One of the most straightforward diagnosis that I encounter in clinics daily is that of ear infections, yet the topic of ear infections and ear tubes, as well as management of
tubes and potential complications can be incredibly confusing if not frustrating for patient families. Why you ask? Even though there is a wealth of research, and efforts by specialists and pediatricians from the American Academy of Pediatrics focused on developing “Clinical Practice Guidelines” to try and standardize what is considered the best for patients, I know that families who come through my office do not know such details nor may not understand how research data and studies translates into actual treatment plans. Don’t’ feel bad, trust me, physicians themselves often do not either. I say this without judgment, but only because day in and day out I have had the opportunity to see such a variation in practice by primary care providers and even other ENT doctors in how they treat issues related to a child’s ear. Let me share with you what I share with families during any visit for consideration of ear tubes.
First, let’s clarify that when talking about “ear infections”, there are 3 kinds of ear infections depending on where the problem is anatomically. “Otitis externa” affects the outer ear or ear canal (skin covered), “otitis media” which is middle ear infection, when there is liquid, inflammation, and pus behind the ear drum in the middle ear space, and then inner ear
infections affecting the hearing and balance organ (labyrinthitis). Thank goodness inner ear infections are extremely rare and serious as they can cause hearing loss and severe imbalance. The most common kind which may cause infants and toddlers fevers, screaming at night, poor sleep, decreased appetite and lead to many doctor’s visits is what we refer to as otitis media or middle ear infection. As we are finally approaching swimming season, I tell parents the simple trick of how to tell if your child has a “middle” or “outer” ear infection (also known as swimmer’s ear). Simply tug or gently wiggle your child’s ear, and if they scream angrily at you and yell then it is a swimmer’s ear. This can be treated successfully and easily with antibiotic and steroid ear drops and does not need oral antibiotics. If treated early you may even be able to avoid a doctors’ visit. See my guest blog on how to treat draining ears in those with ear tubes.
It’s also important to distinguish between “acute” versus “chronic” ear infections. Acute means it is associated with symptoms such as fever and pain, while chronic is used to describe the condition when fluid in the middle ear is present for more than 4 weeks, likely up to even over 3 months! As a parents, what you need the health care professional to be clear with you about is whether on the day of the visit, your child has “fluid” in the middle ear or not, as well as whether it’s pus like fluid or not “pus’ or acutely infected fluid. By definition, a child does not have an ear infection if there is no fluid behind the ear drum! It’s always concerning when a mom comes in with an infant/toddler who was diagnosed with an ear infection, just within 24 hours ago somewhere else, and prescribed oral antibiotics, but when I look, his/her eardrum is perfect and there is not a drop of fluid indicating any inflammation/infection whatsoever! If there is truly an ear infection, then the fluid really does not magically clear up within 24-48 hours! It takes days, and antibiotics does not make middle ear fluid “drain” or clear out faster. The most recent large scale research studies with control groups, comparing oral antibiotics to placebo, to examine whether there is benefit in using oral antibiotics to treat ear infections, shows that there is certainly higher likelihood of decreasing symptoms sooner when a child is given antibiotics. However, this is always weighed against the increased likelihood of side effects such as rash and diarrhea associated with eating antibiotics.
I always explain to families that once a child is prescribed an antibiotic, even though the child may finish eating 7-10 days of the medication, about 80% of children need up to 4 weeks for the middle ear fluid to completely go away, while another 10% may need up to 8 weeks to clear the fluid completely. So, unless someone who is very good at looking at ears, is taking a look and documenting whether the fluid is gone and eardrum is perfect again after treatment, it is very difficult to count the number of ear infections accurately. Many times parents tell me that every time the child is seen the physician states that there is fluid or an ear infection, or that their child has been on 4 rounds of antibiotics in a row because the “infection” is not clearing up, then that infection truly should be counted as the same infection. More on this later, since I personally believe it is at times important to consider how many courses of antibiotics a child has been given and received, despite the imperfect system of “counting” ear infections. Some pediatricians are great with their referrals, they will literally write on a prescription paper the exact date of acute otitis media diagnosis from their office in the past 6 months or 12 months, and have the moms give it to me on the day of our visit. I can’t tell you how often families are disappointed that their primary doctor’s office said they would “fax” papers to my office, yet I have received nothing. I try to explain that I am sure they meant well, but with at least 30 appointment per day through my office, and probably more through theirs, it’s probably not likely that they can keep up with all the papers going to so many different offices for each type of referral. Keep in mind, by the time a child has been diagnosed with fluid in the middle ear, that person can’t tell how long it’s been there, it could have been 2 weeks from the recent cold or for months. SO, the point is, we physicians and care providers are likely doing the best we can, to make educated guesses based on the history YOU provide, as well as records from referring offices. The system is complex and human factors involved in making this diagnosis in essence make it impossible to be a perfect science.
Back to diagnosis and treatment for a child with repeated ear infections. When a baby, toddler, or even an older child comes for an opinion about whether ear tubes are necessary, here is what I ask and whey I ask these questions.
- How many ear infections has your child been diagnosed in the past 6 months? How many in the past 12 months?
For straight forward acute ear infections diagnosed by otoscopy, benefits of tubes should be considered if child has had at least 3 episodes in 6 months or 4 episodes in 12 months. Again, one can only count them as separate if there is documentation that ears were normal and clear in between episodes. Indications for tubes are many, and includes for both recurrent acute, chronic, and complications from acute ear infections. Other indications may include hearing loss and entirely separate from infection problems.
Tubes are also indicated if there is severe complications from an acute ear infection such as “mastoiditis” and even extension of infection into the head like subdural abscess or epidural abcess.
2. How many courses of antibiotics has your child been prescribed and taken in the past 6 months and 12 months?
If a child has only had “3” ear infections, but has been prescribed and taken over 8 course of antibiotics in the past year (especially documented by print out from their pharmacy, not just by mom’s memory/recall), then I explain and discuss the benefit of tubes as well.
3. What led you to take your child to seek medical attention?
Many moms can tell when their infant/toddler behaves differently, or when sleep is disturbed. Often moms tell me they know it’s an ear infection if their child pulls on their ears. I ALWAYS inform families that research shows that ear pulling is not sensitive, instead, fever and actual otoscopy is the most sensitive way to diagnose an ear infection.
4. Where were diagnoses made?
With all due respect to the many walk-in and urgent care clinics in our communities, if most diagnoses are made by individuals that the family never sees again, nor have a relationship with, this scenario is less optimal then most diagnoses being made by the child’s primary care provider and same office where parents do have a relationship with the provider. Let’s face it, accountability is really not a mandate, nor even relevant, if the person seeing you and your child may never see you again. Yet, it is precisely accountability that must be a key part of the medical and surgical treatment decision making.
5. What did the person say when they looked into your child’s ear?
Often, parents will tell me that the person said the ear drum looks “red”, and there was no mention of presence of fluid or not. I ask families to always respectfully push for specific information about presence of fluid, since research also shows subjective description of “redness” of the ear drum is not an accurate way of diagnosing true acute otitis media. Furthermore, please know that the ear canal skin is often pinkish/red, and in fact, part of the normal anatomy of the ear drum where the feeding blood vessels are, also appear red, which would be entirely normal. I truly urge you never to believe that your child has an ear infection simply because someone tells you his/her ear drum is “red”.
6. Does the health care provider always prescribe antibiotics ?
Once again, amazing at the differences in how primary care providers practice, but easy to understand that physicians and providers usually practice how they were trained, and it takes a motivated and disciplined individual to read and keep up on latest research and recommendations and evolve their practice and treatments along with explosive growth of new scientific information all the time. Again, even if the provider has the best intentions and may wholeheartedly believe he/she is doing the best thing for your child, he/she can be wrong if the way they practice medicine does not reflect what’s been recommended as clinical standards based on current research evidence. I never suggest that we providers should act as robots and every human health care decision should be as simple or black and white as some statements or a guideline. However, before we go making exceptions, we have the responsibility of making sure that those exceptions are truly exceptions. You and your child deserve so much more than just someone’s opinion. My opinion must be based on research and evidence, otherwise it’s not good enough for my patients and not good enough for me.
7. How is his/her hearing and speech?
If a child has poor hearing, speech may be affected. There are so many factors, including severity of hearing loss and length of time a child has hearing loss. If a child has normal hearing, he/she can still be speech delayed.
Just because a child has a 3 infections in the past 6 months, if on the day we visit the ears look great, hearing is perfect, speech is normal, and especially if it’s spring and warmer months are approaching, I will often explain everything but reassure parents and ask them to wait. I will not just recommend ear tubes because I do not run my practice like a “business”. Yes, we all work and ultimately, healthcare is a business. However, each and every patient encounter and decisions made that day in the office with the parents should never be a business transaction, and I sleep soundly at night because I never suggest surgery I truly believe the benefits highly outweigh the risk, and we have exhausted all nonsurgical options.
Conversely, if a child has been noted to have fluid in the middle ear, has abnormal hearing test, and has been diagnosed or clearly have speech delay, even if he/she has never had symptoms of acute ear infection, I certainly discuss the benefits and risks of having ear tubes. If your child was born with normal hearing, there is no good reason to live for months with decreased hearing which can impact speech development. This part is not as simple as looking at “flat” lines on tympanograms, because once again, an ENT should consider the entire picture and I have always prided myself is never making surgical decisions based on a “test” alone.
Any child who has clinical speech delay should have a full hearing test when they come into an ENT’s office, and the physician should fully explain the results of the test. If hearing is considered normal on the test, then I send them for formal speech evaluation. Thank goodness moms are often more strict on definition of speech delay than our speech language pathologists! Meaning that often a child will be considered to have speech within normal range despite mom’s perception.
Otoscopy, using our handheld scope to look into a child’s ear canal to see what is going
on in the middle ear, if there is fluid or not, what kind of fluid (infected or not), if there are structural issues with the ear drum, etc. is the most CRITICAL and important part of your visit to the doctor for this issue. Research has shown that nothing is more effective nor impact treatment decisions more than the human eye. While tests like tympanometry can suggest whether there is fluid behind the ear drum, it is not accurate enough to tell us whether your child has an acute ear infection or chronic, since both have “fluid” in the middle ear space.
For infants and young toddlers who may not cooperate in a sound booth and raise their hand in response to sound or repeat “car”, “train”, or whatever words, then my practice has used tests which can give me information without their participation. ENT doctors will have audiologists working with them in their offices, as these are the professional who perform a variety of hearing tests to help provide information for a complete evaluation of your child. I won’t go into the details of a variety of hearing tests but know that there are different types for what is considered most useful depending on the age of the child and what we’re looking for.
Often I meet preschool or school-aged children who may even have “never” had an ear infection, but “fails” a school hearing screen and comes to see me. He/she may have had the fluid for a few weeks or even several months. Clues I ask parents for include whether at home he/she speaks very loud, has the TV up way loud, and always says “huh”, “what”, or need instructions repeated. Sometime these children are bothered by loud noises, this can reflect having middle ear fluid and mild conductive hearing loss. Again, otoscopy by a health care professional as well as hearing test can most accurately help decide on the presence and extent of the problem.
It is clear that I can write several blogs on this topic alone, and plan to. I will stop here and summarize: there remain significant challenges in the healthcare system when it comes to pediatric health care issues. First, we need to prioritize and promote evidence based medicine, meaning diagnosis and treatment plans must reflect more than someone’s opinion. Second, there must be efforts for standardizing competency and training for health care professionals when it comes to how to accurately make the diagnosis of an ear infection. Sounds simple but believe me, this is the part that I believe we need to mandate improvement on as a society, otherwise no amount of research evidence and clinical practice guidelines will make an impact, because every day, decision are being made by a human being in some practice setting, and if you can’t trust the diagnosis, there is no point in discussion which treatment is the best. This is not just for all doctors of medicine, chiropractic medicine, osteopathic medicine, but all physician assistants, nurse practitioners, and anyone who is licensed to treat the human condition and has the power to write a prescription. Finally, by giving families information, education you the consumers of medicine as a commodity, can we empower everyone to minimize over-utilization of our resources, and reclaim health for your hopefully not but likely at times misdiagnosed and over-medicated children. There is so much information out there thanks to the 21st century advances in computer science and search engines, social media, and bloggers like myself. My goal is to help translate some of this important information.
Julie L Wei, MD FAAP
Dr. Julie Wei is a pediatric ear, nose, and throat specialist and the author of A Healthier Wei. As a mother herself, Dr. Wei is a passionate advocate for improving children's health through better diet and dietary habits. She has been committed to helping parents learn how to eliminate their child's ear, nose, and throat problems simply by reducing excessive sugar and dairy intake, as well as minimizing habitual late night snacking. She hopes to raise awareness for the need for accountability by both medical professionals and parents to ensure that children are not prescribed or take unnecessary medications long term.
When she is not in the clinic, operating room, or conducting research, you will find her in the kitchen preparing food with love along with her daughter Claire. If you sit next to her on the plane, she will likely share with you information about how to minimize choking hazards in young children, and many other tips for improving your child's health.