Antibiotics for Middle Ear Infections - Love 'Em or Leave 'Em

Antibiotics have only been in the medical arsenal for about 75 years, starting with sulfa drugs in the 1930s and penicillin in the 1940s. There are now dozens of different and more potent antibiotics, but very few new ones are patented. Since their discovery, antibiotics have saved umpteen millions of lives, and still do everyday. However, antibiotics have been heavily used and abused from their debut. Slowly but surely, they are become less and less effective.

As a child, our local, small town GP used to give injections of penicillin for just about any reason, it seemed. If you had a sore throat or tonsillitis, you got a shot of penicillin. If you had a fever for unknown reasons, you got a shot of penicillin. If you were uncooperative in his office, fearing that you will get a shot of penicillin, you got a shot of penicillin. He was such a shot-doctor, that kids would not even go to his door for Halloween.

In the U.S. as in many other countries, antibiotics are controlled by medical prescriptions. However, in places like Mexico, you can simply walk into a pharmacy and buy them - assuming they are "real ones" and not fake, counterfeit substitutes. With a Canadian doctor's prescription, you can easily buy large quantities in Canada. It is not uncommon for Americans to smuggle antibiotics in huge amounts across the borders, primarily for personal use, or share among friends. Some people have literally become Amoxiholics!

Antibiotics are only used to treat susceptible bacterial infections. They are completely ineffective against viruses - the main cause of most diseases. If they are self-administered indiscriminately for viral illness, not only will they be ineffective, they can make things worse. Sub-therapeutic doses of antibiotics help create resistant strains - the dreaded Superbugs. Primitive microorganisms can rapidly adapt to most antibiotics, even when given appropriately. There are bacterial strains out there that are completely resistant to EVERY known antibiotic. You really don't want an infection from these guys.

One of the major reasons antibiotics are prescribed for children is for the treatment of otitis media - the middle ear infection. Surprisingly, the vast majority of middle ear infections in children will resolve spontaneously in a few days, WITHOUT antibiotics. So, why do clinicians keep giving them and parents keep demanding them? That is the billion dollar question. Controlled, scientific studies in the U.S. and Europe have proven time and again, that antibiotics are only needed for the treatment of otitis media in very young children with immature immune systems, immunocompromised children (children with diabetes, cancer, etc.), or in children that are very toxic-appearing. These are the children who are very ill, in extreme pain, and not fighting off their infections naturally.


In Europe, children with otitis media are not routinely treated with antibiotics for at least the first week. That does not mean they are not treated in other ways for these painful afflictions. Children are routinely given pain medications - usually more than just acetaminophen or ibuprofen - to make them more comfortable while Nature orchestrates the cure. In the U.S., the typical care involves the early use of antibiotics, even in cases where the child does not even have signs of middle ear infection, and mild pain medications.

Over 90% of European children get better, on their own, with just pain medications, and tend to have fewer recurrent middle ear infections and need for surgical tubes. The U.S. kids tend to get better, too, but with potent and expensive antibiotics on board that more and more clinicians feel are unnecessary. Old treatment habits are hard to break.

I had a posting on the Ear, Nose, and Throat message board recently by a person inquiring about the proper dose of amoxicillin for her two children. She felt that the doctor's dosage was way too high, and that she would prefer to give half-doses. I really wanted to tell her that antibiotics are not really needed at all in most cases; but of course I knew nothing about her children and cannot blindly tell her not to use them. I assume that her children were properly examined, and probably treated with the appropriate dosage of amoxicillin. For most clinicians, treating otitis media is really routine stuff. However, most clinicians have not jumped on the "no antibiotic" bandwagon.

When amoxicillin first came out, maybe twenty years ago, it was dirt-cheap - only a few dollars for a standard, ten-day course. Children were treated, based on body weight, at about 20-30 mg/kg per day, in three divided doses. Amoxicillin virtually replaced ampicillin - an antibiotic that had some nasty gastrointestinal side-effects (like explosive diarrhea) and had to be given four times per day, a dosage nightmare for busy parents. The bubble-gum flavored amoxicillin even tasted better. For nearly a decade this dosage seemed to work great. Later, studies started to show that amoxicillin can be given twice a day, even more convenient for busy parents, and for as little as five days instead of ten.

My wife and I used to teach an all-day pediatric class for child care providers. I remember putting my lunch in their refrigerator, only to be shocked by the dozens and dozens of bottles of amoxicillin, all lined up for the various kids.

As the years progressed, everyone started using amoxicillin (a lot), still the drug of choice for otitis media. Unfortunately, amoxicillin started to fail as resistant strains took over. Many clinicians would abandon using it after the first-failure, until studies showed that a higher dose was more effective. Now, the standard dosage for amoxicillin (in children) is 60-80 mg /kg - more than twice the original dosage.

There are now about two dozen different antibiotics that can be used for pediatric middle ear infections. Every day in my clinic, I encounter the otitis media frequent flyers, usually on their way to the surgery center for tubes. There is a better way, but it is going to take a partnership of parent and medical provider to change the way we treat these kids. We need to trust that our immune systems have protected us long before the advent of antibiotics, and will continue to do so, IF we give them a chance.

Parents can help by not insisting on antibiotics, especially when clearly told that the child does not have a middle ear infection at the moment. Sure, they may get one tomorrow or over the weekend, or while you are at Disneyland, but that never justifies giving antibiotics prematurely.

Medical providers need to stand their ground and resist antibiotic solicitation from worried parents. Instead of medication, a healthy dose of EDUCATION needs to be administered. Parents who have children with frequent ear infections need to have a home otoscope, and learn how to use it. Medical providers have an obligation to cooperate with these novice otoscope-users, and encourage, not discourage their use. Parents should choose a medical provider that allows for this type of participatory care.

I still feel that antibiotics are miracle drugs, but the real miracle is to know when and how to use them. The bugs are getting smarter, and we need to be smart, too - always staying one step ahead.

Related Topics:

• Ear, Nose & Throat Message Board with Rod Moser, PA, PhD
• Living Better Newsletter - Wellness news to keep you healthy and strong!

Airing Some Dirt

Photo: √oхέƒx™ / CC BY 2.0

Airplane cleanliness was one of my twelve Dirty Dozen that I discussed on a past Blog. My experience on my most recent cross-country flight has not changed my views. Like most businesses, the airline industry has to cut corners. I guess if I had to sacrifice cleanliness for safety, I would chose safety, hands down.

Hurry Up and Wait
We have to get to the airport now about two hours early due to safety inspections, and I did just that. However, I had to wait in line while only a few people checked us in. I had no bags to check. Now that I have my Rick Steve's travel bags, I can haul a weeks worth of clothes and several books, including a suit, into a backpack. My briefcase has my camera (I always carry it) and my essentials - toothbrush, comb, medications, and busy paperwork. Since 9/11, I have been more anxious about flying, so I try to remain busy. As a non-drinker, I do not have alcohol as an anti-anxiety crutch.

I stood (patiently) in line for over an hour. Once I checked in (I should have printed out my boarding pass the night before, but I worked too late and forgot), I was directed to my gate, about a mile away. That heavy backpack wasn't so convenient at this point. As you might expect, there was another line at security.

People were standing around in bare feet and all I could think about was foot fungus. I saw some pretty funky feet in that line. I was wearing sandals, but I had to take them off, too. I didn't think the space between my toes was much of a security risk, but I guess the soles of my sandals could have been an issue. I had gone to great detail making sure all of my liquids - shampoo, cologne - were in tiny bottles. I had nothing sharp, except my wit, of course. For some reason, my bags were set aside for the sniff-test, checking for explosive residue. I do not deal with explosive, so I had no worries, except that maybe I fit the profile of a mad bomber.

Frequent Flyer Seats
I was able to use my frequent flyer miles to upgrade to first class, although there are several degrees of first class. Every time that I do this, I get into seat 6A - the last row of first class. This is really much better than the first row, of course, since this row is the waiting area for the toilet. Not only do occupants in these seats get frequent whiffs from those open doors, but a few whiffs of those anxiously waiting for that one door to open.

I apparently have a huge bladder, since I can hold it for many hours. I don't like to use public restrooms, especially on an airplane. Turbulence tends to start about the time you try and pee anyway.

The last row of seats gets the meals that are not chosen first. On this breakfast leg of the flight, I just knew I would get cold cereal. So, as I ate my corn flakes, I thought about the cleanliness of my tray table that I forgot to wipe off. Was there a pile of used Kleenex sitting there from the previous passenger, recently diagnosed with H1N1 flu? How many sneezes did that tray get? I made sure not to touch it, or sit down my microwave-heated muffin. Between flights, airline personnel will empty the trash, but they do NOT sanitize the trays or arms of the seats. Since germs can remain on hard surfaces for hours, this concerns me.

Announcements
We live in an age of electronic marvels, so why do announcements on a plane hiss and echo like a New York subway. Granted, my hearing isn't what it used to be, but I had absolutely no idea what the pilot or flight attendants were talking about. They could be announcing a water landing, but I would not have a clue. In the event of a water landing, your seat cushion can be used as a floatation device. I can tell you right now, if we were making a water landing, my own seat cushion would not be suitable. I always listen to those safety briefings and notice where the emergency doors are located.

Pull Back and Wait
Airlines treasure their on-time statistics. This is why they pull back from the gate on-time, only to wait another 30 to 45 minutes on the tarmac. We had a 30 minute delay in Dallas, sitting there in the 100 degree heat, and a 45 minute "weather" delay in Washington, DC, on the way home. I don't mind weather delays, since I absolutely hate the storm cloud roller coaster. Once, while flying into Detroit, our plane hit some unexpected turbulence, the kind that will field test those seat cushions. The look on my face must have concerned my elderly female seat mate, because she took my hand and said, "It's okay, honey, I have been in worse than this. You'll be fine."

Seat Mates
On the first leg of my flight, I was entertained, non-stop, by an embittered newly divorced man. He was ragging about his ex-wife, her attorney, and his child support/alimony responsibilities. I picked up a new seat mate in Dallas, a cowboy (naturally). He was pleasantly quiet, drank a lot of free booze, and was miffed that he had to eat a salad for lunch. I sort of aced him out by choosing the last pasta dish.

A seasoned soldier, home from Iraq, shared one of the travel legs. He was Cuban, having immigrated in the late 1960's, after the Bay of Pigs. He still had a Spanish accent.

My seat mate on the way home was a young woman armed with an array of antibacterial hand lotions, wipes, and other forms of disinfectants. I did admire her recognition that planes are not the most sanitary modes of transportation, I think she overdid it a bit. I don't know why these sanitizers have to smell so much like perfume. It reminds me of those old ladies in church who use gallons of cologne to mask unwashed body odor. I coughed a few times from the fumes, which concerned her a great deal. If she had a mask, I am sure she would have worn it, or at least handed it to me. Incidentally, our clinic now has a "flu table" set up, complete with hand sanitizers, masks, gloves, and even gowns for people to use if they want. The airline industry should take a hint.

Idle Time
I had several books and bought a few magazines at the airport. Just likely eating all of your popcorn before the movie starts, I read nearly all of my magazines before the plane took off. My book is a bit boring, so I did nod off a few times. I am so concerned that I will loudly snore that I tend to avoid sleeping on the plane. My last seat mate had loaded a lot of movies on her laptop and was listening to them on some nice Bose headphones. I would glance at the movie from time to time, and wished that I would have brought my own laptop this time. Knowing that my brother, a Born-Again Apple user again, has one, I decided not to bring mine. I was thinking that I was sparing the extra weight, but your own in-flight movies on a laptop are sure a nice distraction for idle time.

Window seats give you the ability to spot clouds that may cause some unexpected bumps. Over California, I spotted several active forest fires - a seasonal threat to many of us who live in wooded areas. When I saw the deep, blue waters of Lake Tahoe, I knew I was nearly home. Soon, I spotted the rice fields adjacent to the airport. It is always nice to travel, but it is even better to be safely home.

Related Topics:

• WebMD Video: Healthy Airplane Travel
• Travel Health: Precautions Along the Way
• Ear, Nose & Throat Message Board with Rod Moser, PA, PhD
• Living Better Newsletter - Wellness news to keep you healthy and strong!

Tonsils and Adenoids

In years past, tonsils were removed routinely, at the discretion of the doctor. All it took was one infection, and out they came. A tonsillectomy and adenoidectomy were once one of the most common surgical procedures in the U.S. Not any more. Unless children (and adults) meet certain surgical criteria, most insurance companies will not approve their removal.

The tonsils and adenoids are lymphoid tissue; the same as the lymph nodes they you often feel in your neck during infections. Even though tonsil and adenoids are grouped together as one entity, they are distinct, unique structures. They are an integral part of our immune system that protects the upper respiratory tract, fighting off infection in a never-ending battle. As we age and our overall immune system improves, tonsils and adenoids are less problematic.

The tonsils are located on each side of the back of the throat and are easy to see with a good flashlight. Children tend to have relatively large (hypertrophic) tonsils. Some children even have "kissing tonsils" - tonsils that are so large that they touch (kiss) each other. Their appearance alone often concerns parents. Tonsils are filled with little craters or crypts that can trap food or other debris, giving a false impression of being infected.

Of course, large tonsils do not necessarily mean you have tonsillitis (an infection in the tonsils). Normal tonsils are pink; similar to the color of the lining of your mouth. When infected, tonsils appear bright red and inflamed, are painful, and can result in difficulty swallowing. A sore throat (pharyngitis) is different than tonsillitis, although it is common to have both.

The adenoids cannot be seen by looking in the throat, since they are located higher up in the nasopharynx (the area between the back of the nose and the throat). They can only be seen with an endoscope (a flexible, fiberoptic scope that is introduced through the nose), or a laryngeal mirror. A special x-ray of the neck is also used to estimate adenoidal size. The adenoids are located near where the eustachian tubes enter the throat from the middle ear space. Enlarged or diseased adenoids may compromise the normal ventilation and drainage function of the eustachian tubes. Children with enlarged adenoids may have a nasal quality to their voice, mouth-breathe, and can even develop an adenoidal facies - a characteristic facial appearance and dental malocclusion due to chronic airway obstruction. Middle ear fluid (effusion), otitis media, and sinusitis can also develop from enlarged and/or infected adenoids. It is quite common to have the adenoids removed when tubes (Pressure Equalization Tubes) are inserted.

Tonsils and adenoids frequently become infected. The vast majority (90%) of these infections are viral; the other 10% are bacterial, such as Streptococcus (Strep). Mononucleosis (Mono) will also cause tonsillar enlargement. Tonsils that are frequently infected, several times per year, may need to be surgically removed. Rarely, tonsils will develop an abscess on one side (peritonsillar abscess), resulting in severe throat pain (often referred to the ear), difficulty swallowing, and fever. Peritonsillar abscesses often cause the uvula (the little hanging tissue at the back of the throat) to deviate to one side. Peritonsillar abscess may need to be surgical drained; and tonsils may need to be surgically removed for recurrent abscesses. Frequent Strep infections or people that are Strep carriers may also be surgical candidates.

Tonsils and adenoids that are chronically enlarged my compromise the airway, resulting in disturbed sleep, frequent sleep arousals, snoring, and even true apnea (the temporary cessation of breathing). Children who do not sleep well are frequently tired and cranky during the day and can have problems concentrating in school. Obstructive sleep apnea should be considered if your child has an apnea spell lasting ten seconds, loud storing, or daytime sleepiness. Sleep studies, as well as a full cardiac examination should be performed in anyone with sleep apnea.

A frequently-asked question on the WebMD Ear, Nose & Throat message board is about tonsillitis, or tonsillar stones. Food and other debris can build-up in the crypts and craters of the tonsils, and harden to a stone-like consistency. When these tonsillar stones dislodge, they result in a terrible taste in the mouth and halitosis. The only definitive cure for tonsilliths is the surgical removal of the tonsils. As an interim solution, gargling with warm salt water after every meal may help prevent the build-up of this hard debris.

In the adult population, especially in people who smoke, one-sided tonsillar enlargement could indicate a tumor. Lymphomas and HIV infections can also cause tonsillar enlargement, so it is very important to have a thorough medical evaluation.

Related Topics:

• WebMD Video: Child Behavior Issues Could Be Linked to Their Tonsils
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