medical mondays: ear infections

Welcome to Medical Mondays! This is where my love of Pediatric medicine mixes with my real-time mommy experience to produce--BAM--an easy to read post for new-ish moms. In every post, I'll break things down into three sections: questions I encounter from patients at the office, what you'd find in a medical textbook spelled out in layman's terms, and some personal experiences I've racked up in the last 8 months of parenting!

I've been wanting to do this for a while, but I had to overcome some fears, find the time to sit uninterrupted at the computer, and did I mention overcome some fears? I'm kicking this off with some topics that I think are timely for sick season (yes, we in the Pediatric world refer to winter as "sick season" and summer as "well season." Don't judge.)

If you don't mind, go ahead and read this first.

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At the office

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Being a Pediatric provider, I encounter patients with ear pain or an ear infection on a daily basis (maybe make that hourly?). Kids of any age can get an ear infection, which are one of those sneaky things that can only be diagnosed by actually looking in the ear. Parents often want to know how they can tell if their kid has an ear infection, and while, of course, there is no one-size-fits-all list of symptoms, there are a few things to reliably look out for:

- Almost 100% of the time, the kid currently has a cold, or has recently gotten over one. Rarely will an ear infection just "pop out of nowhere."

- In general, laying down will worsen the ear discomfort. Since gravity forces pressure back into the ear, activities in which the baby is laying flat (ie. sleeping and nursing) will likely make the baby pretty fussy. Or maybe, if you have an easy-going baby, you won't see an increase in fussiness, but rather just a decrease in good sleep or full feedings. The kid is hurting, so he doesn't want to continue those things for very long! 

- Fever usually happens, but not always. If a kid has a common cold for a few days without fever, and THEN a fever develops once the cold has progressed a little, that is a more tell-tale sign of an ear infection than just having a fever in general. 

- Pulling on the ear. Well, this one is tricky. Since babies at some point in time "find their ears," it is really hard to tell if pulling is from pain, or just because the joy that comes from finding a toy attached to their head is too exciting to ignore.

- The bottom line is that I tell parents ALL THE TIME (especially the newbies like myself) that it is never an inconvenience for me to check their babies ears if they are just not sure. It's never a waste of time to give parents reassurance. 

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The other thing I most often discuss with parents are the options for treatment once an ear infection is diagnosed. I would say about 90% of the time I prescribe antibiotics (oral if it's a middle ear infection; oral and/or ear drops if it's swimmers ear. See next section for an explanation). When a kid is in pain, or if they have a cold and it's going to be hard for the infection to resolve on its own, or they are getting on a plane tomorrow, or this is her third ear infection in six weeks, or the ear looks like it's about to bust open, antibiotics are definitely the right way to go. We need to get this infection calmed down, and calmed down fast! There are potential consequences to not treating an ear infection; mainly I worry about an increasingly invasive infection (think about the structures near your ears: skull... brain... eyes... things we'd rather keep infection-free). The risk of permanent damage to the ear, potentially resulting in some hearing loss, is certainly something to think about, but rarely happens since we are so on top of treating them. 

So what about that other 10% of the time? There are times when an ear infection is in its early state, and the kid looks and sounds healthy otherwise, and this is his first ear infection, and they aren't going on a plane tomorrow, and the parents are willing to do some watchful waiting, when trying some other measures are appropriate. Things like elevating the head of the bed and sitting upright for feedings will help with discomfort and keep pressure from building up in the ears. The main focus for a watchful waiting approach has to be to focus on clearing out baby's sinuses. 

There's one more treatment option I just want to touch on before we move on. I'm sure you've heard of kids getting "tubes put in." Ear tubes are a more long-term option when a kid has ongoing issues with ear infections. The tube is placed in the ear drum itself, allowing a small opening to continually be available for the junk that develops in the ear, causing an infection, to drain out. I refer a kid to an ENT (Ear, Nose, and Throat specialist) so that this doctor can give his or her opinion about whether it's time for tubes, and can discuss the pros and cons of doing so. While the situation is different for every child, some general guidelines I use for deciding whether it's time for referral are:

- This is our fourth or fifth infection in six months. Or it's the second winter in a row where the kid is showing the trend of getting an ear infection with every cold.

- Several of his ear infections have been resistant--as in, we've had to use multiple antibiotics to fix them.

- They have an older sibling who had the same issue as a baby. Since traits like ear anatomy are passed on between siblings, if the younger sibling is starting to follow in big sister's footsteps, it's better to stop the problem before it inevitably gets worse (and we give a big thank you to big sister for being the guinea pig that now allows us to anticipate this problem in little sister).

- We are becoming concerned about the kid's hearing being compromised. Basically, your ability to hear depends on your ear drum being able to vibrate freely. If there is continual pressure built up behind it, vibrating freely is not an option, and the kid will not hear as well as he should. 

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OK to some this pic might be borderline gross, but I figured it was worth the risk. This is an ear tube inserted into the ear drum. This way, when pressure builds up behind the ear drum because of an infection, it can drain out rather than sit there and get worse and angry and scary. These tubes are TINY and can't be seen from outside the ear. They usually fall out on their own between 6ish and 18ish months. Sometimes kids have to get another set placed. 

In the textbook

- Your run-of-the-mill ear infection refers to an infection in the middle ear, as in, behind your ear drum.  Often babies and kids develop a middle ear infection when they have a cold because the middle ear cannot drain into the sinuses like it normally does because the sinuses are full of snot. This is very different from...

- ... swimmer's ear! This refers to an infection in your outer ear, as in, from the opening of your ear up to the ear drum. When you swim, the pH of your ear canal changes as a result of it being too wet, and different bacteria or fungi can grow there that couldn't before. That's why swimmer's ear hurts when the outside of the ear is touched, but regular middle ear infections rarely cause pain like that. 

I really like this simplified picture of the ear anatomy:

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So now that you are looking at this diagram, it makes sense that an ear drop (put into the ear canal) can treat swimmer's ear, but will not be allowed to penetrate past the ear drum, making it useless for treating a middle ear infection. That's why oral antibiotics, not drops, must be used to treat the middle ear. 

Take a look at that fancy pink tunnel called the eustachian tube (you-STAY-shun tube) (I didn't realize I didn't know how to spell that word until this very moment). This is the part of the ear that drains into the sinuses, which is why, as I mentioned earlier, it's important to keep the nose clear if a baby is prone to ear infections. This tube is also the reason why some kids are more prone to ear infections. Some baby's eustachian tubes are genetically designed to be more horizontal, and some more vertical. If you've got the flat-lying kind, it will be harder to drain and the bad bugs might get trapped easier.

Before we move on, let's emphasize the distinction in our "tubes" here. We talked earlier about the ear tubes used to treat ear infections, and now we are talking about eustachian tubes that are part of everyone's anatomy. You may hear the term "tubes" used to describe either, as in: "My kid has had twenty ear infections and had to get tubes put in" (referring to treatment tubes), vs "My kid has messed up tubes so he always gets an ear infection when he gets a cold" (referring to dysfunctional eustachian tubes). Make sense?

At the Buck house

Jonathan ALWAYS has a stuffy nose (most babies do), so I am constantly checking him for an ear infection. I have even had to bring home the ear-wax-getter from work so I could scoop that stuff out and see his ear drum more clearly. Luckily, he's never had an infection. I think the mark of a pediatrician's kid is that he recognizes and fears my ear light before he recognizes and fears most other things... dogs, loud noises, strange people...

Anywho, I think our kid has pretty good genes, since neither Jon nor I were prone to ear problems as kids (right, Moms?), but I still try to be diligent about shooting some saline up his nose and sucking it out with the nose-sucker. I probably do at least a little saline every day. I also bring him into the bathroom when I take a shower so he can breathe in the steamy air. And we also run the humidifier in his room, which, I really didn't think it was doing anything until Jon was about to fill it up again and as I was mid-sentence ("Don't even bother. That thing doesn't do ANYTH---"), I realized that in the past few weeks, Jonathan had been snorting less. 

[Don't you wish I had a picture of my kid's face as I jammed that otoscope into his ear? No such luck. If he's going to tolerate my obsessiveness, he certainly will not ALSO pose for a photo-op.]

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Hope that was informative... and not TOO boring. :) We medical nerds get excited about nerdy things. I'd LOVE to know what you think--likes, dislikes, or topics/questions you'd like to see in the future. Thanks for reading!