category: Antibiotics

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    Ears and Tubes

    My almost-five-year-old is having the same ear problems she has had since she was five days old! It seems like she gets one ear infection after another. When she was about two, we finally put in tubes; what a glorious year and a half that was! We hoped that she would outgrow them, but currently she is on preventive antibiotics for fluid retention, and she has a granuloma problem in one ear. Should we be concerned about reinsertion? Any pertinent questions we should ask? Thank you!

    Acute Otitis Media (inflammation of the middle ear) is a common problem in childhood. One third of our children will have had three or more ear infections by their third birthday. Acute Otitis Media can pose significant health hazards for children. Children are most susceptible to ear infections from six to thirty-six months and then again from four to six years of age.

    If the Eustachian tube (the tube which normally protects the middle ear from nasal secretions) becomes obstructed, it can lead to sterile fluid being trapped behind the eardrum in the middle ear. The sterile fluid behind the eardrum can be contaminated by aspiration of nose and throat secretions. Obstruction of the Eustachian tube can be caused by a number of things including infection, allergies, enlarged adenoids or inefficient opening of the tube. In most young children, the tube does not drain properly because of the angle of the tube and the fact that the cartilage it is made of is soft and can easily collapse.

    In addition to the anatomical predispositions to ear infections listed above, there has been a definitive causative link between passive inhalation of secondhand smoke and ear infections. Lying flat down while sucking a bottle or pacifier may also contribute to the collection of fluid behind the ear. Risk of smoking in the home around children is clearly detrimental and should be avoided.

    Recognition of an acute ear infection is different in each child and within each age group. "Classic" symptoms include ear pain, fever, and hearing loss; these symptoms may appear two or three days after developing cold symptoms. Younger infants may only show signs of irritability, decreased appetite, difficulty sucking, or fever. Some children develop no symptoms at all.

    Otitis Media with an effusion (fluid behind the ear drum without evidence of acute infection) usually lacks the classic symptoms but holds the risk of hearing loss. In addition, the fluid is a good breeding ground for bacteria and may lead to an acute infection.

    Acute Otitis Media may be recurrent, and Otitis Media with an effusion may be persistent. Ear infections should always be treated with antibiotics because it is difficult and painful to get a culture of fluid from behind the eardrum. Amoxicillin has always been the mainstay of treatment. However, recent studies by prominent investigators have found that the numbers of resistant bacteria are increasing dramatically. Bacteria have a remarkable way of mutating itself to adapt to new threats upon its existence such as repeated exposure to the same antibiotic. Personally, because of this rise of resistant organisms, I am inclined to start with a stronger antibiotic. I prefer Biaxin (clarithromicin), Suprax (cefixime) or Zithromax (azithromicin). This approach seems to virtually eliminate the need for "switching" the antibiotic two to three days into treatment. Additional supportive treatments include pain relief, antihistamine/decongestant, and topical therapies. All patients should have their ears rechecked for persistent infection or retention of fluid after treatment.

    Pain from an ear infection can be managed either topically or systemically. Topical therapies include Auralgan drops or herbal mullein flower oil drops compounded with hypericum. Children's ibuprofen (Children's Motrin or Advil suspension) helps with pain and inflammation. Occasionally, especially in older children, Tylenol with codeine may be necessary. Antihistamine/decongestant therapy, especially with concomitant allergies or cold symptoms, seems to help relieve the fluid pressure.

    Some children are prone to multiple episodes of acute ear infections with almost every upper respiratory infection they get. They tend to have dramatic symptoms, but respond to therapy and gradually outgrow them with age. This type of child generally can be treated in the above fashion unless bouts become more frequent and/or closer together. Generally, children who are missing an unreasonable amount of school or are showing signs of chronic illness are treated more aggressively. Other children tend toward chronic ear infections with fluid behind the eardrums; these children seem to respond to long-term, once-daily antibiotic therapy with either Amoxicillin or sulfonamides ( Bactrim /Septra /Gantrisin). The addition of a decongestant/antihistamine (Dimetapp or Rynatan ) twice daily, appears to be effective as well.

    In addition to decreased hearing acuity, children who have a chronic amount of fluid behind the ears often exhibit behavioral disturbances such as the impairment of cognitive and language development. Hearing loss can also disturb psycho-social adjustment for some children. Chronic fluid usually resolves on its own; however, the reason for treatment is to reduce the possible significant hearing loss. The treatment options are oral antihistamine/decongestant, topical or systemic steroid therapy, allergy shots and/or trial of antibiotics. It is important to point out that none of these treatments have been shown to be effective in clinical trials.

    If the fluid persists for three months, or if there are multiple recurrences of acute ear infections, an evaluation must be done. This evaluation looks for enlarged adenoids, respiratory allergies, cleft palate, or other obstructions. At this point, Myringotomy tubes should be considered. These tubes drain the fluid behind the eardrum and allow the mucous membrane to become normal and hopefully prevent reaccumulation of fluid. One drawback to tubes, however is that ventilating tubes may be associated with granuloma formation (a foreign-body reaction, leading to scar tissue) or chronic ear drainage. In addition, Myringotomy tubes often spontaneously fall out in about six months. The treatment and decision making process must then start over.

    Prevention of ear fluid accumulation and infection is not an exact science. Careful attention to possible risk factors (like secondary smoke) helps to decrease the incidence, but there are many children who will continue to have ear problems anyway. I have found that prompt treatment with the herbal compound of Echinacea at the first sign of a respiratory infection seems to reduce the subsequent ear infections in some children. Echinacea targets the secretory immune system and activates cellular immunity associated with viruses. It also has an anti-inflammatory type action and, like antihistamine/decongestants, it may help to halt the accumulation of nasal secretions spreading to the middle ear via the Eustachian tube.

    Ear maladies are a challenge to children, parents and physicians alike. This problem involves a spectrum of decision making. For parents, some of the anxieties about the decisions involved can be alleviated by being well informed.

     






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