Latest / Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner / Ear Infections Part One: Otitis Media

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Ear Infections Part One: Otitis Media · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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Welcome to Pediatrics Now, cases, updates, and discussions for the busy practitioner.
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I'm your host, Holly Wayment. I work for UT Health San Antonio's Department of Pediatrics.
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In this podcast, we explore how we can provide the best, most cutting-edge,
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compassionate care for children.
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We hope to give you a unique and behind-the-scenes edge from our expert guests.
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After listening, click on the link on this podcast for free credit that may
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include CME, MOC, or ethics credit, depending on the topic or podcast.
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Joining me here in our podcast studio, Erica Scher and Nadine Haeckel,
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pediatric ear, nose, and throat doctors at University Health and the University
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of Texas Health Science Center at San Antonio.
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Thank you so much for being here today in the podcast studio. Thank you for having us.
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Erica, you went to medical school at St. Louis University, residency in Syracuse, New York.
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Yep. And then I did a fellowship in pediatric otolaryngology at Boston Children's
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Hospital. Is that where the two of you met?
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No, we actually met on the interview trail for applying for fellowship.
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Oh, okay. It worked out great when we ended up here.
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So just in that on the trail in that short time, you're kind of competing for
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spots, but then you became friends?
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Kind of. I think the pediatric ENT world is pretty small. all.
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And so we all kind of get along and root for each other and are mostly all still
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in communication even a few years later.
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Yeah. That's like the best part about it. I think we're all still friends and
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we all really help each other out.
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So my medical school was in El Paso and then I did my residency at SUNY Buffalo.
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So in Buffalo, New York. And then I did my pediatric fellowship at University of Pittsburgh.
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And you were drawn to this specialty because Because you love children and the
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child patient, not necessarily the adult.
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Yeah, that's exactly it. I think kids are much better as patients.
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I'm not particularly a fan of having adults as patients just from like previous
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training, but I knew I was going to work with kids more.
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Even well before medical school. So it was a no-brainer. It was always going
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to end up there. The question is, in which realm?
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And you also both were drawn to the kindness you saw, the people who were training you at the time.
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Yeah. And this has been true with other people I've talked to in pediatric ENT
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that almost everyone has agreed that the pediatric ENTs they worked with in
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training and residency were some of the nicest people they had ever worked with.
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And that was a big draw to go into the field.
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I think that says a lot because ENT in general, I feel like we're kind of a
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overall really nice specialty.
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And so to have the subset of pediatrics were even like nicer,
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it's just, it makes it great.
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Like it was a great experience. And I think generally most people,
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regardless of what, you know, whether they need general ENT or some other specialty in ENT,
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most will probably agree that the pediatric side are probably very nice,
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very sweet. And it shows the power of kindness.
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There's no reason to be a jerk, right? doesn't help. Absolutely.
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Yeah. And I've definitely seen people be turned off from a field,
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even in training, just because someone they worked with was less than pleasant to them. Yeah.
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So it can really impact a person.
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And you both also, you like the, there's the variety in this specialty and also
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figuring out the puzzle when something's not working, let's get to the bottom of this.
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Yeah. I think it's great with pediatric ENT. So like I said,
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some people can do general ENT where they do kids, adults, and kind of a little bit of everything.
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And then there are subspecialties, so facial plastics, laryngology,
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head and neck, neurotology.
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There's a bunch of different subspecialties and pediatrics is its own division.
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But the nice thing about it is that we get to do a lot of everything.
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Some people even further subspecialize too,
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but we kind of, the nice thing about being here is that we get a little bit
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of everything and you almost can't subspecialize, I think, in this area because
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there's so few of us, but that makes it great because I love doing a little bit of everything.
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And it definitely keeps us on our toes. Yeah.
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And you both see patients out of the relatively new University Health Clinic
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on Heubner Road here in San Antonio. We do.
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The clinic has been open since like beginning of April.
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Yeah, we opened actually March 26, 2024. And it's been, it's a really great place.
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I know the patients and their families love it. And we moved with the audiology department.
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And it's just, we're so connected with audiology that the move and putting us
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together in a new spot just made complete sense.
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And it's just made a better transition for our patients, especially we do have
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a lot that do have hearing loss.
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And so the ease of it being kind of all together other has been really nice.
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And it's pretty. And there's windows.
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And they like the parking better. And they love the parking better coming to the hospital.
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Nice. Yes, it's a beautiful clinic. A lot of our listeners, they see a lot of ear infections.
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And it can be difficult to get in, get their patient in to be seen by a pediatric
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ENT specialist, as you know.
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What's your first piece of advice when a child comes in and has an ear infection?
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So I think maybe the hardest part is getting an accurate diagnosis.
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Truthfully, kids are naturally a little bit tough to examine their ears. They're pretty wiggly.
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And parents don't always have a good sense of how to help and hold them.
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So I think getting a good exam is probably the first step of the puzzle.
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And then even you know for us and for our trainees even once you look at an
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ear it's not always easy to figure out what's going on so I think being able
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to come up with that diagnosis first is you know step one and we certainly rely
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a lot on our audiologists to help us with that sometimes.
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Utilizing things like tympanometry to see how our eardrums are moving and particularly
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in the kids who we might not be getting the best view on yeah so I mean we can we understand like with.
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Pediatricians who generally see these patients first for the infections,
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that it can be super tricky.
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And I think a lot of times they probably assume that it is an ear infection
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because they're fussy, they're febrile, there's really nothing else.
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And really ear infections, it's true, are kind of probably more realistically
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what's going on, but you're not having a good look.
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We have the luxury of, we look at a lot of ears all the time.
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We have microscopes, we have staff that but sometimes to help us hold kids a
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little bit more steady because we want to make sure we're doing the right care
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for them as far as the next steps, especially if you're talking about a surgical intervention.
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Our Grand Rounds speaker on Friday, the podcast that's up now,
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he showed a slide and talked about how otitis media is the number one reason
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that antibiotics are overprescribed. Right.
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What do you want to say about that? A question I have from a community pediatrician,
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she said, if I don't prescribe the antibiotics, if the family wants it,
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they'll go to an urgent care and a nurse practitioner will prescribe those for her.
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And for our nurse practitioner listeners too, you know, what's the advice there?
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They're doing the best they can, you know, and not specialists in this area.
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So what do you say to all that? I think probably one of the first things,
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and you're going to reference the guidelines in a second, but that we have to
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remember is that otitis media with effusion, which is just essentially you have
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fluid behind the eardrum, that doesn't necessarily mean it's an infection.
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And so even treating with an antibiotic may or may not really help that.
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And then we're just increasing antibiotic resistance.
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And so we really shouldn't be treating fluid just because it's fluid.
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And so kind of reminding ourselves that fluid isn't always infection,
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although infection will typically always have fluid.
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So there are two different pathways for that.
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Yeah. And so as Dr. Haeckel mentioned, there are recommendations from the American
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Academy of Pediatrics about what kids should get treated with antibiotics and
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which kids you might be able to observe a little.
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And I think it is difficult because a lot of times, you know,
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if you're going to observe the kids, then you do need an avenue to see them
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back sort of in a short fashion to check the ears and make sure they're still doing okay.
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And I know that can be a limiting factor for a lot of providers.
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But from the American Academy of Pediatrics, they do have recommendations for children six months up.
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They don't include kids under six months just because they don't have any studies to include them.
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But I think it's probably safe to assume if you have a child under six months,
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it fits the six month to two year range.
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But basically for those younger children, if they're having an ear infection
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with severe symptoms, so that's, you know, high fever, a lot of pain in one
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or both of the ears, they should really be getting treated with the antibiotics.
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However, older children, if they don't have severe symptoms,
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you do have an option to observe them.
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And the idea being for those kids two and older than two, a lot of it's going to be virally mediated.
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And so the antibiotics themselves are obviously not going to treat that infection
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then, and it's going to get better on its own.
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And I think it's kind of like you have to think, you know, if you get a cold
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or maybe during COVID time when people were getting a lot of fluid built up
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behind the ears, you know, they have a viral infection and the ears may have
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a lot of fluid, so it may be uncomfortable.
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You know, you feel muffled. There might be a little soreness.
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That also may self-resolve within a couple of days or so.
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And so you don't really need the antibiotic because it hasn't really become bacterial.
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And so if it's viral-mediated, treating with an antibiotic may or may not do anything.
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And it's a chemotherapeutic agent, our infectious disease doctor was saying,
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talking about how people don't realize that.
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Increases resistance nowadays. And so you're seeing a lot of kids that,
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you know, amoxicillin, as we may get into this, But that is generally the first-line
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therapy as an antibiotic.
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But some of these infections can be polymicrobial. And so amoxicillin doesn't really cut it anymore.
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And so you have to either do Augmentin or Ceftonir, things that have a little
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bit more extended coverage to cover the three typical bacterial species that
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usually tend to grow in the ear.
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And so, you know, with increasing resistance, that can be a problem.
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And so in MRSA being prevalent, and especially kids that have needed to be hospitalized,
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that adds kind of a whole other component to it. But we want to try to prevent
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that as much as possible.
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And then we also try to remember that outside of antibiotic resistance,
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a lot of these kids will have GI upset and other side effects from the antibiotics
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that are not completely benign. It can be pretty significant for some of the children.
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That's a great point. Yeah. And then when they do have the GI upset,
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the parents tend to stop the antibiotic prematurely. Now you basically increase
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your chance of having resistance or incomplete infection, which allows some
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of those other bacteria to thrive in that environment.
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And so now you have, again, a more polymicrobial infection and maybe need,
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quote unquote, stronger antibiotics.
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Okay. So let's start with.
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Start with what antibiotics should be used first and go through the list.
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What's important is that a lot of the initial infections pretty much are treated
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by our primary care physicians, which are so crucial. They're on the front lines.
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They're the front lines, yeah. And the antibiotic regimen that they have is
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actually in the American Academy of Pediatrics.
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So a lot of their guidelines and actually our otolaryngology guidelines kind of can work hand in hand.
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And so we actually reference the AAP guidelines quite a bit,
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just as we would hope, you know, for kind of going forward, if a pediatrician
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thinks that a child might need ear tubes, that's where our guidelines really do come in.
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So it's a really great reference just for the general pediatrician to refer
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to, especially for what should be done first, you know, what are the next steps,
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you know, which antibiotics to use, when do you advance, bands, things like that.
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And we'll put a link to that in the text. Yeah. So our first-line treatment.
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Is recommended to be amoxicillin or Augmentin for the children who do not have a penicillin allergy.
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And in the AAP, they do specify that it's supposed to be a high dose of either
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of those antibiotics, which I will admit, I have had a hard time prescribing sometimes.
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The pharmacists tend to call back and say they think it's too high of a dose.
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I don't know if the pediatricians in town I have run into that,
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but I certainly have a few times. So I have found that a little frustrating. Is this oral or drops?
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Oral. Yeah. So otitis media that drops unless you have a hole in the eardrum
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are not going to be helpful.
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It has to be oral. Yeah, so it should all be oral. And then if someone's penicillin
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allergic, they have options for ceftonir, ceferoxime, or ceftrioxone,
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which is an IV or basically a shot that the children need to get.
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And I think we typically see the pediatricians in town doing that for three days is the most common.
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But interestingly, the AAP does say that there is an option to just do a one-day dose of that.
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And obviously, that may depend on how the child is doing if they want to see
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them back and reassess for other doses.
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And then if someone has failed that first line, then they kind of move down the ladder.
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So if you fail the moxicillin, then usually Augmentin is the next line.
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And then maybe if you fail that, going to that ceftriaxone shot or IV.
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And then alternatively, they do say you can use clindamycin.
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And then I know we wanted to mention, because we do frequently see,
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particularly maybe someone's been seen at an urgent care somewhere,
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not their usual pediatrician, that they get prescribed azithromycin,
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and that is truthfully not anywhere on the recommendation from the AEP. Not at all.
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And so we would not recommend it. We don't think it is particularly useful in
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treating acute otitis media.
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Yeah, and they're finding more side effects with azithromycin. send.
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And so that really should be reserved for other uses, in my opinion,
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particularly since it hasn't really been shown and is not part of any guideline
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for use for acute otitis media.
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Why is it out there being prescribed for this? Do we know? I have no idea.
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I'm kind of surprised because it's not in the guidelines. So I do think that they tend to treat...
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I'll see it for like tonsillitis. Occasionally, even in that setting,
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it's not great, but maybe that's what some providers feel comfortable prescribing
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and that's how it gets to that point.
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That would be my assumption, but I don't know. And I'm not sure because I know
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if it's just an easier thing to prescribe because you can prescribe the Z-Pak
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for people and kind of send them on their way. I'm not sure.
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And it's usually like a five-day course of treatment as opposed to 10 days,
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which is the typical recommendation for the other antibiotics.
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And so maybe they're trying to reduce the amount of GI side effects.
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Not really sure. And then you kind of get to the point of, did they really need
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the antibiotic and they would have been better anyway?
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I think one of the other things that, you know, you'll see a lot of people feel
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like they get better when they get antibiotics is because antibiotics do help with fevers.
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And so if If kids are less febrile, they feel like, okay, well,
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I got the antibiotic, I'm feeling better.
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But, you know, is it just that you would have had a little bit of time if you
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didn't get the antibiotic or, you know, in the case of a true,
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like, bacterial infection?
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And I know we mentioned this, but can you go over again?
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So how do you know when it's otitis media for sure and that this patient needs
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antibiotics in the first place or should you have watchful waiting?
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So the biggest thing is when you look in a kid's ear, they want half to half
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fluid behind their eardrum.
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And if you can't tell by looking, that's when some other modalities might help you.
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As I mentioned, our audiologist can do tympanometry to see how well the eardrum is moving.
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And then a lot of places are able to do what's called pneumatic otoscopy.
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Where they basically are able with just using their own otoscope,
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do a little puff of air to see if that eardrum is moving.
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And if the eardrum is not moving, that's usually a good sign that there's fluid behind the eardrum.
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So that's kind of the first step is determining if there's fluid.
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If there's no fluid and that eardrum is moving perfectly, it's not acute otitis media by nature.
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And so what should the community pediatrician do in that case?
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Wait. So if there's really no fluid, that eardrum is moving,
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they definitely do not need antibiotics.
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Now people can have eustachian tube dysfunction, and that could be a whole nother
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talk about how to manage eustachian tube dysfunction.
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But that is a common cause of having ear pain and discomfort.
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And we do frequently see that when people have coughs, colds, allergies.
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And so you may have a fever and resulting eustachian tube dysfunction giving you ear discomfort.
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But if you don't have fluid behind that eardrum, you do not need to be treating
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them for an ear infection.
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Right. And that's kind of going back to you can have flu without having an ear
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infection, you have to have fluid to have a bacterial ear infection, but we can see.
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Viral, kind of like a viral picture where a kid has an upper respiratory infection,
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they're complaining of maybe some ear pain, they have fevers.
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When you look in the ear, the eardrum may or may not be a little red,
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but if there's no fluid behind there, that is a situation where I wouldn't necessarily
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jump to prescribing antibiotics.
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I might watch and wait, because if it is viral, it may just pass within a couple of days.
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But if you see thick, generally what you will see is this sort of thick, white fluid.
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Maybe the eardrum is bulging at you. That's typically what, if you see that
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in the setting of the other factors, ear pain, fevers, you know,
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fussiness, crankiness, kids tugging at their ear a lot, that would be a good
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sign to do the antibiotics.
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And if you look online at the AAP guidelines, as well as in our ENT guidelines, there are pictures,
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that show both like a normal eardrum, fluid behind an eardrum that's not infected,
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and infected acute otitis media to kind of give you that comparison to help
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you kind of distinguish between those different entities.
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And I think one other thing that I would add to is that, say you do treat an
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ear infection, looks like an ear infection, you give the antibiotic,
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and then I will see situations where the providers will see them back in the
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office, and we'll give them another round of antibiotics, and all they'll mention is fluid.
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Obviously, we're not there. We can't really see what they're seeing.
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So if it's obviously thick, white, red still, looks still very much infected
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and they've completed their course of treatment.
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For sure, give another course of antibiotics. They might need it.
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However, we have to remember that after a treatment of an acute otitis media,
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a lot of times kids can have fluid behind their ear for up to four to six weeks.
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And again, that doesn't necessarily mean it's infected.
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It could be usually this clear fluid. It's not super white. The eardrum is not
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bulging. It's not really red.
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Those are situations I would not do another round of antibiotics,
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but instead check back on them maybe after about four to six weeks.
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And then if they still have fluid, not necessarily, again, treat them with antibiotics,
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but just something to kind of be aware of that you don't have to treat that type of fluid either.
18:45
Yeah. So it's okay if that fluid is present or what's normal for it. It is. It is. Yeah.
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Because I know there was one pediatrician who called me and this pediatrician's
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patient was on, I believe it was the seventh round of different antibiotics
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and waiting to get in to see the specialist.
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So what would you say there that could have possibly been a fluid case where?
19:06
Yeah, so that can be just a case of what we call chronic otitis media with diffusion.
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So it's just chronic fluid sitting there. They probably had an ear infection at some point.
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Or even we have kids who the parents say they've never been diagnosed with an
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ear infection, but maybe they've had bad allergies.
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And so they just have this kind of chronic kind of mucusy fluid that sits behind their ears.
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And so that can last, I think our guidelines say actually considered normal
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to be there for up to three months.
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And then after that, if it's still there, it's considered chronic otitis media
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with effusion. And that's when we start to think about ear tubes for those kids.
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But a lot of times it's just kind of a waiting game to see if that fluid goes
19:43
away on its own. But again, not an infection, not something to treat with antibiotics. Yeah.
19:48
And the eustachian tube disorder, and Erica, I know you're helping my daughter with that.
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And And for the pediatrician who's listening, community pediatrician,
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because it could be that and it's very common, what are a few things just we
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could, we'll do an episode down the road on that, but a couple things to try
20:06
that you would want to, anything you want to say?
20:09
So some of it depends on the age of the child.
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By nature, young children have poor eustachian tube function.
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It's just the nature of what they think is the length of the eustachian tube
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and the orientation of it.
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And as we get older, it tends to get a little longer and it's thought to become
20:24
more vertical, so it functions a little bit better.
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And so that's why we sort of say kids outgrow their ear infection problems,
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usually around age five to six, because that's when we see those changes in the eustachian tube.
20:35
So younger kids, truthfully, that's just the nature of their ears.
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Depending on what their symptoms are. You can sometimes try allergy medications for them.
20:45
I will be honest, though, our guidelines actually recommend against using that in young kids.
20:50
So I wouldn't do that unless they have separate allergy-related symptoms,
20:54
so things like antihistamines or nasal sprays.
20:57
Older kids, though, so we start to think about in kids six and older,
21:01
if they're really still having eustachian tube issues, a lot of ear infections
21:04
or ear pain, then it is generally thought to be more of an allergy-mediated phenomenon probably.
21:10
So for them, we do tend to be a little more aggressive starting them on some
21:14
nasal sprays like Flonase, nasal saline, maybe some Zyrtec and things like that.
21:19
And keeping the ear dry. So that is more for like an outer ear infection where
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that becomes very important, like a otitis externa or a swimmer's ear.
21:28
And that's why we talked about that the eardrops don't tend to help otitis media,
21:32
especially with a closed eardrum. So if you have a draining ear,
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that's a different story.
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But for otitis media, acute otitis media, eardrops don't help because basically
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what it is, is it's an antibiotic drop or an antibiotic plus a steroid drop
21:45
that goes into the ear canal, but it doesn't penetrate behind the eardrum.
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And so the problem, though, is behind the eardrum.
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And we do see, I think, sometimes the eardrops get prescribed because they'll
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do the one with the steroid.
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And what happens is it may help cool down some of the topical inflammation,
22:03
but is actually not going to treat the infection.
22:07
Okay. So Titus Media, what other advice do you have regarding age and when to
22:13
wait, when not to wait? for antibiotics?
22:15
So I think the biggest thing is young kids like under age two,
22:19
if they're having high fevers and symptoms of ear pain or anything,
22:23
they should really be getting treated.
22:25
And some of that has to do with their increased risks of bad complications like meningitis.
22:30
But I think for older kids, so age two and older, really, if they're not having
22:35
high fevers, their pain can be controlled with maybe some Tylenol.
22:39
They are usually a safer bet that you You could observe them for a little bit
22:43
and see how they do with the caveat being you do need a way to recheck their
22:49
ears, you know, in a few days or a week or so.
22:51
That can be kind of the hard part for a lot of providers and pediatricians because
22:56
they like us are obviously very busy and have full schedules.
22:59
And I do see we see the situation where the pediatrician or urgent care physician
23:03
will prescribe a course of antibiotics and say, you know, like,
23:06
don't take it unless you're not getting any better in the next 48 hours,
23:09
which I think is totally fair.
23:10
I think that's appropriate. Like you said, it's so difficult to see these kids back.
23:15
I feel like there's just the access can be more and more difficult.
23:19
So I think that's a fair thing to do. I just feel like a lot of parents will
23:24
automatically just go ahead and start it.
23:27
And so I think it kind of to do something like that, too, I would kind of gauge
23:32
the parent, you know, if they seem like, yes, they don't really want to do antibiotics,
23:37
but would do it if they needed to after a couple of days. I think that's a great idea.
23:41
If you're concerned about the patient or, you know, you're not really sure,
23:46
it may be better to try to fit them back in. The other thing is access.
23:50
So if, you know, we were in San Antonio and a lot of patients come from very far.
23:54
And so if they happen to be coming from far away, that might be a situation
23:57
where, yeah, go ahead and send them home with the antibiotic just in case so
24:00
that they're not, you know, struggling days later.
24:02
And now they have maybe a ruptured eardrum. And that's what doesn't happen all
24:05
the time, but at least they're kind of protected just in case and antibiotics
24:10
can be relatively cheap so it's it's at least it does not put sending them back
24:14
if they wanted to buy it have it on hand just in case.
24:16
And Nadine, if they live in town, suggest could you come back in a week or so
24:21
so I can take a look at the years again?
24:22
I think generally they say about 40 to 72 hours is sort of the,
24:27
especially if they're still having symptoms, you're going to want to treat it.
24:29
If, you know, or at least take another look, you know, at least you take another look a few days later.
24:34
If it's just fluid, maybe they have some allergies to stuff.
24:37
You're like, OK, well, at least we know it hasn't kind of turned into an infection.
24:40
I think you have to gauge it. You know, a little bit of that has to do with
24:44
how symptomatic the child is. But usually it's, I think, shorter.
24:48
And but for children older than 24 months, you could err on the side of waiting, watching.
24:55
Yeah, particularly if they're having mild symptoms.
24:58
I think we get a lot of parents who say when you ask them what their symptoms
25:02
were, they'll say, oh, actually, we went in for something else and they were
25:05
just sort of incidentally diagnosed with having an ear infection.
25:08
I think in that case, you know, if the kid is, you know, four years old and
25:12
they're not complaining of anything and they seem otherwise well,
25:14
that's definitely a good case where you could wait on some antibiotics. Mm-hmm.
25:17
When should the child see a specialist?
25:21
So there's a couple scenarios in which they get sent to us.
25:26
And the main question for us is always, would this child benefit from having ear tubes placed?
25:31
So the first scenario is a kid with what we call recurrent acute otitis media.
25:37
So that's the kid who's getting diagnosed with this acute otitis media,
25:41
getting treated with ear infections. Mm-hmm.
25:43
And for us, what we're looking for is a child who in either the last six months
25:48
has been treated for three ear infections.
25:50
And our guidelines are pretty specific that it should be three separate ear
25:53
infections, not, you know, one ear infection that perhaps they failed a first
25:57
line of antibiotics and then they got a second line.
25:59
You know, that does not count as two. That should be still one ear infection.
26:02
So it would be three ear infections in six months or in one year, four ear infections.
26:07
And at least one of them needs to be in the last six months.
26:10
And then the very last part of that guideline is that for us to recommend ear
26:14
tubes, they actually should have fluid behind their eardrums on the day that we see them in clinic.
26:20
And I think that can be very frustrating for parents because they frequently
26:24
come in and say, my child's been treated for 10 ear infections in the last year.
26:28
And I look at their ears and their ears look absolutely pristine and their hearing
26:32
test is absolutely perfect.
26:33
And so for those kids, the current recommendation would be to not put ear tubes
26:37
in, that their benefit is pretty minimal.
26:40
At this time. Yeah. And those are the general guidelines, but obviously we take every case by case.
26:46
So like if I have a kid that comes to me and they've actually had a couple of
26:49
febrile seizures from some of theirs, I'm more inclined to put ear tubes in.
26:53
But I do find that a lot of families too aren't super keen to just jump to surgery.
26:57
And I think they feel a little happier when I'm like, we don't have to rush
27:00
to do this right now. And I think it makes them feel a little bit better.
27:03
Obviously ones that are like constantly being pulled out and antibiotics and,
27:06
you know, if the parent is working and the child is in daycare,
27:09
it can be, from that standpoint, can be very taxing and tiresome and a big burden
27:14
so that, you know, they kind of want something to be done.
27:17
But also, I think parents are super happy. I'll a lot of times try,
27:21
even though it is not necessarily part of the guidelines, to do some of the
27:25
allergy regimen. We do see a lot of kids who are in daycare with just heavy
27:29
congestion, runny nose all the time.
27:32
They're just kind of exposed to all these germs. Their immune system aren't really strong. So,
27:36
I will tend to kind of give them allergy medicine for a short course of time
27:39
and bring them back pretty soon and see if that had any effect.
27:43
And so I think parents have liked that idea of not necessarily rushing to surgery,
27:47
but if they do need it, we take them very quickly. It's not something that we try to wait on either.
27:54
And then as Dr. Hackel mentioned, some of the, there are kind of what we consider
27:58
like higher risk kids that we might push to ear tubes a little little sooner.
28:04
So somebody who may not be able to take a lot of PO oral antibiotics,
28:09
some parents just say they cannot get their kid to take oral antibiotics.
28:12
So they're getting shots or IV antibiotics every single time.
28:15
That's a kid I would be a little more inclined to offer ear tubes to,
28:19
as well as kids who are at a higher risk for either they've already been diagnosed
28:22
with a speech delay or they have another medical comorbidity that's going to
28:26
increase their risk for a speech delay.
28:27
We're probably going to be a little more aggressive about making sure sure their ears are optimized.
28:31
So we tend to do a lot more ear tubes on kids who are syndromic,
28:35
expressive language delays, things like that.
28:37
Now, just because they have a language delay, we also take it with a grain of salt.
28:40
So if they have something like autism or something that's going to set them
28:44
up that increase the risk of having a speech delay where there may not be the
28:48
association, you can maybe monitor that a little bit.
28:52
But if they do have chronic fluid, lots of infections because they may have
28:55
a speech delay or are going to have a higher risk, I'm more inclined to do that
29:00
as the first thing when I see them.
29:02
And so then that kind of brings us into the second group of kids that we offer
29:05
ear tubes. So that first group was the recurrent acute otitis media.
29:08
And so then the second group, as we had mentioned before, is the chronic otitis media with effusion.
29:13
So the kids who maybe have never been diagnosed with an ear infection,
29:16
but they've had this mucousy fluid sitting behind their eardrums.
29:20
And so for our definition, we say if it's been there for three months or greater,
29:24
that's considered chronic.
29:26
And it's either three months from the time somebody diagnosed it.
29:29
So if the pediatrician has diagnosed it and documented, we can use that or we
29:33
can see it on a hearing test.
29:34
But if no one has that, unfortunately, it's three months from the time we meet them.
29:38
And then also if they have, we want to see that they are maybe having documented
29:42
complications for it, meaning is their hearing not perfect?
29:45
Some kids will have balance issues from it.
29:47
Maybe they are having some ear discomfort from it. All those things kind of go into that decision.
29:52
Would those children also benefit from ear tubes? loops yeah
29:54
and i think something to to say is
29:58
i get a lot of parents that will be like okay i you know i've
30:01
been trying to keep water out of their ears i don't let them swim i block their
30:04
their ears when they're baiting them and that is not
30:06
why they're building the fluid this is more of an internal fluid not an
30:09
external thing so so i always have to tell parents because they feel so guilty
30:14
and i'm like it's not your fault like it water going in the ear is not causing
30:18
the type of problem that they're having now if they have like a swimmer's ear
30:21
that's a whole different type of problem that can be from water coming into
30:24
the ear and moisture. But this is not from that.
30:27
So I think that's also a good reminder is that it's not from external exposure to water.
30:32
That's a great point. And with ear tubes, is it normal to cause some scarring?
30:37
Or do you want to say anything about that?
30:39
Yeah. So what I tell parents, you know, ear tubes is the most common surgery
30:42
that we do as otolaryngologists, especially pediatric otolaryngologists.
30:47
And so lots of kids have them. My niece and nephew have them.
30:51
You know, it's one of the most common, it's the most common surgery we do.
30:55
And the risks are generally very low. The ear tubes lost anywhere from,
30:59
they say on average, six to 18 months, maybe even up to 20 to 24 months.
31:04
That doesn't mean, I mean, I've seen tubes fall out earlier.
31:06
We've seen tubes stay in there for forever and don't want to come out.
31:09
So they're generally self-limited.
31:12
They fall out on their own. When they do fall out, they can develop a little
31:16
scarring in the eardrum.
31:17
Most of the time, it doesn't really cause any issues. Now, when the eardrum
31:21
does heal back, it does heal back a little thinner. So the eardrum is three layers thick.
31:26
When it heals back, it's usually no more than two.
31:29
And so it is a little thinner. That means it can be a little floppier in that area.
31:33
But not most of the time. We find with just one set of ear tubes,
31:37
it's not causing that big of a deal or causing them any symptoms or issues.
31:41
I will say too that, you know, when parents ask me about the scarring issue,
31:45
I will also tell them that I have seen kids who have so many just chronic infections,
31:52
had so many infections or chronic fluid.
31:54
And the fact that they had that put them at risk of developing scarring because
31:57
our eardrum is trying to protect itself and will develop kind of a thickness there.
32:01
Or they've spontaneously perfed before, meaning that they had a rupture of the
32:05
eardrum. And so when it healed back, it healed back with some scarring.
32:09
So the scarring in and of itself isn't necessarily a problem.
32:13
Now, if you have multiple sets of ear tubes and repeated scarring,
32:16
that could over time cause some issues with thickened hearing,
32:19
poor mobility of the eardrum, sometimes a little bit of hearing loss associated with that.
32:24
But generally from one ear tube, you don't really see it. Even two or three,
32:28
it's not necessarily an issue.
32:30
And for the parent listeners, the parent guilt that everybody feels,
32:35
feels like when you say that, like thinking like, oh, well, maybe that all of
32:39
those ear infections should have been treated or before the eardrum burst.
32:42
Is it, I mean, what would you say there?
32:44
Is it? I think there's no way to predict if it's going to rupture.
32:47
I've seen kids develop symptoms in like in the same day and rupture.
32:51
I've seen, I have, we have kids that have a million infections and never rupture.
32:55
And so the, you know, waiting a couple of days, especially if it doesn't look overtly infected.
33:01
It's totally fair. If it ruptures, it's just unfortunate and it is really sad.
33:05
But that doesn't mean that the antibiotics would have changed it necessarily.
33:09
Is that necessarily causing scarring or damage or does it?
33:13
So the perforation, just like
33:15
any hole on the eardrum could cause a little scarring on that eardrum.
33:19
But like I said, just like with ear tubes, it's not necessarily going to cause a permanent problem.
33:25
It's like someone putting a ear tube in the ear because it's a hole.
33:30
But, you know, when it does rupture, a lot of times kids feel a whole lot better
33:33
right after that. What do you want? Is there anything else you want to say about otitis media?
33:38
Any zebras out there that it could be something more serious that you would
33:41
want to mention to look out for? Yes, of course.
33:46
I would, I would, the one thing I would say for the pediatrician that especially
33:50
if you have a child that's around, you know, four or five years old,
33:53
they've just had chronic fluid, maybe chronic drainage,
33:56
never really had any ear tubes before, or maybe never really had a history of overt infection.
34:01
Just make sure you get a really good look at the eardrum too.
34:04
We can get something, again, this is not as common, but there's something called
34:07
a congenital cholesteatoma.
34:08
And so that's just during development.
34:11
It's the way I tell parents, it's essentially like trapped skin cells inside
34:16
the ear during the developmental process. So no one caused it.
34:19
It's not their fault. And they generally are these tiny little perfect little
34:23
pearls in the, And for medical terminology, the anterior superior portion of
34:27
the eardrum, that's generally where they're located.
34:30
But they can be found a lot of times after the age of five just because they're
34:35
nice and protected in a little ball, but eventually they may start rupturing and growing.
34:39
And that's where you can get chronic effusions and infections in a draining
34:44
ear. And that should trigger you to think, okay, is there something else going on?
34:48
And that's why it's super important to always, whenever you look in the ear,
34:51
make sure you can look at the whole eardrum because you will see this white
34:56
circular look kind of in the, like I said, in the anterior superior portion.
35:00
And if you're not sure, then send them to us, you know, and you can Google some
35:05
really good pictures of congenital clustyotoma and how it looks like on otoscopy.
35:10
And it's pretty obvious when you see it.
35:14
So it's something they'll have since birth, but generally the bad ones we see
35:17
are the the ones that get diagnosed after five.
35:19
That would be one kind of like, I guess, a zebra thing to look out for.
35:22
Again, it's not as common.
35:24
Anything you want to mention? I think the other thing would be,
35:27
I think people are always worried about people developing mastoiditis,
35:32
which is an infection of the bone behind the ear that spreads from an ear infection.
35:36
It is not super common in kids. It does happen from time to time.
35:40
So it's just important to keep that in the sort of your, the back of your mind
35:44
that it is out there and can happen.
35:47
Frequently what happens is the kid has a bad ear infection. They get sent to
35:50
the emergency room because they've tried some antibiotics, hasn't worked.
35:54
And then they get a scan of the ears.
35:56
And there's always fluid when the kids have an ear infection.
35:59
It always goes into the bone. And by nature, then it gets reported back as mastoiditis.
36:05
But truthfully, it can just be fluid just means there's an ear infection.
36:08
So to have real mastoiditis, it has to actually hurt when someone's pushing
36:12
back on it. On the bone behind the ear.
36:16
And then frequently on the scan itself, you'll see an actual abscess like behind
36:20
the ear and the ears kind of pushed forward.
36:22
Yeah. Clinically, usually there's a little bit more rendis over the skin.
36:26
The ear is bulging forward. And I will have to say, though, that there are kids
36:32
you just have to also look at them because some kids just have their ears a little pushed forward.
36:37
So always make sure you look at the other side to kind of see, OK, do they just have.
36:42
Anteriorly displaced ears and that's normal? Or is it really a swelling behind
36:46
the ear? It's tender, it's swollen.
36:48
That is an actual sign of mastoiditis.
36:50
But mastoid fluid is not necessarily infected or mastoiditis.
36:57
You have that with just your normal acute otitis media.
37:01
It's all the same space or even chronic effusion, chronic otitis media,
37:07
because that space is all connected, the middle ear space and the mastoid.
37:10
So if you have fluid in one, you're going to have fluid in the other,
37:13
but it doesn't mean it's mastoiditis.
37:15
Okay. And we'll be covering more ENT topics down the road.
37:20
We talked about doing an episode on sore throat, also tongue tie.
37:25
Am I missing anything big? I think we want to talk about hearing loss.
37:28
Hearing loss, yeah. And then we'll put the other guidelines.
37:31
Yeah. So it's just our American Academy of Otolaryngology has guidelines for everything.
37:36
And those look great. It looks very clear. Yes. Yeah. And there's a lot of resources
37:41
for patients specifically because they can be dense to read.
37:46
And so the information that they have for patients and their families is very
37:52
easy to read and is very helpful.
37:54
I love how that's being done now. That's so great. So, well,
37:58
thank you so much for being here in the podcast studio. Thanks for having us.
38:03
We hope you've enjoyed this episode of Pediatrics Now. Click on the link for
38:07
free credit if you're a practitioner.
38:09
You can also email us with questions or episode ideas.
38:12
That address is pediatricsnow at U-T-H-S-C-S-A dot E-D-U.
38:19
We release a new episode every Friday.
38:22
I'm Holly Wayment. I hope you can join us for our next episode.
38:28
Hi, my name's Nadine Haeckel. I'm a pediatric otolaryngologist through the UT UMA system.
38:33
We worked at the Huebner Clinic, the pediatric ENT clinic on Huebner.
38:38
We are happy to see if you have any ENT-related issues. I'm Erica Scherr.
38:42
I am a pediatric ENT through UT Health at the University Hospital in San Antonio.
38:47
Also work at the Huebner Clinic.
38:49
And again, we're happy to see anyone with ENT issues who is under the age of 18.
38:55
Coming up next week, there's so much, as we know, coming at them and say the
38:59
35th patient they're seeing today, like what is really to look for?
39:04
Media and externa, as long as there's no hole in the eardrum, are pretty distinct.
39:09
If, however, you have a kid who has an ear tube or a known perforation in their
39:12
eardrum, chronic drainage can lead to kind of an otitis externa.
39:16
So it's a little bit of both.
39:18
That's probably one of the only situations I feel like I see a little bit of both.
39:21
That's next week. I'm Holly Wayment. I'll see you soon. Thank you so much for listening.