NESTLED BEHIND THE EARDRUM is a small space called “the middle ear,” known to parents of small children as a Den of Iniquity, the infamous birthplace of “Oh no, another ear infection.”
Across this cramped space arcs a linkage of three tiny bones—the Nina, the Pinta, and the Santa Maria. These connect the eardrum to the cochlea, the snail-like portion of the inner ear that converts the vibrations of the eardrum into electrical impulses that the brain recognizes as sound.
The middle-ear space is connected to the back of the throat via the eustachian tube, which allows us to “add” or “subtract” air from the middle ear, depending on pressure changes. If you’ve never had ear pain while riding on an airplane, you can thank your functioning eustachian tubes.
The trouble typically starts with a cold—a viral infection that plugs up the nose and, particularly in kids, the eustachian tubes. With their tiny tubes blocked, the middle ear becomes an enclosed, undrained space where fluid can collect. Under low pressure, the only clue to its presence may be loss of hearing. A parent may experience this as having to say, “You can’t go to school barefoot—would you get your shoes on?!” six or seven times, rather than the usual three or four.
If the fluid is under pressure, the child may experience pain, especially if it is infected with either bacteria or the ugly cold virus that started the whole episode. Fever and a general crankiness help transform the little cherub into a sleep-deprived, unsoothable potentate.
The medical term for infected fluid in the middle ear is “acute otitis media,” or AOM. It’s one of the top diagnoses in the United States for children, responsible for billions of health-care dollars and 15 million antibiotic prescriptions each year.
We can always print more money, and we do. But overusing antibiotics can weaken their effectiveness, and replacements are hard to find. Rather than reserving antibiotics for just severe infections, we’ve been handing them out for low-grade infections, or for “this might be an infection,” or for “you’re not infected now, but certainly you could become infected, if not now, then at some point in your life.” They’ve become candy with a co-pay.
Now the chicken is coming home to roost, traipsing in bacteria that are resistant to many first-line antibiotics. Bacteria may be mindless, but they’re not dumb: given time, they will figure out how to counter the effects of an antibiotic. And We, The People, have developed a mentality that if we have a bacterial infection and don’t get antibiotics, we will die. Or miss a day of school or work, or worst of all, a social function.
Deciding whether to treat an “earitable” child with antibiotics begins with determining whether he or she truly does have AOM. Several studies have shown that physicians are unsure of these diagnoses as much as 40 percent of the time. So despite all the practice we get with this malady, we could use some more.
Some parents believe they have an extra-sensory ability to detect middle-ear infections in their children, but clinical symptoms are actually a poor predictor of AOM (though they’re an excellent predictor of kids being sick). Ear pain (sometimes manifested as tugging), irritability, and fever are prominent symptoms in children with middle-ear infections, but they’re also common in those with bad colds.
Because clinical symptoms can’t differentiate a cold from AOM, an ear exam is crucial. This is not as easy as it seems, particularly with infants and toddlers. At the close of the cartoon classic The Incredibles, baby Jack-Jack reveals two of his special powers: turning first into a gigantic ball of flame, and then into a hideous version of the Tazmanian Devil. Youngsters who aren’t feeling well share Jack-Jack’s transformative powers, which makes examining their ears an acquired skill. And even if the child’s head is not spinning like an Indy driver who got loose going into a corner, all too often there will be earwax obstructing one’s view. Removing it does nothing to soothe little Jack-Jack.
Assuming one can eventually get a view of the eardrum, we’re looking for two things: fluid and inflammation. Sometimes the fluid is easy to spot: the eardrum is bulging outwards, rather than in its usual flat or slightly concave position, and the fluid gives the eardrum a yellow or orange hue. Small amounts of fluid can be more difficult to detect; then the physician may push a little air into the ear to see if the eardrum moves normally. If there is pressure in the middle ear, it will not move well.
Step two is looking for evidence of inflammation, like the swollen redness one’s nose exhibits during the acute phase of a cold. White fluid—i.e., pus—behind the eardrum indicates that a lot of white blood cells have been called into the area and strongly indicates infection, whether viral or bacterial. A red eardrum can indicate inflammation, although it also can look red if the child has been screaming his or her guts out.
Step three is to decide whether antibiotics are warranted. According to a position paper from the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP), children under 2 with a definite diagnosis of AOM should receive antibiotics. Older kids can be treated with just pain relievers as long they do not appear markedly ill (usually, with a high fever or severe ear pain).
A recent study from the Netherlands attempted to narrow this protocol even further by crunching data from six studies and asking, “In which children would antibiotics be most beneficial?” The researchers found two such groups: children under 2 with AOM in both ears, and children of any age with AOM and drainage from the ears. It wasn’t that antibiotics didn’t help other subgroups—it’s just that the benefit was small enough that doctors would end up treating a large number of kids just to help one child avoid an extended course of AOM.
Why stand by and watch when we’re certain a child has AOM? Because the majority of children will get better on their own without antibiotics, and because antibiotics are not harmless.
The AAP-AAFP position paper states: “The potential of antibacterial therapy at the initial visit to shorten symptoms by one day in 5 to 14 percent of children can be compared with the avoidance of common antibacterial side effects in 5 to 10 percent of children, infrequent serious side effects, and the adverse effects of antibacterial resistance.”
Should a child’s condition worsen or not improve with time, antibiotics can then be initiated. This “wait-and-see prescription” is quickly becoming the standard of care, and it held up well in a study recently published in the Journal of the American Medical Association. Children 6 months to 12 years old with AOM were randomized to either start antibiotics immediately, or receive a prescription to be filled only if the parents saw no improvement after 48 hours.
Clinical outcomes for the two groups were similar except that those who started antibiotics right away had their ear pain resolve about 10 hours sooner. This allowed more time to focus on the diarrhea that occurred in 23 percent of the children who left the ER on antibiotics—three times the rate of those in the wait-and-see group.
Sixty-two percent of those in the wait-and-see group got better on their own, without antibiotics; overall, this patience-centered approach reduced antibiotic use by 56 percent. That’s a good start. We need to be more judicious with our antibiotics. Save them for a rainy day. After all, none of us wants to end up in the hospital with a pneumonia caused by a highly resistant bacterium, one that eats antibiotics for lunch and is susceptible only to Agent Orange or an intravenous mercury infusion.
Craig Bowron is a Twin Cities internist and a father of three, husband of one. This is his last regular column for Minnesota Monthly.