One of the very painful experiences is an acute ear infection. For the parent, seeing a child in pain is extremely distressing. Some children seem to keep getting infections. Parents are always looking for the reason for these infections. The following is an attempt to help explain why your child may be getting sick so frequently, and to make suggestions about things you can do to try to break the child's cycle of infection, antibiotic, infection etc.
Let's start with a review of the anatomy of the ear. The parts which transmit sound to our brain are (1) the ear drum, and (2,3 & 4) the bones of the middle ear. In order for hearing to work properly, this area needs to be kept full of air, which comes through the eustatian tube from the back of the throat.
When an otoscope is used to examine the ear, the ear canal and the ear drum are usually clearly visible, unless there is an abundance of wax. While any ear infection can be painful, the major concern is of infections of the middle ear because they may have a long-lasting impact on hearing. The other major concern about repeated infections is the effect which antibiotic use will have on the immune system.
Ear Infections include:
- infections of the outer ear and ear canal (otitis external)
- infections of the middle ear (otitis media)
- another type of ear pain, but not directly caused by infection,, is caused by pressure on the eardrum from inside. This is caused by fluid build-up and has has several names - glue ear, water on the ear, serous otitis.
This is an infection of the ear canal. It often follows swimming or being in water. Perhaps this is because the organisms which live in the ear canal get an opportunity to flourish when water is present. This may happen after swimming and especially when this water is contaminated by bacteria.
Examination of the ear canal usually shows a boggy, white ear drum - if it is visible beyond the discharge.
This infection produces an itchy, watery, and occasionally malodorous discharge, and possibly pain in the ear and decreased hearing. The organisms responsible for these infections may be bacteria or fungal.
Treatment of external otitis
Therapy involves killing the fungus or bacteria present in the ear canal. This is effectively done using ear drops. One of the old mainstays of treatment is Locacorten-Vioform™ which works quite well as long as there is no perforation in the ear drum but which cannot be used if there is. More recently, Ciprodex™ - an antibiotic/steroid preparation (or some other such medication) is frequently prescribed.
Alternate approaches have included the use of garlic oil, tea tree oil, hydrogen peroxide or oil of oregano. While these may work, their use should only be undertaken with appropriate supervision and should not be used if there is a perforation in the ear drum. The discharge and discomfort should clear after a few days. If these persist, the ear should be assessed again.
More commonly, middle ear infections are the problem. They occur frequently and often return after what should have been effective therapy. I hope the information presented here will help you to break this cycle.
Definition of acute otitis media
An inflammation of the mucus membranes of the middle ear.
The middle ear is an area which extends, from the ear drum (visible using an otoscope), to the eustachian tube which leads to the back of the throat.
This mucous membrane is susceptible to all of the same problems as the throat. It can become infected by viruses, bacteria and yeasts. The illustration below shows inflammation in the eustatian tube extending into the throat.
Pain, one of the first symptoms of infection in the ear, is not always a sign of bacterial infection (usually responsive to and often requiring an antibiotic). Quite often ear pain is the first sign of the flu (always caused by viruses). In this case, the virus has invaded the eustachian tube where it proliferates. Several days later, a sore throat develops, associated with sore muscles, headache,and fever.
The most common cause of painful inflammation in the middle ear is from bacteria. It is because of these bacterial infections, which are so common in childhood, that most parents have grown to expect a prescription for an antibiotic. An antibiotic may however not be the right approach at that time. Let's see why.
The normal middle ear is full of air. The ear drum, when seen with an otoscope, is translucent, slightly pinkish or papery and can easily be moved often by asking the patient to swallow or with a puff of air (using a rubber bulb attached to the otoscope).
Progression towards an ear infection
There are usually several well-defined conditions which usually precede a bacterial ear infection.
A 'cold' or upper respiratory infection (always viral), produces inflammation seen as a reddening of the mucus membrane. This redness (see above) is usually, but not always, seen in the throat. The inflammation from the virus may be limited to the eustatian tube where it cases ear pain. Many people who are in the early stages of the flu have a very painful sore throat and ear pain.
As viral inflammation progresses, the mucus membrane swells, releasing mucus, and this swelling begins to plug the ear canal (see white arrow below).
It is at this point, when there is some redness in the ear drum, that there is a difference in opinion about the correct approach to treatment. Some physicians will prescribe an antibiotic. Some will counsel parents to wait. Why? It is often the case that this redness is caused by viruses or even just by fever.
Studies have shown that a significant number of patients with early ear infections get better on their own - with no treatment. Treatment with an antibiotic at this stage may not make any difference to the outcome.
Unnecessary treatment with an antibiotic should be avoided if at all possible because of potential problems like the emergence of antibiotic resistant bacteria and the development of yeast infections like Candida. Pain in these cases may be helped with the application of external heat (hot water bottle or even a loving hand), an NSAID i.e. acetaminophen or ibuprofen or a homeopathic remedy.
Bacterial Otitis Media
- Viral inflammation (from a cold or flu), leads to an excess of mucous secretions in the nose, throat and lungs.
- The mucous membrane of the middle ear and the eustachian tube, which should contain air, may become full of mucousy fluid which pushes the ear drum out. This distention is extremely painful.
- The eardrum, seen from the outside, with an otoscope, appears bright red and bulging.
- The local immune system, in this case has become compromised, making it possible for bacterial infection to set in. Fever and ear pain intensify.
In the illustration above, there will be pain and fever.
As the situation intensifies, as in the following illustration the eardrum bulges (black arrow). This is extremely painful. In the extreme, the infection may lead to rupture of the ear drum. The patient will have a sudden pus or watery, and sometimes blood-stained discharge. The acute pain may lessen.
Treatment of Acute Bacterial Otitis Media
Almost all physicians will, at this point, prescribe an antibiotic. There is however dispute about the correct choice of antibiotic. In years past, amoxicillin was the preferred treatment. Many children and parents know the 'banana' medicine.
When antibiotic sensitivities of bacteria which cause acute middle ear infections were studied in the early 2000's, the bacteria in about 80% of ear infections responded to amoxicillin. The advantage of using this long time approach was preferred because it caused far fewer resistant bacteria to emerge.
I suspect however, that the sensitivity of the bacteria involved in these infections has fallen to about the 60% level. If the patient has not had many antibiotic prescriptions, I still will prescribe it first. If however, there have been many prescriptions, I often give azithromycin (Zithromax™). It offers once daily dosing with good results after 5 days of treatment. After the end of 5 days azithromycin persists for several days in the body making it possible to get good results with a shorter course of therapy.
I feel it is very important that everyone treated with an antibiotic also take the probiotic, Saccharomyces boulardii . It is usually available in pharmacies as Florastor™ and should be taken at the same time as the antibiotic. This probiotic yeast has been proven to reduce later infection with harmful bacteria like Clostridium dificile. I suspect that it's use reduces Candida infections which frequently follow antibiotic therapy.
Candida may be responsible for the pattern of frequent ear infections in younger children. Candida can produce intense irritation and a fluid discharge which may be the breeding ground for the bacteria in the next round of bacterial infections.
Diet and Ear Infection
I have often wondered why I so often see children in the same family, who, one after the other, have repeated ear infections. And why do so many Asian children have them? Why are there so many after Halloween?
I think the link is diet. Some children likely have less tolerance to some foods. We know that food sensitivity runs in families. Could dairy products, with their ability to increase mucus production have something to do with these repeated infections? When I recommend reducing or stopping dairy foods, some of these children who previously got repeat ear infections, subsequently have fewer infections. Frequently the parents of these children will report that one of the child's parents have lactose intolerance - that they get a lot of gas, cramping or loose stool after drinking milk.
Could wheat or the gluten found in wheat and some other grains be another problem for some children? I think it is possible that for another group of children, of Asian parents, there is a difficulty in digesting wheat. Wheat is not a food found in the traditional diets of the Chinese, Thai, Korean, Philippine or Japanese. It seems that a number of children of this group do better when they stop eating wheat or, in some cases, gluten. In some cases the added benefit is an improvement in their asthma or eczema.
General food recommendations for the recovery from and reduction of ear infections.
- reduce sweet foods including baked goods, fruit and fruit juice
- reduce dairy products
- reduce bread and bread products
- increase watery drinks, teas and soups
- encourage rest and discourage excessive exercise
- keep warm
- take probiotics like acidophilus and bifidus daily
- consider adding a WGP™ beta-glucan supplement daily
Read further in the section, Strengthen Your Immunity