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Pediatrics - Chronic childhood ear infections

Treatment with surgery and antibiotics often unwarranted

by Paul Bergner

Medical Herbalism 4(3):1,4,6

Minor ear infections are the most common medical problem in children under six years old in the United States. About nine out of ten children under six years old have at least one ear infection. One child in three develops chronic congestion in the middle ear, which can cause minor hearing loss, and make the child a candidate for the myringotomy—a surgical operation to place tiny tubes through the eardrums to relieve pressure, allow drainage of fluid, and restore hearing. The operation is one of the most common in the U.S. More than 600,000 such operations are performed each year at an annual cost of almost one billion dollars.

The procedure is controversial, however, and some MDs have recommended in journals as long ago as 1987 that the operation be discontinued until it is proven to be effective. Alternative practitioners claim success treating most ear problems without the operation.

Acute ear infections are usually treated with antibiotics. If infections recur despite antibiotic treatment, a child may develop chronic congestion of the middle ear, sometimes called “glue ear.”

The eustachian tube, which runs form the middle ear to the throat, becomes blocked and the ear cannot drain normally. The eustachian tube normally adjusts the pressure or drains fluid from the middle ear three or four times a minute with swallowing. This process is responsible for the “popping” of the ears with a sudden change in elevation.

The myringotomy is the usual next step in treatment. A microscope device is inserted in the ear, and small incisions are made in the ear drum. Tiny tubes, shaped like grommets, are then placed in the incision. The tubes eventually fall out and degrade. The procedure takes about fifteen minutes, and does not require an overnight stay in the hospital. The total cost, including hospital and physician fees is about $1500. Sometimes the doctor may also remove the adenoids, lymphatic tissue in the upper throat that can swell and block the lower end of the eustachian tube. The adenoid operation may require a longer hospital stay.

Almost everything about conventional treatment of chronic ear infections, including both antibiotic and surgical treatment, is the subject of controversy within the medical community. Studies supporting the use of antibiotics and surgery usually measure only short-term hearing improvement. Other studies, measuring the frequency of subsequent infections, long term adverse effects, or long-term hearing loss question the necessity of the treatments. Studies appearing in various journals show the following:

Doing nothing may actually be more effective than surgery. In one study, children with congestion in both ears had a tube implanted in only one ear. The untreated ear had fewer subsequent infections than the treated one. A 1989 study showed that the surgery offered no advantage over doing nothing in terms of duration of the disease, recurrence of disease, subsequent surgery, or hearing loss after twelve months, even for patients with serious initial hearing loss.

Routine removal of adenoids, practiced by many surgeons, has no beneficial effect on the accumulation of fluid in the middle ear and consequent hearing loss.

Most children receiving the operation continue to get ear infections.

The operation may have to be repeated, about 30% of the time, according to one study, and more than 50% in children under two years old.

Chronic fluid in the ear and accompanying hearing loss tends to improve spontaneously. A study shows improvement without treatment in more than 80% of children, with 50% returning to near normal.

Treatment for allergies or food sensitivities may solve the problem.

Minor delay in speech development due to chronic hearing impairment is not likely to have long-term consequences. Some physicians inappropriately warn parents that the hearing loss will lead to learning disabilities.

Placement of tubes causes permanent scarring of the eardrums in about half of patients.

Serious complications, such as meningitis or brain abscess, are rare, and the operation does not apparently reduce such complications. A Scottish study found that in the twenty years between 1966 and 1986, these complications remained stable, even though the frequency of the ear tube operation increased sixty-fold.

Children spontaneously outgrow chronic ear problems, usually by about age seven. The adenoids naturally reduce in size, and as the skull becomes longer and higher with normal growth, the eustachian tube becomes more vertical and drains more easily.

The immediate benefit of the surgery is immediate improvement of hearing and reduction of pain. To a child with fluid in the ears, a normal conversational voice sounds like a soft whisper. To compensate, the child amy turn up the television sound unusually high, or may not hear the teacher well in school. Sometimes the parents think the child is ignoring them. A few weeks after the operation the hearing usually returns to normal. The tubes also relieve the main cause of pain—pressure in the middle ear. Many ear specialists recommend surgery if an ear infection persists for more than thirty days, but others wait six months in most cases, with medical supervision, until it is clear that hearing impairment is continuing.

The dangers of surgery are those inherent in general anesthesia. Adverse reactions to anesthesia affect about one child in three. The most common is simple nausea after surgery, but reactions are life-threatening in about one child in a thousand. Antibiotic therapy also has risks. About one patient in ten develop allergies to antibiotics. Bactrim, an antibiotic commonly used to treat ear infections, can produce more than sixty kinds of side effects. Some, although rare, are potentially fatal.

Conventional medical texts cite reasons for the tube becoming blocked. Many causes have nothing to do with bacteria, showing why antibiotics may often be inappropriate treatment. The myringotomy does nothing to remove these underlying causes. See the accompanying article by Dr. Mary Bove for a review of causes from the perspective of a naturopathic physician.

Bacterial infection

    The most common cause of acute ear infections is an upper respiratory infection that spreads to the ears. Inflammation from the infection causes the eustachian tube to swell shut, and traps bacteria in the middle ear cavity. However, no bacteria at all are present in about a third of acute ear problems, and in more than half the cases of chronic eustachian tube blockage.

Antibiotics

    Inappropriate use of antibiotics may actually cause the problem it is intended to solve. Over-prescription of antibiotics or prescription of the wrong kind can promote the development of stubborn resistant strains of bacteria and lead to chronic infection of the lining of the eustachian tube. An important cause of inappropriate use is also parents’ failure to follow prescription instructions. Antibiotics should be given for the full period on the label, even if symptoms improve before then. Stopping the treatment in mid-course can promote resistant strains of bacteria.

Allergies and environmental irritations

    Allergies or sensitivities to food, dust, pollen, animal hair, or other substances may cause swelling and lbackage of the eustachian tube. Household cigarette smoke may also cause problems—children with one or more smoking parents have significantly higher incidence of ear infections than children in smoke-free households.

Bottle feeding

    Babies who drink out of a bottle while lying on their back may get milk directly into the eustachian tube. Many studies have also shown that children who are breast fed for the first year have fewer infections than children who are weaned earlier.

Food sensitivities

    Conventional journals do not in general recognize food sensitivities, but some physicians routinely screen for milk sensitivity, especially when the history shows that the problems began immediately after introducing cow’s milk to the diet. MD allergy specialists suggest that allergies are responsible for about half the cases of otitis media in children. Naturopathic physicians condsider food sensitivities as a major cause of otitis media, and routinely screen for allergies to substances such as milk, wheat, eggs, citrus, peanut butter, and soy (especially if the baby was fed a soy formula.) Besides screening for offending foods, naturopathic physicians may treat acute or chronic ear infections with homeopathic and herbal medicines and nutritional supplements. The rationale is to remove underlying susceptibility to infection, rather than to fight bacteria directly. See the accompanying article by Dr. Bove for more details about treatment. By removing the cause, other related problems such as poor sleep, bad mood, headaches, skin rashes, digestive upsets, bladder problems in girls, and bed wetting often improve with natural treatment.

Case 1

Diagnosis: Suppurative otitis media with performation of tympanic membrane and non-strep pharyngitis.

Patient: Four year old female, 38 inches, 47 lbs., with single mother. Low income status affects diet.

History: Patient has been sickly most of her life, with frequent colds.

Herbal treatment: Commercial “ear drops” (hypericum oil and garlic oil with mullein). Warm the oil, then place two drops in the ear with a cotton plug, four times a day. Tincture of echinacea (mixture of E. angustifolia and E. purpurea: five drops in back of throat three times a day, away from meals. Continue for two weeks.

Other treatment: Hydrotherapy for fever reduction (“wet sock” treatment; cold wet socks on feet wrapped in warm dry socks or blanket). Counseled to decrease sugar, milk, and citrus.

Follow up at seven days Ear pain and discharge had resolved three days after treatment began. The membrane was closed with evidence of scarring; hearing was improved. Sore throat and runny nose were resolved. Patient’s energy and appetite were normal.

Follow up at fourteen days No evidence of infection in ear. Tympanic membrane has scar in midline. Mucous membranes of nose, ear, eyes, throat within normal limits. Ear drops discontinued. Echinacea discontinued for ten days. Reinforced nutritional guidelines. Patient to continue with echinacea with 14 days on and ten days off for remainder of the winter.

Practitioner’s comments: The patient responded quite well to the infection despite a compromised immune system, borderline nutritional and environmental support. The closure of the tympanic membrane and the complete healing of the ear in the short duration was remarkable.

Case 2

Diagnosis: Bilateral otitis media.

Patient: Fifteen-month-old male. 28 inches, 20 lbs. Middle Eastern culture, parents want natural treatment.

History: Treatment with a course of antibiotics was ineffective. One ear was red, swollen and painful, and the other slightly red with increased serous fluid.

Herbal treatment: 2 drops of Lomatium dissectum isolate in office, plus five drops of echinacea tincture (mixture of E. angustifolia and E. purpurea). Take five drops of echinacea each two hours during the day only for three days.

Other treatment: 500 mg. Vitamin C. daily. “Watch diet.”

Follup up at three days Mother called to say patient was almost 100% better. Reduced dosage of tincture to five drops three times a day.

Follow up at seven days Patient almost completely better. Discontinued echinacea. Continue with vitamin C. supplement.

Practitioner’s comments I assume after lack of resolution with antibiotics that the lomatium/echinacea treatment was the reason for the cure. Strict diet, vitamin C. probably increased speed of recovery.

Case 3

Diagnosis: Serous otitis media.

Patient: Eleven-month-old boy.

History: Treatment with a course of antibiotics was ineffective. Has recurrent ear inflammation once a month.

Herbal treatment: Commercial “ear drops”: (garlic oil, hypericum oil, with mullein.) Three drops in ear. Child started crying and was extremely irritable. Ear was extremely red. Discontinued use and gently wiped out the ear canal. Three hours later tried another dose. Child screamed again. The ear canal again appeared a bright red color. Drops were permanently discontinued.

    Follow up at ten days after a ten-day course of antibiotics, the otitis media had cleared up.

    Practitioner’s comments This botanical formula was unsuitable for this patient. I think the garlic oil in the tincture was simply too irritating to an already inflamed surface and hypersensitive ear. The next prescription will contain echinadea and/or pokeroot, mullein, and hypericum oil.

Case Commentaries: Paul Bergner

    Case one was included here because it demonstrates a typical successful treatment for ear infection, using both topical and internal treatment, with some artful nuances. Warming the ear drops adds to their soothing properties and may make the herbal components more available to the tissues. Some practitioners smoke mullein and blow the warm smoke into the ear through a rolled up piece of paper. It’s not clear whether mullein smoke has a medicinal effect, or whether the hot smoke alone is relieving for some patients. Putting echinacea directly onto a sore throat is soothing for some people. Taking periodic breaks while taking ehinacea for long periods is also prudent. It is probably best in the long run to let the natural immune system do its work unaided as much as possible. Echinacea is an immune stimulant, and, as a rule, what stimulates can exhaust if given for long periods. I’m not aware of any evidence or testimony, either from Eclectic literature or from modern research, that echinacia is safe to take for indefinitely long periods of time. Most natural healers would not consider its main noted side effect—joint pain—to be a minor one on the scale of possible side effects, ie. It is deep in the system rather than near the surface. Note how the practitioner integrated herbal therapy with lifestyle modifications. Many cases of otitis media require a modification of the diet for permanent relief.
 

    In case two, the “lomatium isolate” is a proprietary product extracted from Lomatium dissectum, an herb with suspected antiviral properties. L. dissectum is relatively rare, and has possible skin rash as a side effect. [Ed. Note: we’d appreciate correspondence from anyone observing this or other side effects with Lomatium.] Note the high frequency of the echinacea dose in the acute phase, reduced to three times a day after the condition is stable. This same strategy is appropriate for adults. This dose can be arrived at by a rule of thumb for doing: weight/150 lbs x adult dose. Thus 20/150 x 30 to 40 drops is 4 to 5.3 drops. This formula can be used for adults of various sizes as well.

    Case three was included for the side effect. Garlic’s energy is extremely heating. Watch for aggravation in “hot” conditions. I saw a patient once who took garlic capsules because she heard they were “good” for her, and they aggravated a long-dormant case of rheumatoid arthritis. I think the practitioner here gave up on herbal treatments too soon. I think the suggestion of putting poke root in the next formula is probably not appropriate for a child this age.

Commentary: Sharol Tilgner

    In case one, putting echinacea directly on an inflamed sore throat is soothing to some patients, but irritating to others. It may be the alcohol that is irritating.

    In case two, it is possible that herb worked where antibiotics failed because there was a viral or fungal infection in the ear. Antibiotics are only effective against bacterial infections, whereas immune-stimulating herbs will increase resistance to any kind of infection.