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

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

• 0:00
  I'm Holly Wayment, and this is Pediatrics Now.
• 0:03
  Today, we're talking about ear infections. I'm so excited today because joining
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  me here in our podcast studio are doctors Erica Scher and Nadine Haeckel,
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  pediatric ear, nose, and throat doctors at University Health and the University
• 0:19
  of Texas Health Science Center at San Antonio.
• 0:22
  Thank you so much for being here today on Pediatrics Now.
• 0:26
  Thank you for having us.
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  Otitis externa so that's otherwise known
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  as summer's ear that's essentially where you have
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  our ear canals like a dark tunnel it's imagine
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  like a cave and so it's moist and there is heat and if the environment is just
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  right you can get an infection very easily and a lot of times what we see is
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  when it kind of arises from kids who are swimming in the summer a lot or exposed
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  to water those that are in like swim team things like that that they're just
• 0:57
  constantly water exposed I suppose.
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  Again, it doesn't necessarily just have to happen with water.
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  You can just have the right environment, but I think that's the most common
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  thing that we tend to see.
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  I was going to say, we do see also a fair amount of like teenagers and even
• 1:10
  in adults, you can get what's called like a chronic eczematous otitis externa.
• 1:15
  And so I explain it like your ear skin is like your skin all over your body.
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  So if you have eczema on your arms and your knees and things like that,
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  you can also get it in your ear canal and you can get a similar similar phenomenon
• 1:25
  of that outer ear infection.
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  So, and then when it gets infected and swollen, it can be very painful.
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  That's where the ear, just touching the ear can be very painful to just even
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  moving it a little bit. A lot of times they may see drainage coming out of the ear.
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  And that's where it can be kind of difficult if you do have a ruptured eardrum
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  that if it's just draining into the ear canal actually can cause some swelling
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  in the ear canal. And so then you have kind of a little bit of both.
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  But that's where the eardrops are really helpful in keeping the air nice and
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  dry to help treat those situations.
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  Swimmer's ear or a drop that does, drops that do that every time you get in the water.
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  I wouldn't do the antibiotic drops every time you get in the water.
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  The dark swimmer's ear prevention drops, the alcohol. You can, yeah, yeah, do that.
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  Some people will mix like equal parts water and vinegar. So it's.
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  People who are more prone, you can just kind of do that creatively,
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  put a few drops in the ear and just kind of let it dry it out.
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  But equal parts water and vinegar can work just as well. White vinegar and water.
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  Yeah. Oh, wow. Yeah. And I think they do have some like pre-made formulations
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  that you can buy at like any Walmart pharmacy or anything like that as well.
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  And if you have a known hole in your eardrum, that's where I would say you just want to be careful.
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  And if you're not sure, then go see a medical professional because not necessarily
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  every drop is safe to put in an ear that has a hole in the eardrum.
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  You don't want everything going behind that eardrum. Some things are safe, some things are not.
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  And if a child is getting chronic swimmer's ear, keeping that ear dry,
• 2:48
  putting earplugs in, swimming in a body of water.
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  Yeah, so for those kids, definitely prevention is the best medicine. Yes, it is.
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  So yeah, definitely keeping the ears dry. And I'll even tell patients that they
• 3:00
  should try to keep them dry when they bathe and shower. So either doing earplugs.
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  And some people recommend getting a hairdryer on a super, super low setting
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  because they don't want them to burn themselves.
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  And they can hold it over outside their ears after they bathe to help dry the ears.
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  That's helping with my daughter so much. Thank you.
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  And then, and you can also take, so I guess we should mention,
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  but absolutely we are very anti-Q-tip.
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  No Q-tips. No Q-tips. You can actually hurt the ear even worse,
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  whether that's accidental traumatic perforation of the tympanic membranes of
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  the eardrum, putting a hole right through it, that can can cause a lot of damage.
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  Or in people who have like eczematous like otitis externa or swimmers ear of
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  any kind, when the lining of the skin of the ear canal is sensitive or the barrier is not as strong,
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  using a Q-tip can actually cause some scraping and cause an even worse infection.
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  So we recommend against, in any ear, healthy or not, don't use Q-tips.
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  And why don't people do, I mean, are there commercials out there showing it? Because.
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  People think that it's used for the ear. Because they feel great when they clean
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  their ear out. My husband loves it. It drives me crazy.
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  Yeah. So what you can't do, what is safe, is that you can get like a tissue
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  and sort of twist it into like a spear looking thing because a tissue is soft. It's not hard.
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  It's not going to hurt you. And you can stick that in the ear canal and sort
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  of twist while it's in there.
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  That can help catch any extra moisture or wax or, you know, whatever.
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  And it's it's not going to hurt anything, especially in kids,
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  because, you know, kids, you don't want to they you don't know which way they're turning.
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  You don't know what they're going to do. They can flip in a moment.
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  And so that's not something you want to see. You want to cause trauma, too.
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  And I have unfortunately seen a lot of acute trauma and it is never good.
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  And so avoid, avoid, avoid. And it can require surgery? Absolutely.
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  Yeah. Wow. And anything else you want to say for the pediatric practitioner about otitis externa?
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  And they have so much, as we know, coming at them and say it's the 35th patient
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  they're seeing every day. Like what is really to look for, whether it's to tell
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  the difference between externa and media or anything you want to say there?
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  I mean, media and externa, as long as there's no hole in the eardrum, are pretty distinct.
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  If, however, you have a kid who has an ear tube or a known perforation in their
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  eardrum, Chronic drainage can lead to kind of an otitis externa.
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  So it's a little bit of both.
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  That's probably one of the only situations I feel like I see a little bit of both.
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  Otherwise, externa is pretty obvious. It's swollen. The canal is swollen.
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  The skin is, that's where it's, it's a skin infection.
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  So the skin is swollen, red, draining, angry, sensitive to touch.
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  But if you know a kid had a recent hole, there's signs of a previous perforation
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  in the eardrum, or they have tubes, that would be a situation where it's like,
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  like they may have a little bit of both.
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  And that's where those medicated eardrops can be super helpful because it can
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  treat both if there's a hole too, and it's safe.
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  And then sometimes they do require multiple debridements. So if it's not going
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  away with just general treatment drops, sometimes what they end up needing us
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  is us to, or, or if the pediatricians do it, some, some pediatricians will clean out ears.
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  And so cleaning out a lot of the sort of.
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  You know, sort of squamous white debris that's in the ear canal,
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  getting that out is super helpful because if the ear is full,
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  then sometimes the drops can't really penetrate where it needs to to work.
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  So you do have to take all that stuff out in order to really get it to,
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  for the eardrops to take effect.
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  And with a tissue or a cotton? They can do a tissue. Some of the pediatricians, they flush the ear.
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  I probably wouldn't add too much more moisture to the ear in a case of otitis
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  externa, but if they feel comfortable, like doing a little suctioning or something
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  like that, you could do that if you're really, really not comfortable and you're
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  worried, I would send them to an ER or somewhere where there's,
• 6:51
  ENT coverage or someone who can fully debride the ear.
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  But you can always try a course of eardrops first, especially if they're not
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  having horrendous pain. Some people also do oral antibiotics as well in those cases.
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  So I do think from our standpoint, and there is actually a clinical practice
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  guideline on otitis externa from the Academy.
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  And one of their main points is for an uncomplicated otitis externa.
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  So there's no surrounding like skin infection. They don't have that your other face isn't swollen.
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  Really, the only treatment is supposed to be eardrops. So for the most part,
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  that would be Ciprodex eardrop.
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  That's the first line? Yeah. Yeah. So that should always be the first line.
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  Now, if the kid has a swollen face, they have a surrounding cellulitis,
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  that's a little bit different, and they probably do need an oral antibiotic.
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  But without that, the first line is supposed to just be a Ciprodex eardrop.
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  And Ciprodex works very, very well. It has a very, very high concentration.
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  And so if it's not working, as Dr. Haeckel mentioned, it's usually an issue
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  of it's not getting to where it's supposed to go.
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  So either there's too much gunk in the ear, as she mentioned,
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  that needs to be cleaned, or frequently when these kids, the ear canal gets
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  so swollen that the drops just aren't getting down.
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  And so in those cases, that's when using something like an ear wick,
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  that's that little, like, looks like a tiny little straw that you put in the
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  ear, in the ear canal, because what happens then is when you put the drops in,
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  it actually just goes down that wick to get lower into the ear canal.
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  And it helps keep the ear canal from really... totally collapsing and collapsing
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  on itself so it keeps it open during the healing process yeah.
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  So anything else you want to mention to the pediatric practitioner that we haven't covered?
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  I did want to mention one thing because this is what I see a lot too.
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  So kids who do have ear tubes and will have, so kids who have ear tubes can
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  still get ear infections.
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  Usually the ear infections are
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  not as bad. So they're not getting as high fevers. They're not as cranky.
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  Usually the way they're diagnosed is that they'll have drainage coming out of
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  their ear. So that could be. And then it gets really worried.
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  They can get really worried. But I feel like on our end, we tend to really warn
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  them that like, hey, if you see drainage, just give us a call.
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  Go ahead and use those drops.
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  But I think it's super important that with the ear tubes, now you do have a
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  hole leading to the middle ear.
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  And so you don't necessarily need to treat with oral antibiotics.
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  The first line therapy, a lot of times for kids with ear tubes and drainage
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  or otitis media with the drainage is going to be the drops because the drops are more concentrated.
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  They work better topically. And a lot of times you can just without having the systemic side effects.
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  So that way, like, you know, these kids who had a million ear infections before
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  have taken so many oral antibiotics.
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  Now they have tubes, say they've made it to the tube phase.
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  All you really need to do is treat with drops. And then, you know,
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  if the drainage is too much and the drops aren't really being able to get through
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  the tube, then that might be a case where you need to order not only the drops.
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  I still do both because I think it helps keep the tube clean and open.
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  But you might need to do oral antibiotics in those cases. But a lot of times,
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  first line is just ear drops.
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  And I do see a lot of kids back because we tend to check on our kids with the
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  ear tubes. I see them every six months to check on the ear tubes.
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  And they'll tell me, oh, yeah, we had drainage. We went to a pediatrician.
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  They gave us oral antibiotics.
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  And I'm like, well, did you do the drops? And they're like, no,
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  they gave us oral antibiotics.
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  But the whole point of the tube is that you can do the drops first.
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  And do you want to mention any other antibiotic drops to try?
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  So Ciprodex is really going to be the main ones that we use.
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  Unfortunately, it can be somewhat pricey and not all insurances cover it equally.
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  And it's in that tiny bottle. It is tiny.
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  And most of the eardrops are in a tiny bottle. And the benefit of that is that
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  it has a steroid component to kind of cool down some of the inflammation.
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  But you can do just Just plain antibiotic drops. So, ofloxacin drops are really popular too.
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  And you can, if you use that, because that is very cheap for most insurances,
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  and if someone is still wanting to use a little steroid with it for like an
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  otitis externa, you can prescribe dexamethasone ophthalmic drops.
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  So, it's designed for the eye, but you can also use it in the ear.
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  So, you can prescribe that separately and have someone use them together in
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  the ear and get the same effect for cheaper.
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  One thing I do caution people about,
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  The pharmacists love to suggest cortisporin drops when the insurance won't cover
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  Ciprodex because, again, it's an antibiotic and a steroid.
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  However, the antibiotic in it is, I think, neomycin, which is theoretically
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  autotoxic and could cause hearing loss if it's applied directly to the middle and inner ear.
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  So for our kids with ear tubes or if there's any concern that there's a hole
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  in the eardrum, we do not recommend using cortisporin drops.
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  Now, if they have a sealed eardrum, they don't have tubes. Correct.
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  If you know that eardrum is intact, you can certainly use it.
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  But if there's any concern, you know there's an ear tuber, there's any concern
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  if there's a perforation, we do not recommend using cortisporin drops.
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  And also the nature of neomycin.
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  So, you know, the triple antibiotic whitements tend to have neomycin in them.
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  And neomycin can be a little bit, almost cause a dermatitis. It's very irritating.
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  So if, just kind of an FYI, this is sort of an aside, but if you're using anything with neomycin,
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  have I've seen it a lot when it's been used on the face for
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  cuts ears you know any sort of lesions and it
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  seems like they're getting worse sometimes it's not necessarily a worsening
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  of the infection but they're getting just local inflammation because of the
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  irritation from the neomycin which can also help happen with the with those
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  drops too so just something to kind of keep in mind and also to keep in mind
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  it's normal for kids to have ear infections all kids get them Yes,
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  all kids can have ear infections.
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  Yeah, there's some stat out there that's like by the time kids are age,
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  like elementary school age, something like 70 to 80% of them have at least had one ear infection.
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  And that at any given time, I don't remember what the percentage is,
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  but a very large percentage will have middle ear fluid at any given time.
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  Anything else you want to mention that we didn't cover? This has all been so
• 12:46
  insightful. Nadine and Erica. That's it that I can think of right now.
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  How did you become known as the she and T? Tell me about your team.
• 12:56
  I love that. Well, so I feel like that's like a thing in ENT,
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  maybe because of the way it flows.
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  That if there's like, like I remember when I was a resident,
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  if we were on a rotation and it was just the female residents,
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  it was she and T. Yeah. It's like a thing.
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  And so when we joined, it was Dr. Early and then Dr. Sher joined and I joined shortly after Dr. Sher.
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  And so we were three girls and she and T. And actually, our nurse practitioner
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  is also a female. And so we're very she and tea.
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  A lot of our staff in our clinic happen to be females. And this is not a preference.
• 13:29
  It just happened to be that way. So we love it. We do have one guy, Leo.
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  Oh, yeah. I was going to say. But he's in the audio. He's in the audio.
• 13:36
  We adopted him. Yeah. We adopted him. We love Leo. Yeah.
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  But it just, I don't know. It just increases morale. We kind of love it.
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  Not that we don't. Yeah, it's great bonding.
• 13:47
  And there's actually, I'll shout out Dr. Bo. So she's a pediatric ENT with the
• 13:52
  military program here in town.
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  And she's sort of the head of the San Antonio She and Tea group.
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  And she just hosted, I unfortunately could not go, but over the weekend had
• 14:01
  a She and Tea event at her house that she tries to host. We call them sassy events.
• 14:05
  Nice. There's even She and Tea events. Yes. But that encompasses all female
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  ENTs in town, not just pediatric, but it just so happens that we're all female.
• 14:15
  And maybe we should mention the new University Health Clinic in Deerfield for
• 14:21
  our listeners in the San Antonio area is open now, pediatric ENT.
• 14:25
  Yeah, Dr. Sharimana and Dr. Mo. So Dr. Mo's been here for ages and ages.
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  A lot of people know him. He's a really nice guy.
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  Yeah, the University Hospital brought them over onto our side.
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  And so they're part of our extended group. And they're still going to be in
• 14:40
  their same location out in the Deerfield area. They were under the...
• 14:45
  A different private practice kind of domain before and now they're with us,
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  but they still have their opening.
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  And so they're open for business and ready to bring anybody in.
• 14:55
  So we're really fortunate because now basically there's not a lot of pediatric
• 14:59
  ENTs in the city and between the UT-UMA kind of combo, we have five. So it's great.
• 15:05
  And UMA doctors who work for University Hospital.
• 15:09
  Yes. Yeah. Yeah. Yeah. So here on Pediatrics Now, we like to promote having
• 15:15
  a life outside of medicine.
• 15:16
  And Nadine and Erica, I know, Erica, you recently had a baby. Yes.
• 15:22
  Hopefully, are you getting sleep? And how is that going? Yeah.
• 15:26
  She is generally a good sleeper, although I will say the last couple of days she's been less good.
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  But I think that has to do with her trying to figure out how to roll.
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  And then she wakes up in the night and tries to roll and gets mad.
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  But yes she's very cute she's very cute she's
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  got cheeks for days love that
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  she's cool dude in the pool when we have we
• 15:47
  did our baby shower after she was born she was just
• 15:50
  so cute yeah she went swimming for the first time and was just snooze taking
• 15:53
  a nice nap taking a nice nap in her nice little lounger that was the best part
• 15:57
  hopefully she hasn't or has she had an ear infection yet man not that we know
• 16:02
  of i've been trying not to doctor her though yeah yeah how How does that affect
• 16:07
  your doctoring when you become a mom?
• 16:10
  In some ways, I think it's made it. It's like, I don't want to know.
• 16:13
  Just don't. Yeah, I don't know. I don't look at her ears.
• 16:15
  No, but I think in some ways it's been nice because there are things that in
• 16:21
  my mind I always assumed were kind of normal baby things, but I had never really experienced them.
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  And so to actually have the experience of when people talk about,
• 16:28
  oh, my kid gets congested at night. I'm like, I don't know. I guess that's a thing.
• 16:32
  But now my kid goes to daycare, and so she gets very congested at night. That is real.
• 16:39
  Yeah, that's a whole other topic. Talking of conversations. Another podcast. Yeah.
• 16:43
  Completely separate. And you both have dogs? Yes. We all have dogs. All the G&Ts.
• 16:49
  Yes. I have two rescues. One's 13.
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  She's been with me since my first year of medical school.
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  The other one's two. And I also have a cat who is my oldest dog's cat.
• 17:00
  Do they love each other? They get along very, very well. My cat thinks he's a dog too.
• 17:05
  So I think that's probably why he's the first to go to the dog food when I put
• 17:09
  it down. So, I mean, he thinks he's one of the gals, actually,
• 17:13
  because my dogs are girls and he's a boy.
• 17:15
  And then Dr. Scher here has two. Yeah, I have two very energetic German shepherds.
• 17:21
  And then Dr. Early has three labs. She has one of every color.
• 17:24
  That was her goal. And she got it all. She has a black lab, a yellow lab, and chocolate lab.
• 17:28
  I have a black lab. And he's so sweet. He was a rescue as well and a border collie.
• 17:35
  And we're talking about Marissa Early. So we hope to have her on the show soon. Soon as well.
• 17:40
  Yes. And I know she would love to be on it. She loves this stuff.
• 17:44
  She can't wait. I know she can't wait. She was sad not to make it. So next time.
• 17:51
  And then in your spare time, though, to unplug, spend time with your family,
• 17:54
  animals, anything else? Animals, hiking. Dr. Early and I spend a lot of time together.
• 18:00
  Adventures with our dogs, basically. So, yeah, we just we love being outdoors.
• 18:04
  San Antonio is great for outdoor activity.
• 18:07
  I'm originally from Houston. So I always love the terrain out here.
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  So it's great for being outdoors.
• 18:12
  Do you have a favorite hike? I went to Eisenhower Park this weekend and it was. I love Eisenhower.
• 18:17
  It's so convenient. It's so it's so nice that it's in the city and it's very
• 18:20
  convenient. I want to check out the what is it? Las Maples.
• 18:24
  Yeah, that is what I'm hoping to do this fall to see the leaves change.
• 18:27
  So I'm looking forward to that. It fills up fast. Get your reservation. Yeah. Yeah.
• 18:32
  Anything else you want to add before we sign off?
• 18:36
  I think it's a great point about doing the hard work that the community pediatricians are doing.
• 18:42
  That helps you all because by the time the patient gets to you,
• 18:46
  all these right things have been done and it helps everyone, right?
• 18:51
  Oh, yeah. Yeah. No, I think we just, we appreciate all the pediatricians out in the community.
• 18:55
  We know they have a hard job and we know it's tough to get people in to see us.
• 19:01
  But I do think with the addition of the people out at Deerfield too,
• 19:04
  I think our access has improved quite a bit.
• 19:07
  We're certainly in a better spot than we were last summer when I think we had
• 19:11
  like a six month wait. Yeah.
• 19:13
  I think it's definitely improved. I will say too, they're probably one of the.
• 19:21
  They enter daycare or school for the first time and they'll have a bunch of ear infections.
• 19:25
  And by the time I see them, most of the time it's like they've had the ear and
• 19:30
  I see them in the summer and I ask them, I'm like, when was the last time you had an infection?
• 19:33
  They're like, well, during, you know, April, May.
• 19:36
  It's been months since they've had another one. And in those cases,
• 19:40
  you know, it's great to get plugged in with us, but I always tell the parents
• 19:43
  just like, you know, a lot of times kids, their immune systems are just adjusting
• 19:46
  to the new environment, particularly if they were at home for a long time before
• 19:50
  and not really exposed to a lot of other kids.
• 19:52
  And so a lot of times their immune system kind of takes a big hit that year.
• 19:56
  And so I'm a little bit more conservative and I tell them, let's just see what
• 19:59
  happens as the new year comes along, because it could have just been a bad year
• 20:03
  and really they just needed to adjust. just.
• 20:05
  And I think that's another thing I would just add is that, you know,
• 20:09
  in those cases, a lot of times for newcomers to school, newcomers to daycare, they can be bad.
• 20:14
  Now, if they're kind of in the crucial, you know, speech development phase,
• 20:19
  that's maybe a different story.
• 20:20
  But especially those kids that are like going to pre-K or kindergarten for the
• 20:24
  first time, they're talking, you know, those are the ones I'm like,
• 20:28
  it could just be a bad year. They had a bad hit.
• 20:31
  Let's see what happens, especially if they haven't really had one in a few months. So I think.
• 20:36
  Parents understanding that, you know, our immune systems are developing.
• 20:40
  And so we don't know what kind of, we don't know what's going to happen in the
• 20:43
  next year when they start their next year at school.
• 20:45
  So as long as they're not still consistently having issues, it could be something we can monitor.
• 20:50
  And Nadine, do you want to mention what are some warning signs when it's serious,
• 20:54
  when this child would need to go to the ED or to the emergency room?
• 20:59
  For very high fevers, like we talked about with otitis, for otitis externa,
• 21:03
  like summer's year, again, like Erica said, if the, you know,
• 21:07
  if the face is getting really red, like it seems like a spreading cellulitis, it's a different story.
• 21:11
  If kids have a seizure from a fever, are lethargic, not eating,
• 21:17
  not drinking, so then now they're probably dehydrated.
• 21:20
  They seem just very, very uncomfortable, like they can't sleep.
• 21:23
  If there's signs of a spontaneous perforation, I would go definitely go to the
• 21:27
  the ER and get checked out because, you know, at least to get eardrops and some antibiotics.
• 21:32
  I think those are signs of mastoiditis. And signs of mastoiditis. Yeah.
• 21:36
  Or if they're complaining of like lots of headaches, their balance is very off.
• 21:41
  Those would be other major signs where I'd urgently take them in.
• 21:44
  And when pediatricians refer patients, do you look at the referral and bump
• 21:50
  people up as needed or how does that work?
• 21:53
  So we do have people reviewing our referral queues.
• 21:58
  We do not, I will be honest, we do not review all of them. There's just far too many for us to do.
• 22:03
  We do have people that do review the referral queues. If the pediatricians mark
• 22:07
  a referral as like stat or urgent, it gets reviewed more quickly.
• 22:12
  And then usually the people who are reviewing it will discuss it with us.
• 22:16
  And we'll look at the chart to
• 22:17
  see if it needs to come in sooner based off what we can see in the chart.
• 22:21
  Yeah. But unfortunately, just a referral for recurrent ear infections does not,
• 22:26
  unfortunately, get put super, super high all the time on the list.
• 22:30
  It's not necessarily an urgent or emergent.
• 22:33
  Some of those things can be done in time. And like we said, there are things
• 22:36
  that the pediatricians can do if they're older kids who have a lot of allergy symptoms.
• 22:41
  And I do see some pediatricians do this, but just as a reminder,
• 22:44
  you know, try nasal sprays, you know, especially if they're over the age of
• 22:48
  two, you can try things like Flonase, just even the saltwater nasal sprays,
• 22:52
  like the ocean sprays, keeping the nose clean a lot of times can help a lot.
• 22:55
  Those are things that they can kind of do to try to help. And in the younger
• 22:59
  kids too, saline flushes are great because they are so congested.
• 23:04
  A lot of times, like we mentioned, the eustachian tube connects the back of the nose to the ear.
• 23:08
  And that because they're so So interconnected, if a kid is just chronically
• 23:13
  congested and they're having these ear symptoms, really flushing them out a
• 23:17
  lot of times can really help prevent them from getting more infections or inflammation.
• 23:23
  So little things like that that aren't even medication can help a lot.
• 23:26
  And they can start that pretty much as soon as they see a lot of these kids.
• 23:30
  Okay. And we'll be covering more ENT topics down the road. Well,
• 23:34
  thank you so much for being here in the podcast studio.
• 23:37
  I really appreciate it. Pediatric ENT Doctors at University Health and the University
• 23:43
  of Texas Health Science Center. Thanks for having us. Thank you.
• 23:47
  We hope you've enjoyed this episode of Pediatrics Now. Click on the link for
• 23:52
  free credit if you're a practitioner.
• 23:54
  You can also email us with questions or episode ideas. That address is pediatricsnow.org.
• 23:59
  Music.