Notitis Media: False Alarm Ear Infections

Working in pediatrics, one of the most frequent reasons for a medical visit is to determine if a child has a middle ear infection or not. Some days, I wish that I had a drive-up window.

Parents are very sensitized by middle ear infections (otitis media) since they can be so painful and so untimely. Ear infections love to appear in the middle of the night, just before you go on vacation, while you are on vacation or out of town, or when you are between insurance policies.

The early symptoms and signs of otitis media vary from child to child, and parents are convinced those are infallible, and predictable. They are not. A verbal child will simply tell you that their ear hurts. Assuming this was an unsolicited comment; then this is usually a reliable sign. A pre-verbal child may exhibit a variety of vague/non-specific symptoms. One, isolated vague symptom of an ear infection in a child is less likely to be a valid indicator. However, if a child exhibits SEVERAL non-specific symptoms and signs, the likelihood of a middle ear infection increases.

PULLING ON THE EARS: Ear infections are typically painful; but there are many other things that can cause a child to pull on their ears. Getting water (or milk, formula) in your ear can result in some odd symptoms that may cause them to pull on their ears. Children who are learning to feed themselves often find a why to get mashed potatoes and peas in there as well. Ears that are stuffy can "pop" or crackle. This is an annoyance that can cause a child to pull on their ears, but this is not an ear infection. Sometimes, children just pull on their ears... or their toes... or their penises (if they have 'em). If every time a boy pulled his penis, a parent would bring them to my clinic, I would never get home. Penis-pulling, a fine art practiced by many, is rarely, if ever, a penis infection.

FUSSINESS: Some parents feel that when a child is fussy, they may have an ear infection. Maybe they do, but there are a few hundred other things that can make a child fussy, from gas pains and teething, to just being tired and uncomfortable. Fussiness is probably the most non-specific of all presenting symptoms.

FEVER: Children with ear infections do get fevers, but fevers can also occur with colds, roseola, gastroenteritis, meningitis, Mad Cow disease, and just about any of the hundreds of different viral infections. Fever is another non-specific symptom. The height of the fever is not necessarily an indication of the severity of the illness. For instance, a child with roseola may have a 104 degree fever for 2-3 days; a child with appendicitis may not have much of a fever at all. Although it is well-known that fevers are not dangerous, are a normal immune response, and do not need to be treated, fevers remains one of the most feared of all symptoms for parents.

STUFFINESS: Most middle ear infections in children are preceded by a cold. The most common scenario for the diagnosis of otitis media is a child who has been sick with a very stuffy cold for about three days prior. Congestion can cause the eustachian tubes to compromise; fluid builds up in the middle ear space; bacteria migrate from the throat into this pool of stagnant middle ear fluid, and a rip-roaring, painful middle ear infection will emerge.

DAY-CARE ATTENDANCE: Middle ear infections are preceded by colds. Colds are readily transmitted in day-care, or by play groups. As soon as children hit that ripe 'ol age of six months, their immature immune system is a virtual magnet for viral illnesses.

FAMILY HISTORY: If parents were plagued by middle ear infections as children, or had tubes (pressure equalization tubes) inserted, then there is a very good chance they will rear a child that carries the "ear infection tendency".

SMOKING: Children who are exposed to cigarette smoke have a higher incidence of ear infections. When I see a child in the clinic who reeks of stale smoke, I want to beat the parents senseless. I spend most of the visit time actively chastising the parents about second-hand smoke. Most of the time, they deny smoking around the child. They claim they smoke outside, never in the car, and never around the child. They lie; just like they lie when they say they only smoke two cigarettes a day, or plan on stopping. If our Child Protective Services were not so impacted by other abuses of children, I would turn in smoking parents for child abuse and endangerment. Both of my parents smoked when I was a child. The air in our windowless television room was literally a blue haze. I used to lie on the floor (below the smog) in order to breathe.

ALLERGIES: A child with environmental allergies may have a higher incidence of middle ear effusion (fluid) and/or infections during their allergy season. If their allergy season is all year, then this is a definite risk factor. Allergies also run in families.

TEETHING: Teething can result in "referred ear pain", but not ear infections. Children who are actively teething have a lot of inflammation in their mouths. This inflammation can cause the lymph nodes in the neck to react/enlarge, and this can cause discomfort to be transmitted to the ears. Children who rub the sides of their jaw and face due to teething discomfort might be misconstrued as having ear-pulling or rubbing.

Ear pain may not be an ear problem at all. There are many, many things that can cause OTALGIA, the medical name for ear pain. Tonsillitis, pharyngitis (sore throat), dental infections, lymph node infections, salivary gland infections (mumps), wax impactions, sinus infections, trauma, foreign bodies, etc. ALL can cause ear pain. Once it is determined that the child does NOT have an ear infection, other sources of ear pain must be investigated.

By understanding all of the various symptoms and signs of childhood ear infections, parents can better judge WHEN to seek medical intervention. About half of the patients that I see for suspected ear infections, do NOT have a middle ear infection; a fact that often disappoints a parent. Not only do I have to carefully justify my medical decision, I am often asked to PREDICT if they might have an ear infection tomorrow... or over the weekend. There is absolutely no way for me to predict outcome, and it does not make biological sense to just treat an ear infection that does not currently exist. I understand that parents know their own children, and to a certain extent, know their child's particular signs and symptoms that existed prior to past infections. I experience a lot of desperation and pressure from parents just to give them an antibiotic, when it is clearly not needed.

Some suggestions to FALSE ALARM ear infection visits:

1. Treat the pain; not just the fever. Ibuprofen and acetaminophen help control the symptoms. When a child is more comfortable; a parent is more comfortable. Pain is always counterproductive and all effort should be made to help a child deal with discomfort.

2. Use some eardrops for pain. Medications such as Auralgan, or the generics, can help middle ear pain. Ask your medical provider for a prescription to keep at home for possible ear pain. Children with tubes, or those that may have a ruptured eardrum should not use them. Make sure that all ear drops are instilled at BODY TEMPERATURE; never cold.

3. Stay out of the ER. A potential ear infection is not life-threatening. In most cases, it can wait until morning when you can see your regular medical provider - one that knows your child - or a less-expensive urgent care facility.

4. Get a home otoscope and learn how to use it. This is a safe, simple tool that can be quite helpful to parents of "frequent-flyers". When your child has an ear infection, ask the medical provider if you can see it. This is how you will learn. Educate yourself. If your child gets a prescription, read about it. Read as much about ear infections that you can.

5. Keep an ear infection diary on your children. Include information on dates of service, symptoms, signs, treatments, false-alarm visits, etc.

6. Don't jump the gun and head for the doctor at the first, vague symptom. Ear infections in a child can have emerging signs. A child pulling on their ear for one hour is less likely to have a diagnosable middle ear infection, than a child with a plethora of symptoms over two to three days. In most cases, it is okay to Count to Three (days that is) before seeking care. Believe it or not, most ear infections will resolve, on their own; IF you give the immune system a fighting chance.

Related Topics:

• Top 10 Questions About the Flu
• Ear Tubes Not Always Needed

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