Latest / Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner / Do You See What I See? Identifying and Treating Otitis Media, Otitis Externa and Eustachian Tube Dysfunction

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Do You See What I See? Identifying and Treating Otitis Media, Otitis Externa and Eustachian Tube Dysfunction · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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Music.
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Click on the link in this podcast for free credit that may include CME,
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MOC, or ethics credit, depending on our topic or podcast.
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I'm thrilled today because here in the podcast studio, we are going over an ENT update.
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And here with me is Dr. Marissa Early.
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She is an associate professor with the Department of Otolaryngology at UT Health San Antonio.
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Dr. Early, thank you so much for being here today in the podcast studio.
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Thank you for having me. I'm excited.
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And I know you have some previous experience doing podcasts and you really enjoy
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this. Yes. This is like a secret dream of mine.
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When I was a fellow at NYU, we had our own Dr. Radio studio in there with Sirius XM.
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And so I got to do a couple of episodes during that time. And it was really, really fun.
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Well, I'm excited to talk to you. And I know we have a lot to cover.
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And like you mentioned, so you're from the New York area.
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You got your medical degree from Rutgers New Jersey Medical School in 2010.
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Yes. And from there, you did residency at State University at New York,
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and then a fellowship in pediatric otolaryngology at NYU.
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You're board certified by the American Board of Otolaryngology Head and Neck
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Surgery. That's a pretty amazing background.
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Thank you. And that was pretty amazing pronunciation because I do not have the
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easiest specialty to pronounce.
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Well, and some of your, and thank you, some of your special interests that we'll talk about.
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Surgical management of pediatric airway obstruction, obstructive sleep apnea,
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chronic ear disease, neck masses, and sino-nasal disease as well.
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As you started the first aerodigestive clinic here in San Antonio?
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Yes. So that has been something that I've been really passionate about is the
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complex interplay that our gastrointestinal and our airway systems have with each other.
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And so oftentimes if kids have complex swallowing or breathing disorders,
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it's not just ENT, pulmonology, or gastroenterology. It's often all three of us that are involved.
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And so for parents, that's three separate doctor's visits waiting for the time
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for us to talk to each other between visits.
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And then if they need an evaluation in the operating room, that's up to three
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times they're being put under anesthesia.
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And so I had a great model from when I was a fellow for how to do a clinic like
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that and thankfully had the interest with the pediatrics department in the divisions
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of pulmonology and gastroenterology.
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And so we have been successful at creating the first air digestive clinic here in this area.
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And just like our normal encatchment, we cover all the way down to the Rio Grande
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Valley and the U.S.-Mexico border.
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So we really do provide a great service, I think, to kids with complex needs.
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And we are able to take kids to the operating room together.
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Every third Thursday, we do our aerodigestive operating room.
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And then that way we can problem solve, make treatment plans,
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and intervene at the same time.
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And where is this aerodigestive clinic, Marissa?
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It's housed in the new clinic that we just moved to. So the Huebner Specialty
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Clinic on Huebner, not too far from Floyd Curl.
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And so we have access to all of our scopes and everything like that that we
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would normally use for ENT visits, as well as hearing tests and can clean ears
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if they need it at the same time.
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And then pulmonology and gastroenterology come to us.
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We have a dedicated nurse clinic supervisor who is outstanding,
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and she coordinates the OR.
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And so it's been a great experience. A lot of growing pains,
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but we're happy that we're up and running.
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So as we know, pediatric community practitioners have so much coming at them
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right now in this season, lots of respiratory viruses and pneumonia and lots of ear infections.
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And as we know, managing, helping treat that patient, it falls on the shoulders
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of the pediatric community practitioner, the family practice doctor.
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For our listeners here in San Antonio, Texas, and the United States and around
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the world, let's go over what is your first, second, and third advice if a child
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comes in with an ear infection? Sure.
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So I think, you know, this is the in the top two reasons that kids go to the
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pediatrician's office.
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And so we always are very appreciative of our colleagues in pediatrics and family
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medicine that are managing these kiddos.
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But I think some of it depends on age.
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So what I will often tell parents is in kids under two, we tend to be much more
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aggressive with antibiotic management.
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Whereas once you're older than two years old
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because there's less of a risk for meningitis and
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complications of acute otitis media aka an
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ear infection then you can be a little bit more watchful waiting and I think
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parents are in my opinion starting to get used to the fact that providers cannot
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always just immediately give an antibiotic because that may not be appropriate if it's viral,
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an antibiotic is not going to help.
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And many times the body can clear it on its own.
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So I often will try to empower pediatricians and family medicine providers to,
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you can do a rescue antibiotic if you need to, because it's a weekend and they
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won't be able to get back in. But in a.
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Does not have a very high fever, who is not in uncontrollable pain, who is older than two,
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and has no signs of any other complications that you see on exam,
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just with an acute ear infection, you can do watchful waiting and reassure those
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parents that they should get better on their own within a few days.
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In terms of antibiotics, if they're not penicillin allergic,
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we typically have an escalation plan that we follow with amoxicillin being first
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line, and it is a whopping dose.
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And so sometimes new pharmacists will be like, is this really what you meant?
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And yes, I really meant 90 milligrams per kilogram per day. It is a lot of antibiotic.
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If a child has had amoxicillin for acute otitis media within 30 days,
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then they should get Augmentin a second line.
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If they've had Augmentin within 30 days, they should get ceftonir.
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If they've had that within 30 days, they often have to go to a ceftriaxone shot.
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And then the problem lies with, well, what if we've done all of these things?
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And then now they're back in my office. Or you'll have parents that are like,
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oh, amoxicillin doesn't work
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because a few months from now, my kid's just going to have another one.
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And that's where I love guidelines. I fall back on them and I say, I hear you.
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I know it may seem like it doesn't work, but the antibiotic isn't getting rid of the fluid.
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The antibiotic is getting rid of the bacteria that are causing some of these
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symptoms. But that's what we're here to talk about today.
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Eustachian tube dysfunction and the reason that fluid builds up behind the eardrum.
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And so that's sort of like the antibiotic management.
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And then as we talk more about eustachian tube dysfunction, anything that we
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can do to help the ears drain that fluid naturally through their eustachian
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tube is going to be helpful.
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So I will often give videos on how to do a sinus rinse, how to do a sinus flush
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in little babies, because you absolutely can, saline sprays and things like
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that. But my one word of advice is.
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Do not underestimate how challenging it is for parents and tell parents that
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you understand that because they may try to do it the first time and it's just
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overwhelmingly difficult to hold their kid down or talk their kid into it.
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And so there are some tips and tricks to make it easier.
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But if we can help that drainage pathway work on its own, hopefully they don't have to refer to me.
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Is there anything you want to mention of those tips and tricks? Sure.
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So I think, and one other thing, kind of going back to guidelines,
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our guidelines do not show that nasal steroids, antihistamines,
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or antibiotics are going to really help with that just stagnant fluid behind the eardrum.
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And so just for clarity, so I'm making sense when I'm talking,
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eustachian tube dysfunction is when the natural drainage pathway from behind
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the eardrum to the back of the nose called your eustachian tube is not working well.
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And the reason kids are at particularly high risk is under the age of five to
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six years old, that tube isn't fully mature.
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And so that means it's at a more horizontal angle as opposed to a 45 degree
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angle. So it doesn't have gravity helping move that fluid along.
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It tends to be floppier. And so it collapses on itself and it will not let the
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fluid drain out to the back of our nose.
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And it just takes time for it to mature. And so that's a lot of the reason that
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pediatricians and family medicine doctors are seeing this in young kids.
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And I think parents often worry, there's something wrong with my kid's immune
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system. What's going on? But it is a normal part of being a kid.
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It becomes a problem when either the fluid that is behind the eardrum,
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and I tell parents, just like our nose makes boogers, your ear makes boogers.
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And adults have experienced it when you have that clogged ear feeling with a
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cold or with bad allergies.
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But thankfully, many of us, whether we know it or not, know how to send air
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up our eustachian tube by holding your nose, closing your mouth, and blowing.
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And you can't explain that to a kid. So it's hard for kids to clear their own eustachian tubes.
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And if we can't have it drained naturally, then we need to talk about either
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getting rid of some of the blockage that's obstructing the opening for the eustachian
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tube in the back of the nose or potentially going to ear tubes.
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And so any fluid behind the eardrum is otitis media with effusion.
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If it's been there for more than three months, that's chronic otitis media with effusion.
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And then acute otitis media always has effusion because that's when there's
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pus behind the eardrum and symptoms come on rapidly and are more severe,
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like fever, pain, fussiness.
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But for rinsing the nose, most important things, in my opinion, are,
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giving the child some degree of control as long as they're old enough.
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Obviously, babies, you just have to swaddle them and do it for them.
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Making sure that kids and babies are leaning slightly down so that when you're
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flushing up one side of the nose, it will come out the other side or a little
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bit out the mouth and they don't feel like they're choking on it.
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Always use saline. Do not use tap water or even just plain distilled water.
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You have to get a packet of salt.
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They are commercially available everywhere.
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Think of like the neti pot or the NealMed sinus rinse. I have no financial disclosures.
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I just happen to love NealMed products.
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And you want to follow those instructions to make it where it's usually one
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packet of buffered salt solution that you mix with distilled or previously boiled
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water and heat it up a little bit.
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So microwave that eight ounces of water for 10 to 15 seconds so it's a little
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warmer and you're not just shooting cold salt water up their nose.
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And I think you'd be happily surprised with how many kids start to enjoy breathing
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better, feeling better, and everything like that, and will start asking for their nose rinses.
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So it takes a little stick-to-itiveness, but kids are amazing.
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That's why I love taking care of them.
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And so I think supporting parents, empowering them, and providing little YouTube
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videos so that they kind of see some of those techniques is helpful.
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So at what age would that be helpful for a child? I flush infants in the NICU, whoever is congested.
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And so people often forget, but babies under six to nine months of age are obligate nasal breathers.
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So they really need a clear nose or they can't breathe, feed or sleep well.
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And so in that case, I just give parents a 10 cc syringe.
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I teach them how to make the saline solution. I demonstrate for them in the
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office and you just hold that syringe up to one nostril,
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flush the whole thing through do it again on the other side
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and so typically once they're more toddler age
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three to four years old you can switch more to the NealMed bottle
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there are some fancy powered irrigators out there I think they make a lot of
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noise and are kind of scarier to kids but I'm not opposed to them in any way
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but you can start incredibly young and that's the great thing you can do it
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during pregnancy like saline is safe for everyone even neonatal babies in the ICU.
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And the key, though, is not using tap water. Is that dangerous?
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Yes, we worry about it not being clean. Exactly.
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So there is a brain eating amoeba that hypothetically you could get exposed to.
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But if your water source is not from an area that this amoeba is endemic,
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I'm less worried about that and more worried about we have a lot of minerals in our water.
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And do we really want that kind of rattling around in our sinuses?
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You can control the content of your saline rinses much better if you use distilled
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or previously boiled water.
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And how often do you recommend? When kids are sick, you can do it multiple times a day.
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What I beg my eustachian tube dysfunction or chronic ear or chronic sinus patients
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to do, especially once they're older and I can negotiate with them.
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So like once they're about five years old, I say, please, just once a week.
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And I promise you'll start to notice a difference.
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So as little as once a week can make a huge difference in somebody who suffers
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from allergies, who suffers from ear problems. As they get used to it,
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I try to convince them to make it part of their daily routine,
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either when they have a bath or a shower or if they're brushing their teeth.
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But I think you can't force kids to do it too often unless they are actively sick.
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But when a kid is sick, you can do it 5, 10 times a day, whatever they need
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to breathe better, whatever they will tolerate.
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And what is the product line that you recommend again? I like NealMed,
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and it's N-E-I-L-M-E-D, because they often have great coupons.
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They usually will send us starter sample bottles so we can offer them to some
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people in clinic or even use them in the hospital for really sick kids.
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Sometimes I just buy the Walgreens or H-E-B generic packets to refill it,
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though, but I do like that bottle.
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And they have a good line of other products related to nasal congestion,
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such as like a carbonated saline spray that really helps get up in your nasal
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passages and get more out. But it's not as overwhelming as a rinse.
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So it's kind of in between effectiveness for a rinse and a saline spray.
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Do you recommend that over, it seems like we're a culture of where people will
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try to do anything to stop the congestion or even take allergy medication, which...
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I think can open us up to getting an ear infection in the first place if we
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don't have that congestion.
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So yeah, it's tough because we want an instant fix.
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And the things I try to teach parents and patients is we have a nasal cycle
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where every two to four hours, one side of your nose becomes more congested than the other.
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It has to do with our autonomic nervous system and sending different signals via our nervous system.
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And so we will see it where you're looking in one nostril and you have a normal-looking
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turbinate, those structures that warm and filter the air you breathe.
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You look in the other nostril and it looks huge. That's just part of nasal cycle.
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And so some people will freak out or get nervous that, well,
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it seems like this side was congested.
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Now this side's congested. So just reminding people that that's pretty normal.
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Also reminding them that if we really have allergies before you just are taking
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medicine every day for the rest of your life, consider allergy testing.
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Now, they often won't do it in kids under five just because your immune system is changing so much.
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And I'll tell parents that Zyrtec, Claritin, Allegra, those are all quite safe
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and well-studied in children, but they can have side effects.
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They cause dry mouth. They can cause sleepiness.
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And so it's more, I don't want people to be on medicine if they don't need it.
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And saline sprays and rinses can get some of those allergens out of your nasal
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passages and clear you up better.
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And then if somebody is sick and doesn't want to take Sudafed or it's not an
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allergy, so an antihistamine is not going to help,
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I recommend often even to kids like a Breathe Right nasal strip,
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a little sticker with a metal wire in it that goes over the top and outside
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of your nose to help gently pull it open a little more.
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Kids obviously feel silly wearing it to school, so typically they'll do it more
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for nighttime, but for a lot of us, nighttime congestion is worse anyway.
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So I'm less worried about infections from antihistamines and more just that
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without showing you actually have allergies, they may not be doing anything.
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And so I'd hate to see somebody on a medicine for a long time if it's not helping.
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For acute otitis medias, still then it's better to watch and wait and take medication
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for the pain. Right. So symptom relief.
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Yep. So if the child's over two, they're not having fever above 102 and their
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pain is bearable, particularly with Tylenol and ibuprofen, then watching and
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waiting is best because it's often preceded by a viral illness.
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And so the kind of cascade of events is that they may or may not have baseline
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eustachian tube dysfunction. So maybe they did.
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Maybe they didn't have some non-infected fluid behind the eardrum.
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But either way, they had some illness that caused more inflammation of their eustachian tube.
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And it also caused the lining of their nose and their ears to make more mucus.
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It's trapped in this very protected area of our body.
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And bacteria can access it via the eustachian tube and can cause an infection there.
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But if you can symptomatically treat the congestion and just rinsing things
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out and letting the body take its natural course, majority of the time it will get better.
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But if they are younger than two, if they are having high fevers,
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if pain is very severe, then absolutely go the antibiotic route and don't feel bad.
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But if it's not a high fever, say if it's less than 101? Our guidelines say
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102, which seems really high, but it has to do with parent and I think provider comfort.
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So, you know, I consider 101.5 a fever. And so if it's just that low grade temperature
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type thing, then I'd be less inclined to do an antibiotic for that.
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But it can take a lot of reassurance because parents just want their kids to feel better.
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And, you know, they're looking to you for an option. But the body is an amazing
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treatment modality if we let it be.
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And you're running less risks of side effects of dysbiosis in your gut.
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And I will often remind parents a large part of the neurotransmitters that help
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with our mood and everything like that come from our intestines.
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And if you kill all the bacteria in your intestines, they can't make those for you.
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And let alone the diarrhea, the diaper rash. If kids are older and especially
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female patients that are preteens and teens, they can get a yeast infection.
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Like antibiotics are not benign and then not even including antibiotic resistance.
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So I think it is our job to be good stewards of antibiotics.
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Dr. J.B. Canty, who's double-boarded in Neonatology and Infectious Disease and
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writes for Redbook, and he's been on the podcast several times,
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he'll be on again soon, but he was talking about how antibiotics are a chemotherapeutic agent.
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So to really, when you think of it that way, you know, we all need to be really
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careful about when we use them, and they're amazing when needed, but.
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As we all know, they're prescribed way more often than you do, right?
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Is there anything you want to say, Marissa, in terms of like this,
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you know, you could be pretty secure if it's less than 101.5,
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even in a child under two, to manage the pain, give it some time.
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And then anything else you
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want to say there or a case you want to mention to help just to help
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the pediatric community practitioner where they're they don't
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have a whole lot of time in the exam room to spend
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and they're trying to help this family but to be able to not feel like they
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have to reach for the antibiotics necessarily yeah so i think taking the time
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at some point to either find pre-made literature that you really like that's
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understandable for patients or to use whatever your electronic health record has,
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if you like it and agree with it, can be really helpful.
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So that way you're not going over everything super in-depth,
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but you can say, like, I'm going to give you this information.
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And I'll often say to families, you know, we only really can take in about 20%
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of what a doctor says to us.
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So I want to give this to you in writing so that you can have it for later for reference.
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And then, and for kids under two, I do treat aggressively, but for that kid
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who's over two, who's not super severe, It's just telling them that this is our plan.
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We are doing something. We're not doing nothing.
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We are getting rid of some of the source of blockage by treating with nasal
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saline. We are managing the pain.
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We are giving you a rescue antibiotic if needed, but this still is management.
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So reminding them that you are doing something, you're not just ignoring them,
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because I think that's where providers get burned is there's only so much time
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in the day, we're all super, super busy.
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And so we know that we're managing it appropriately.
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But not all parents know our clinical practice guidelines.
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And so they feel that watchful waiting is not actually a management tool.
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And then our academy has in its published guidelines, like some patient information section.
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And so there's one that I like that is on a shared decision-making page that
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says watchful waiting, ear tube placement, adenoidectomy.
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And so it's asking questions that parents typically ask and then responding
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for each of those treatment modalities.
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And so having stuff like that at your fingertips to give parents,
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I think, is a great option. So you're handing them something.
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Yep, that they want. And we will also put an episode on this in our Pediatrics
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Now for Parents podcast, our sister podcast, also found wherever you get your
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podcasts or pediatricsnowforparents.com.
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It's meant to be one less thing you have to say in the exam room.
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That's awesome. And you also, thank you. And, but if it's, so if the child's
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less, two or less, and the child has a 101.5.
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Fever. So what would you do in that case? So even if they didn't have a high
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fever in kids under two, I start the antibiotic cascade. So it's rare that a
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kid comes to me for an acute otitis media.
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Normally they come to me for recurrent acute otitis media.
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It's hard to get in. Yes.
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Yeah. And so I would start them if they had not been on any antibiotics within
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30 days, I start amoxicillin.
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Even if the last medicine they had gotten 45 days ago was ceftriaxone,
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I go right back to the beginning of that antibiotic cascade,
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and I try to remind parents, I know that you escalated before.
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It doesn't always mean that you need to start back at ceftonir,
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because I think that's a lot of times what happens is pediatricians feel pressured
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to, the parents will say, well, amoxicillin doesn't work, but it's more that
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fluid persisted, not that the infection persisted.
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Now, if there are kids that have antibiotic resistance or they ruptured an eardrum
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and you had something to culture and you appropriately change antibiotic regimen
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based on that, by all means.
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But I would start them on an antibiotic, either amoxicillin augmentin or ceftonir,
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depending on what they had had within the last 30 days, if anything.
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And then I would have them let me know if they're not getting better within
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24 to 48 hours, because I have seen in young children complications from acute
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otitis media, such as facial nerve paralysis, meningitis.
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Acute mastoiditis, which is where the actual bone of the mastoid air cells behind
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your ear starts to break down from the infection, and all of those require surgical intervention.
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Anything else you want to say before we talk more about eustachian tube dysfunction?
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I think that the guidelines for recurrent acute otitis media are important, too, because,
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it is stressful having a kid with ear infections and having to miss work or
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school or whatever it may be.
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But that doesn't mean that everybody needs surgery.
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And so that's why we have the guidelines.
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And obviously, there are times where other things will be at play.
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But in general, for a healthy child, up to three infections in six months or
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four episodes of acute otitis media in a year is considered normal.
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More than that is abnormal and would be an indication for tube placement.
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And the main reasons for tube placement are recurrent acute otitis media,
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chronic otitis media with effusion.
24:31
And so two separate things, but I would also say be careful with how you describe
24:36
things to parents because acute otitis media, if you have access to a pneumatic
24:42
otoscope where you have the little poofer and can make sure the eardrum is not moving,
24:46
if the eardrum moves, it's not acute otitis media.
24:49
And so acute otitis media should be rapid onset of symptoms,
24:53
more severe symptoms, meaning pain, fever, things like that.
24:58
And as opposed to... What does it mean if the eardrum does move?
25:02
If it does move, then there's no fluid behind it. And so there can't be an effusion.
25:06
There can't be acute otitis media without an effusion.
25:08
And so there are tons of studies that show even otolaryngologists are only 70%
25:13
accurate with pneumatic otoscopy diagnosing.
25:16
And so I know how hard it is to look in kids' ears. I look in kids' ears all
25:19
day, every day, just like our pediatric providers.
25:23
And so I know it's hard, but I think that making sure you're explaining the
25:28
difference to parents between just plain effusion,
25:30
fluid, and an infection, and not feeling pressured by the parents to give antibiotics
25:35
if it's not indicated, and if you're able to have something to give parents
25:40
so that they do feel like part of that shared decision making.
25:43
And so they understand the difference between fluid and an infection, because it.
25:49
An effusion or fluid should clear itself up within three months.
25:53
So they don't need to be seen back for another three months.
25:56
And then if they still have fluid, yes, get a hearing test, send them to us, et cetera.
26:01
But up until that point, it's all normal and appropriate for being a kid.
26:07
And that effusion or fluid shouldn't cause pain or can cause pain?
26:13
It can cause a little discomfort.
26:14
We particularly see it, and parents will often have this more recollection and
26:19
hindsight, but it can cause more fussiness at nighttime because once the kiddo
26:24
is laying down and more relaxed, especially, it's like that pressure.
26:28
They finally feel it. They're not distracted anymore.
26:31
And so these are kids that were great sleepers and then suddenly they just are
26:35
terrible sleepers and they're not snoring and they're not doing anything else,
26:38
but they just are nightmares at bedtime.
26:40
And if they have had a fusion on previous exams, it probably is chronic otitis
26:45
media with effusion but typically it's only mild pain if it's just an effusion
26:49
because there's no inflammatory cytokines there's no pus that's causing all
26:54
these other chemical reactions that really cause a lot of pain and inflammation and so.
27:00
Adults we don't love the feeling of our ears being full but kids can tolerate
27:04
it way better than we can so that's why typically a fusion alone in a kiddo
27:08
without an infection is not painful all.
27:10
And what if they're having trouble hearing because of it? So that's a great
27:14
question. And that's where it sort of parlays into eustachian tube dysfunction too.
27:19
Any fluid behind your eardrum is going to cause some degree of conductive hearing
27:23
loss where the sound waves cannot conduct to where they need to go.
27:27
And in a child who is not quote unquote at risk, if that is not going on for
27:34
more than three months or is not causing moderately severe hearing loss,
27:38
you can still watch and wait, just fluid.
27:41
So there's a lot of ifs, ifs, ifs.
27:44
So an at-risk child would be your child who has hearing loss not related to otitis media.
27:51
So they're already have one thing going against them for hearing,
27:54
and then fluid is causing an even worse hearing on top of it.
27:58
At-risk kids are also going to be your syndromic kiddos, Down syndrome or other
28:02
genetic syndromes, craniofacial abnormalities, or cleft palate,
28:07
which can impact your eustachian tube function.
28:10
A child who already has a speech and language delay or a learning disability,
28:14
because any hearing loss is going to put this group of kids at a much higher
28:20
risk for not progressing in speech and language or for a complication.
28:25
And then kids who have visual impairment because they are relying so much more
28:29
heavily on their hearing that even a little bit of hearing loss from just plain
28:34
old fluid effusion can really compromise them.
28:37
So those kids, you can be aggressive with sending them to us for surgical intervention.
28:42
We are aggressive about taking them to the operating room and we explain to the parents why.
28:46
They're at risk and this puts them at a much higher likelihood of having a lasting
28:50
speech and language delay.
28:52
And so the sooner we correct that, the sooner that can improve and they can
28:56
catch up with their peers.
28:58
The other part of that is, so you have your at-risk kids and then your kind
29:05
of severity of symptoms.
29:08
And so if they have hearing loss that is moderately severe or worse,
29:14
which you're not going to be able to check, so you'll probably have to send
29:16
them for a hearing test, then they are already, now they kind of fall into that
29:20
at-risk group or at-risk adjacent.
29:23
So if it's just kind of mild hearing loss, they're saying, huh,
29:26
a little bit more often, or you get them a hearing test and it's in the mild
29:29
hearing loss range, I reassure parents we can still safely watch and wait for
29:33
three months and see if this clears.
29:35
But if they're already in the moderately severe hearing loss range,
29:38
probably that fluid's been there much longer. It's causing the little ossicles
29:42
behind the eardrum to become a little more sticky to each other, not vibrate as well.
29:46
Or the fluid is so thick from being there for so long, it's causing a worse
29:51
hearing loss because normal fluid
29:53
behind the eardrum should not cause a moderately severe hearing loss.
29:56
So those are the two things are at-risk kiddos or the degree of hearing loss
30:01
that is present because of the fluid.
30:03
Those kids were much more aggressive with. Okay.
30:06
And Marissa, is there something, by the time the child gets to you,
30:10
you were talking about how hard it is for any doctor or specialist to look in a child's ear.
30:16
Is there anything, a mistake that you see happening that you would want to point out?
30:22
That's a good question. So I think a common mistake that probably a lot of us
30:28
experience, especially early in our career, is that the screaming,
30:31
crying kid's eardrum is going to look red, as is their face.
30:34
Because they're screaming. Because they're screaming.
30:36
And so the little blood vessels on the surface of your eardrum will enlarge
30:40
just like the ones in their face. And so it can look red.
30:44
And that's why our guidelines do recommend pneumatic otoscopy,
30:47
which I think is a little bit of a too much pressure to put on the average provider
30:52
because not everybody has a pneumatic otoscope.
30:55
I do because I'm a nerdy ENT, but I don't expect every pediatrician to.
30:59
But that is part of why, because if you can see that eardrum move,
31:03
you can confidently tell the parents, okay, there's no fluid behind this.
31:06
It just looks red because they're angry.
31:08
But I have so many parents that will say, I was just at urgent care yesterday
31:11
and they said the eardrum was red. They started me on antibiotics.
31:15
I look, not only is the eardrum not red, there's no fluid. It's mobile.
31:19
And so then I try to explain to them, oh, you know, it's hard to look in kids'
31:23
ears. You don't actually need to do antibiotics.
31:25
And then there's a conundrum of, if they've already started three days worth,
31:28
do I stop them? Am I going to make antibiotic resistance, we would have to ask JB. I don't know.
31:33
But I think not being misled by the red eardrum and then earwax is really hard to get around.
31:41
And so in kids who don't have ear tubes or a known hole in their eardrum,
31:45
I recommend five drops of baby oil every night at bedtime for a couple of weeks
31:50
because that will help soften the wax so it comes out naturally on its own since
31:53
the ear is a self-cleaning organ and that's what it should do.
31:56
And then maybe recheck them since they can confidently say to parents,
32:00
you know, your kiddo doesn't have a fever. They're not in severe pain. They're older than two.
32:04
Maybe there's an infection, but it is very safe to watch and wait.
32:08
And so why don't I see you back in X amount of time? I want you to do this in the meantime.
32:12
And then hopefully you can actually see their eardrum next time.
32:15
And it's hard to know if something's hurting because kids don't like being looked
32:18
at. And so when you put the otoscope in their ear, yeah, like even my patients yell at me.
32:23
And I think I'm pretty gentle and have a lot of finesse. So I think just not
32:27
getting duped by pain just because they don't want you to look at them.
32:31
Remembering that none of us can see through wax, myself included,
32:35
but thankfully I have lots of tools in the office to deal with that.
32:38
And then red eardrum does not necessarily mean that.
32:41
Do you recommend trying to keep doing it and the child maybe will stop crying?
32:47
Or what do you do about that red eardrum?
32:49
Anything else you want to say about that? So I can cheat because I can poof
32:53
it with my pneumatic otoscope.
32:55
But if you try to sort of envision almost like a magic eye puzzle,
32:59
like you're seeing through the eardrum, can you see through it?
33:02
Can you see that it's like kind of gray in between?
33:05
Can you see the outline of the ossicles behind it? If so, there's not fluid.
33:10
If you don't see like obvious bubbles, if it's not amber colored,
33:14
if it's not kind of pus colored where it's completely opaque,
33:17
bulging at you like a big donut pushing out of the eardrum, even if it is a
33:22
little red, that's not acute otitis media because you're going to see a bulging,
33:27
opaque eardrum with pus behind it.
33:30
And then chronic otitis media, with effusion, you'll usually either see some
33:34
bubbles or fluid levels. Or when fluid's been there a super long time,
33:38
it turns this like yellow-amber color because it's actually breaking down some
33:42
red blood cells in that mucus.
33:45
How long is it normal for otitis media to be going on? Present for?
33:51
Up to three months. And so that's why it's hard to tell exactly how long it's
33:56
been going on for. So I tell parents, you're in my office.
33:58
Today's day one. And I completely understand that today is not actually day one. I do get that.
34:03
But we are calling it day one, and I'm going to check you in three months.
34:07
So then that way you're not, our goal is to not overoperate on kids,
34:11
right? Like there's risks of anesthesia.
34:13
Nobody wants their child to have to have surgery if they don't need it.
34:16
And so most parents are appreciative of that, that if they're not coming to
34:19
me with loads of infections, but it's just for fluid or hearing loss,
34:22
and the hearing loss is mild, the kid is doing well, they have good speech,
34:26
then I reassure them, it's okay that you have fluid today.
34:28
I'm going to check you again in three months. We'll talk if it's still there.
34:32
And then if the child's older than two, would you say something to the effect
34:37
of, take this for pain and call me next week if it's unbearable? Or what would you say?
34:44
Yeah. So I'd say the things to look out for are sudden onset of fever between
34:48
doses of Tylenol ibuprofen, worsening of pain, and like just any other like
34:54
really sick signs. Do they seem lethargic?
34:57
Do they have worsening irritability? Things like that. Is the ear starting to
35:02
protrude in any way? Is there drainage?
35:04
The stuff that I always tell parents, trust your mommy, daddy,
35:08
spidey sense. You know what to look out for.
35:10
If those things are getting worse, this is our nurse leg number.
35:13
This is my chart, how to message us. I find that relieves some of the burden
35:18
off of me too as the provider that I don't have to schedule an appointment in
35:22
a week because Lord Lord knows I can't.
35:24
It takes forever and a day to get into my office.
35:27
But they can get in touch with my staff who will get in touch with me if the
35:32
question is beyond their expertise.
35:35
And that's great advice for the community pediatrician. Call me in a week. Call my office.
35:41
What about otitis externa? The child doesn't have to be a frequent swimmer to
35:47
have it. We still get it in lots of other ways.
35:50
Totally. So swimmer's ear is probably one of the more annoying kind of colloquial terms.
35:56
Yes, our swimmers are more prone to it, but plenty of other kids get it.
36:00
And basically, otitis externa can be tricky because it can look like acute otitis
36:05
media with effusion with a ruptured eardrum because there's stuff draining out
36:10
of the ear. and the ear hurts.
36:13
And that can happen if you burst your eardrum. But the main way I tell the difference is symptoms.
36:20
You know, what was going on before this? Did they have a cold?
36:23
If not, that's leaning me a little more towards the otitis externaside,
36:26
because typically if you had a bad enough ear infection that your eardrum burst,
36:30
you're going to be a sick kid. You're going to have had a fever.
36:33
You're going to have an upper respiratory infection or something going on.
36:36
So if they don't have any of that, even if they're not a swimmer,
36:39
but they have a swollen canal, especially whitish debris in the ear canal.
36:44
The benefit of being an ENT is that I can clean it out right then and there
36:48
and look, but in private practice, I think you have a couple of options.
36:53
I will often start with acidifying drops in a kid who doesn't have ear tubes,
36:59
so it's not going to go into their middle ear space and hurt them.
37:01
And so that's like your prescription BOSOL, V-O-S-O-L, or acetic acid drops.
37:07
I also often have parents make homemade drops with equal parts,
37:12
70% rubbing alcohol, white vinegar, and distilled water, especially for my swimmers,
37:17
and then they use that at the first onset of symptoms.
37:20
If that really is not improving symptoms within a couple of days,
37:24
or if it is so exquisitely tender or so swollen shut you can't see anything,
37:30
then I will move to an antibiotic steroid drop like Ciprodex,
37:33
which is the ciprofloxacin dexamethasone.
37:36
Sometimes otitis externa can be fungal because we have bacteria and fungus that live on our skin.
37:42
And basically what happens is the skin gets swollen, which then traps even more
37:47
moisture in the ear canal.
37:49
And then bacteria, fungus, whatever it may be, can grow. And your acidifying
37:53
drops kill fungus and bacteria.
37:55
So that's why they're great for healthy, non-immune compromised kiddos.
38:00
Ciprodex is not going to help your fungal otitis externa. But sometimes the
38:04
dexamethasone part will at least get some of the swelling down so you can see better.
38:09
And fungal elements typically will look like little black dots on things.
38:13
And that is actually like the tops of those fungal hyphae with their little spores.
38:19
It looks amazing under a microscope. So I do understand that I get to cheat
38:23
and look with a microscope.
38:24
And if you can't clear it up just with acidifying drops, I'd say definitely send them to us.
38:29
It's rare that you need oral antibiotics for otitis externa.
38:33
Usually it can be completely managed in a non-diabetic non-immune compromised kid.
38:39
With drops of some kind and those homemade drops
38:42
put in a dropper so i like
38:46
and we've talked about this before but i even use this for my dogs sorry if
38:50
there's vets listening that disagree with me but i have run it by my own vet
38:53
but i have dogs that swim and so they're prone to osteitis externa as well and
38:58
i keep it in old school ketchup bottle like a clear bottle with the kind of
39:02
pointy top And obviously it's way more than four drops. It's like a big squirt.
39:06
But for parents, like a little glass dropper that you can get over the counter
39:09
at the pharmacy, many times they'll have a glass bottle with a dropper that screws in.
39:13
And so those are great because then stuff doesn't evaporate as easily.
39:17
And the other thing that is so simple, and I teach older kids,
39:21
is to make a wick out of usually paper towel because tissue or toilet paper is too soft.
39:27
But you literally twist it into like a teeny tiny little point, put
39:30
it at the opening of the ear canal and kind of gently swirl it around there
39:33
and that will wick the moisture away you can
39:37
also use a blow dryer on cool to get that
39:39
excess moisture out of the ear and so besides my swimmers
39:42
my sweaty kids so texas in the summer teenagers yes kids who wear a ton of headphones
39:49
things like that that make your ear more sweaty those are going to be people
39:53
that are more prone to outtitis externa kids unfortunately with a lot of acne
39:57
it's like a double whammy where they can get acne in their ear canal.
40:01
That narrows it. And it's really anything that narrows your ear canal and traps
40:06
things in it is going to predispose you to swimmer's ear.
40:10
Is it okay to use the blow dryer on the hot or warm setting or does it need to be cool?
40:14
It really should be cool because the skin overlying the cartilage of your ear
40:18
is so thin that it is easy to burn. So it has to be a cool setting.
40:23
And I tell them if they don't have a cool setting, then don't use that option.
40:26
Okay. And I know you're helping my daughter so much. Thank you so much.
40:30
My pleasure. And you mentioned your dogs. So-
40:33
It was your dream to have three black labs of all different colors.
40:37
Can we talk about your dogs? Do you have a black lab?
40:39
Yes, black lab was my first lab because I had had a lab growing up.
40:42
And I think they're, like many of us, the quintessential dog, right?
40:45
Like, that's what I think of when I think of a dog. So I got my black lab, Ziggy.
40:50
And then eventually, poor Ziggy, I decided when he was like seven years old to get him a brother.
40:55
Ziggy was not particularly interested in another lab being in our family.
41:00
So then I thought my yellow lab, Bowie, was lonely. So I got him a brother, and that's Major.
41:06
And if you're not a David Bowie fan, you may not immediately recognize the name
41:10
connections, but it's Ziggy Stardust, Bowie as in David Bowie, and then Major Tom.
41:14
So I have a whole David Bowie theme, but I have my black lab,
41:18
my yellow lab, my chocolate lab.
41:19
All super different personalities, but labs are the absolute best,
41:23
and they're so fun. Yes, I have a black lab bear.
41:26
He's so nurturing and so sweet. And I swear they can smell an ear infection
41:31
on other people. So trust your animals. And I usually tell parents this too.
41:35
Trust your nose. If your kid's ear is smelling kind of weird,
41:39
there might be either a swimmer's ear going on, endotide sexturna,
41:42
or maybe if they have tubes especially, that could be the early sign of an ear infection.
41:47
I have many parents that smell it before they see drainage and they know to start drops.
41:52
And your dogs swim? They do. My middle one swims the most in my pool, yes.
41:56
So I prophylactically use drops at least once a week. And if I notice him shaking
42:01
his head a ton or I flip it over and the inside's a little bit red,
42:04
then I'll do his homemade eardrops more frequently.
42:07
Do they just jump in altogether or whatever they want? Yes.
42:11
Unfortunately. Thankfully, they've stopped doing it in the dark so they don't
42:14
just run back in through the dog door completely wet.
42:17
And for some reason, they sort of know to stay outside for a little while because
42:20
I did just put in a doggy door.
42:22
And they don't often just run right back into the house. But they'll just do
42:26
that, and then they'll lay down until they dry off a little and then come on in.
42:30
But, hey, they will swim for, like, hours by themselves, and I trust them to do it.
42:35
Oh, that's so sweet. Even in the cooler weather? I –
42:39
I was shocked. My middle lab got in the pool last night after our walk.
42:43
Last night was very cool, but he jumped right in and just like swam his little
42:48
laps in the shallow end and then got out.
42:51
So, I mean, my pool is not heated right now, so it can only be like 60 some
42:55
odd degrees. I would not get in it.
42:57
And back to the humans for a moment. Yes, yes. Dare we digress.
43:00
Yep. If for kids with that, do you recommend just with the onset of otitis externus
43:06
symptoms, the homemade drops that you said or also do it once a week as a prevention
43:10
or how often? That's a great question.
43:13
So it sort of depends on the frequency.
43:15
So for my swimmers who they know it's their season or for kids who are more
43:19
prone in the summertime, let's say, I will have them do it maybe every other
43:23
day or whatever they sort of start to see helps them. And I empower kids.
43:28
I tell them, you're a scientist.
43:29
I'm not there to do these experiments. You are. And so I want you to get a piece
43:33
of paper or a little notebook, and I want you to write down what your symptoms
43:36
are and when you do your treatment and how you feel.
43:39
That involves kids in the process. Or I'll tell parents, get like a stick-on
43:42
dry erase board in the bathroom mirror because we all eventually are going to
43:46
look at ourselves in the bathroom mirror. We brush our teeth. We see it.
43:49
That's where I leave myself notes and have them just jot stuff down because
43:53
we're not great at remembering our symptoms and things like that.
43:56
So I may have them do it prophylactically every time they swim.
44:00
A lot of times I'll have them do it after swim practice.
44:03
Or I will just have them do it the first onset of itching.
44:07
Because almost always, if you ask the kid, they'll be like, oh, my ear gets so itchy.
44:13
And then they're scratching it, introducing more bacteria.
44:15
And then that's when it kind of tips over the edge and becomes a full-blown
44:19
infection with pain and drainage.
44:22
Anything else you want to recommend there with Otitis Externa before we?
44:26
I think other things that I'll have them do is like double check their shampoos
44:30
and face washes for parabens because those can predispose you by just taking
44:34
all the good oils off the surface of your skin.
44:37
Overcleaning of the ears predisposes us to Otitis Externa because wax is an
44:43
actually important substance that is helping protect your ear,
44:47
your outer ear canal in particular from infection.
44:49
So no q-tips don't abuse the ear no bobby pins no toothpicks if it's itchy rub it on the outside,
44:56
but i'd say those are the other tricks that i usually tell kids how
45:00
they can help control their symptoms and if there's a youtube link that you
45:04
recommend for that the homemade solution and or using the paper towel to pull
45:10
up we could put that in the link here and then also the guidelines that you
45:14
mentioned definitely so coming up next week i'm here with dr marissa early we
45:19
will talk about eustachian tube dysfunction.
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