Thursday
Dec302010

Ear Infections

Additional Insights on Ear Infections

INFECTION AND FLUID IN THE MIDDLE EAR
(OTITIS MEDIA WITH EFFUSION)

The area behind the eardrum is called the middle ear space and is normally filled with air. This air is constantly absorbed by the membranes lining the middle ear and is constantly replenished by the action of the eustachian tube. The eustachian tube is a collapsible canal or tube that connects the middle ear with the back of the throat (nasopharynx). It intermittently opens and closes and allows air to enter the middle ear from the throat. An example of this is the popping you may feel in your ear when you change altitude, such as coming down in an elevator or descending in an airplane.

 

The reason some children get ear infections and /or develop fluid behind the ear is not completely known. However, when the eustachian tube does not work properly (due to colds, allergies, enlarged adenoids or simply not being a favorable angle) the air is not replenished to the middle ear. This results in a build up of negative pressure (a vacuum effect) in the middle ear and causes the eardrum to be sucked inward ­ this is retraction of the eardrum. This predisposes the child to developing an ear infection (otitis media) and /or fluid build-up, (middle ear effusion). Both conditions are associated with temporary hearing loss.

Middle Ear Fluid

The presence of fluid in the middle ear, usually causing no distress of symptoms is often called an effusion. While many doctors use the term "ear infection" to describe this condition, not all fluid is actually infected. Antibiotic medication is often, but not always necessary to help promote resolution of the effusion. Symptoms of an effusion may include hearing loss, pressure sensation, discomfort or cause no symptoms at all.

A child with fluid, who has ear pain and fever, usually has an ear infection and should have an antibiotic prescribed. This helps the body remove bacteria in the fluid. The antibiotic decreases the chance infection will spread from the ear to the other areas of the body. Fluid in the middle ear interferes with hearing, so the purpose of treatment is to remove the infection and the fluid. Until all of the fluid is gone, the child will probably not have normal hearing.

Your doctor may also be concerned with the number of ear infections the child is having, even if treatment is successful and the fluid disappears each time. Young children commonly have several ear infections a year, often in the winter months. For the child with repeated ear infections and/or fluid build-up, a course of prophylactic antibiotics (low daily doses over several months) may be tried, but has the potential to cause antibiotic resistance. This form of treatment should be used with caution.

The development of an ear infection can be due to many things. Some basic factors include:

Age ­ high incidence between 6 months and 24 months. The eustachian tube is horizontal in young children and may not function properly, predisposing them to infection.

Inheritance ­ children with parents and siblings with history of infections have a higher incidence.

Anatomic/Genetic problems ­cleft palate, Down Syndrome ­ abnormalities that affect eustachian tube function.

Eustachian Tube Dysfunction/Obstruction may be secondary to:

allergies, upper respiratory infections (bacteria, viruses), enlarged or infected adenoids, recurrent or chronic sinusitis.

Environmental Exposure ­ Daycare, placing a baby on it’s back with bottle, and second hand smoke exposure have all been shown to increase the number of ear infections.

Ear Tubes

 

The tube placed in the child’s ear is called a tympanostomy tube. Its purpose is to decrease the frequency of middle ear infections and to avoid the collection of fluid in the middle ear space. The tube does this by allowing constant ventilation of the middle ear. The tube is made of a synthetic material
 similar to plastic and is about the size of a pen tip. To insert the tube, an incision is made in the eardrum. If fluid is present, it will be extracted at this time. The procedure of making an incision in the eardrum is called a myringotomy and is made in an operating room with the child anesthetized by an inhalation gas anesthetic. The risks of anesthesia are not great for a generally healthy child. Specific concerns may be discussed with the anesthesiologist prior to surgery.

 

As the tubes are considered "foreign" by the body, they will be pushed out naturally by the eardrum, usually between 6-12 months. As the tubes come out, the doctor will see how the child does without them. 75% of children will only need to have the tubes placed once. In general, tubes should have extruded by 2 years after placement. If not, the child should be evaluated.

 

Rarely, (less than 1%), the hole in the eardrum may not heal after the tube comes out. If this happens, hearing is not usually significantly affected. This perforation may heal spontaneously or can be repaired with an operation when the child is older.

 

Water

Water exposure in a child with tubes can sometimes be a concern. This often depends on the type of the tube used, the age of the child and the type/amount of water exposure. The problem with water is that it can go through the tube and cause bacteria to settle in the middle ear, causing an infection. Although this happens rarely, your doctor may recommend "water precautions". This means protecting the ear when exposed to water with either cotton coated with Vaseline, over-the-counter ear plugs or form-fitted custom ear molds. The custom molds are made in our office in approximately 10 minutes and are ready for use the next day.

The Operation

Ear tubes are inserted as an outpatient surgery, so your child will go home the same day of the operation. The child must not eat or drink anything before surgery. The time period varies by age and we will tell you how long before surgery the child may not eat. You will be asked to bring your child to the hospital approximately one hour before surgery. The anesthesiologist will meet with you prior to the procedure.

The surgery lasts about 5-10 minutes. After surgery, your child will be taken to a "recovery room" for about 15-20 minutes. The doctor will speak with you as soon as the surgery is over. When your child is awake, alert, and able to drink fluids he/she will be discharged from the hospital.

After the Operation

Your child may be irritable and/or sleepy after the surgery. You may see mucous or bloody discharge coming from one or both ears ­ this does not mean anything is wrong.

Your child cannot feel the tubes and cannot reach them with his fingers. It is likely you will not know when the tubes have come out.

You may be given eardrops to place in your child’s ears. Keep the drops at room temperature and shake the well. Do not throw them away ­ you may be asked to use them again at a later date if your child develops ear drainage while the tubes are in place. Rarely the drops will cause a burning sensation. If this happens, please stop the drops and call your doctor.

Thereafter, your child will be examined in the office intermittently until both tubes are out and the eardrums healed.

When to call for assistance

Call and discuss the problem with the nurse if your child should develop: ear pain, bleeding from the ears, or difficulty hearing.

Final Comment

Insertion of tubes is only one of many treatments for middle ear disorders. If they have been recommended, you should know what is involved. If you do not understand, we welcome your questions.