using the steps listed for the cleansing recipe just above, you are already beginning to decongest your child. But . . . there is much more that you can do.
My decongestion recipe, which I nickname the SADDS (pronounced ‘sads’) program, is a step regimen that instructs parents to use a number of various decongesting agents. I mention the agents in the order of suggested addition. I recommend that parents use as few or as many of these ingredients as necessary knowing that all ingredients may be used individually or in combination with each other. The only ingredient that I feel should always be in use is the saline mist irrigation. Otherwise, I ask that parents feel free to vary the recipe to improve effectiveness and acceptance.