Guest: Dr. David R. White - Pediatric Otolaryngology.
Host: Dr. Linda Austin - Psychology.
Announcer: Welcome to an MUSC Health Podcast.
Dr. Linda Austin: I am Dr. Linda Austin. I am interviewing Dr. David R. White, who is a pediatric otolaryngologist in the department of ear, nose, and throat here at MUSC. Dr. White, anybody who has a child, knows probably what it is to have a child who has an earache at least once or twice in their life and certainly sometimes these are recurrent. What makes a particular child tend to have recurrent ear infections?
Dr. David R. White: That’s a problem that can come from many different reasons. There are children that have poorly functioning eustachian tubes for a variety of different reasons. The eustachian tube connects the part of the ear behind the ear drum to the back of the nose and when the eustachian tube is not working properly, the ear can have trouble clearing infections or it can make it easier for infections to get from the back of the nose up into the ear.
Dr. Linda Austin: Most parents, when their child has a significant earache will take the child to the pediatrician and often time pediatricians will prescribe antibiotics; is that a course you recommend?
Dr. David R. White: Absolutely, I think that’s a great place to start, and most of the time the parents who are in the hands of outstanding community pediatricians and when children reach a point where they have enough ear infections to qualify for ear tubes generally they refer to somebody like me.
Dr. Linda Austin: I just back up a little bit, I had thought that there was some controversy about whether many of these ear infections aren’t viral and don’t really need a prescription of antibiotic. What are your thoughts about that?
Dr. David R. White: Well, there is an approach that has been used in the last five to ten years in the pediatric community of watchful waiting and select children with ear infections and so if you have got a young, healthy child over the age of one to two years who is otherwise healthy, not immunocompromised or an infant, a first way to approach the ear infection will be to observe the child for 48 hours and treat only with Tylenol. If the child then improves, you may be able to avoid treatment with antibiotics.
Dr. Linda Austin: Have there been studies - randomized studies where you take half of the kids with earaches and put them on antibiotics and the other half just do watchful waiting?
Dr. David R. White: There have been. There have also been some very large cross-sectional studies that have been done on large population, specifically in the Netherlands, that have shown that this is a safe way of approaching ear infections.
Dr. Linda Austin: As safe as antibiotics?
Dr. David R. White: Generally speaking -yes, as long as the children are followed closely, and after 48 hours if there is no significant improvement or of course earlier if they start to have more problems then antibiotics will be used and this again would be on selected children.
Dr. Linda Austin: Now, you have mentioned the 48 hours several times; what is the risk to not getting an earache treated after 48 hours?
Dr. David R. White: In that situation, the ear infection can actually expand to other parts around the ear and behind the ear developing there is something called mastoiditis or actually infection can spread up towards the brain or down into the neck, and this can turn a relatively simple straightforward problem, and as a child to more complex problem that requires a lot more intervention and can have more serious consequences.
Dr. Linda Austin: What are the traumatic things that can happen with an earache, is that the ear drum can rupture, which often relieves pain on the one hand but it can be kind of alarming when you have discharge, blood or pussy discharge. Is there a danger to the eardrum actually rupturing?
Dr. David R. White: Generally not. If it ruptures recurrently, then there can be scarring in the eardrum that sets up. There is a very small percentage of children who rupture an eardrum with a hole in the eardrum that does not heal and that could require attention at a later time, but greater than 95 percent of the time when the eardrum ruptures, it heals within a few days.
Dr. Linda Austin: Now, you have mentioned earlier that if these ear infections are chronic, you begin to think about whether that child needs tubes in their eardrums. Can you explain why that would help?
Dr. David R. White: When ear infections become chronic, again it’s often because the eustachian tube isn’t functioning properly and so one option is to allow the ear to drain through the eardrum. This gives you a couple of different ways that ear infections are treated or avoided. The first is by not allowing fluid or infection to build up in the ear and to build the pressure on the eardrum, which causes pain and irritability in children. The tubes also provide a way for us to get antibiotics into the space behind the eardrum without taking antibiotics by mouth and so administering eardrops through the ear canal can help to treat those infections. Placement of the ear tubes additionally allows the ear tube to normalize the pressure behind the eardrum or allows the pressure behind the eardrum to normalize, which can lead to better function of the eardrum and also of the eustachian tube.
Dr. Linda Austin: How long do the tubes usually stay in place?
Dr. David R. White: Tubes last on an average for about a year; depending on the type of tube that is put in and it can be anywhere from nine to fifteen months as an average time but a lot of that depends on the particular patient. I have seen tubes fall out as early as a few months and certainly then you have some that lasts for several years. After two and a half or three years, if tubes have been in place, a lot of times we consider removing them.
Dr. Linda Austin: Any adverse consequences of having tubes or complications of surgery that parent need to be informed about?
Dr. David R. White: The operation is a fairly safe straightforward operation and in fact in adults it is something that is done in the office with just a little topical anesthesia, so there is no going to sleep or anything like that. Adults can come in and have tubes placed and go back to work later that day. In children, because the procedure is done under a microscope, it’s very difficult to do that in the office because children can’t stay still and use of a microscope means that any little motion looks like an earthquake and so using the microscope requires the use of general anesthesia in children. Probably, the biggest risk of the procedure itself is the general anesthesia that is required to place the tubes. Once the tubes are in place, there are a few very minor risks. There is about 2 percent chance of chronic drainage from the ear tube, which would indicate that the tube itself is infected or there is an infection behind the eardrum that isn’t fully treated with the drops that we used to treat it. Chronic drainage happens in about one to two percent of children. Another risk of ear tubes in the long-term is that when the ear tube falls out, the hole where the ear tube was residing in the eardrum won’t heal and typically we approach that by waiting; lot of these holes with time will close on their own, but if the hole is still present by five or six years of age, we would consider repairing of hole at that time.
Dr. Linda Austin: I know that sometimes tubes are placed to drain fluid that is not infectious but may decrease hearing; can you describe what that condition is and why you would put tubes in?
Dr. David R. White: So, that condition is called chronic otitis media with effusion. Effusion refers to the fluid that’s behind the eardrum. When a child or anybody gets an ear infection, the normal course of the disease would be the inflammatory fluid or fluid as a result of the infection would be present behind the eardrum even though the infection itself has resolved and effectively what this does is that it keeps the eardrum from moving as effectively, from vibrating as effectively, and keeps it from transmitting sound to the inner ear as effectively. Some of the sound that hits the eardrum is lost in that fluid and so that results in a reversible hearing loss that goes away when the fluid goes away. Now about 90 percent of the time, this fluid will go away on its own after about 90 days. When the fluid has been present there for more than about three months at that time we consider placement of ear tubes to drain the fluid and also to keep it from re-accumulating. Placement of ear tubes in this situation provides a big improvement in hearing.
Dr. Linda Austin: Dr. David White, thank you very much.
Dr. David R. White: Thanks.
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