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The Other Kind Of Ear Infection: Otitis Externa

My ears are currently killing me and have inspired today’s post on otitis externa. I got it from my habit of swimming for exercise, and it’s being exacerbated by putting a stethoscope in my ears 25 times a day. While I am miserable right now, I’m trying to look on the bright side. At least I have more empathy for my suffering patients who can’t tell me how much pain they are in.

The type of ear infection I have is really common in kids, but parents are often surprised to realize that it is different from a typical “ear infection.” The ear is separated into 3 distinct areas: the outer ear, middle ear, and inner ear.

When people talk of an ear infection, they are usually referring to an “otitis media” (otitis means ear and media means middle), so middle ear infection. Those are the infections where there is fluid or pus behind the ear drum (usually the result of a complication of a cold). These infections are treated with oral antibiotics (because the infection is behind the ear drum and drops can’t get to the infection).

The infections of the outer ear are referred to as “otitis externa” (otitis means ear and externa means outer). This is when the ear canal itself gets infected and inflamed. This usually happens as a result of some irritant/infection touching the ear canal. The most common cause is the water from swimming pools. This is why otitis externa is often referred to as “swimmer’s ear.” However, in kids, there are often many other causes of otitis externa. Namely, kids like to stick things in their ears. The objects then get stuck and start to irritate and infect the ear canal or just injure it altogether.  Repeat offenders in my office are Q-tips, pencil lead, pencil erasers, and rubber balls (don’t know why the last one keeps showing up).

Whenever a kid comes into my office and complains of an earache, I always ask if they stuck anything in it. 99% of the time, the answer is “no.” When I look and see a foreign body, I again ask, “Are you sure you didn’t stick anything in there?” The answer is still 99% of the time, “no.” (Which always surprises me, it’s like they don’t think I can see it). When I pull out the object, the look is always the same-horrified awe. It’s like I magically made the object appear. Usually the parent and I then die of laughter at that point. While the child has the momentary guilt of getting caught in the lie, there is huge relief that comes from knowing the pain is finally going to get better.

Signs and Symptoms:

  1. Ear pain (worsened when the outer ear is touched or pulled gently)
  2. Pain on pushing the tragus (the little tab like flap that sticks out just in front of the ear canal)
  3. Pain in the ear with chewing or moving the jaw
  4. Severe cases may have drainage from the ear

Diagnosis and treatment of otitis externa will require a visit to the doctor:

  1. Examination of the ear (with removal of foreign body if necessary)
  2. Prescription antibiotic drops (usually a couple times a day for about a week)
  3. Keep the ear dry. (Either allow ear to dry on own or use a drying agent or drop. Try to avoid using Q-tips.)
  4. Stop the offending agent (swimming, sticking stuff in the ear, etc.)

The pain with otitis externa can be pretty extreme (believe me, I know). So give your child some ibuprofen if he/she complains. Usually, within a couple of days on the drops, the pain is markedly improved.

Another Ear Infection? Time For Tubes?

Did you know that the number one reason children have surgery or anesthesia in the United States is for ear tubes? (Store that random trivia for your next dinner party conversation). With tubes being so common, you may have questioned whether or not your child should get tubes (the official name is tympanostomy tubes). Tympanostomy tubes are surgically placed when the Eustachian tubes you are born with don’t work very well. When you are young, the Eustachian tubes often don’t drain very well (they are small, have a sharp angle, or are easily clogged). The tympanostomy tubes just create another avenue for the fluid to drain out.

In years past, there was a lot of inconsistency about who did or didn’t get recommended for tubes, which probably had more to do with how aggressive your doctor was than anything else. However in 2013, an official practice guideline (trying to standardize recommendations for docs) was issued by the American Academy of Otolaryngology-Head and Neck Surgery Foundation (say that 3 times fast) on tympanostomy tubes. Here’s the abbreviated take home version for you.

Consider tubes if your child has:

  1. Frequent infections: At minimum 3 infections in 6 months or 4 infections in a year (as an aside, in the community where I practice, most ENTs will also use 5 total as a definitive number, although that is not part of the official guidelines).
  2. Infections that don’t get better with antibiotics: These are the infections you have attempted to clear with 3 or 4 different oral antibiotics and may end up getting antibiotic shots to clear up.
  3. Fluid in the middle ear space (normally it is just air) for more than 3 MONTHS (the medical term is otitis media with effusion) AND there is impaired hearing or the fluid is causing problems like balance issues or pain.
  4. Fluid in the middle ear space that is not likely to resolve quickly and your child is HIGH RISK (child has Down syndrome, cleft palate, permanent hearing loss, speech/language delay, etc.).

While surgery should never be taken lightly, placement of tubes is generally very simple and quick. Usually the anesthesiologist uses a mask to put your child to sleep (they don’t usually intubate or put a tube down their throat). The ENT (Ear, Nose, and Throat surgeon) who does the surgery is usually sitting and only takes 2-3 mins per side to place the tubes. The tube is tiny (typically 0.05 inch in diameter) and falls out in 1 to 2 years (sometimes they will only last a few months though before falling out). It is not uncommon to have to have a second set put in.

According to the practice guidelines, if your child already has tubes:

  1. He or she can bathe or swim without having to use specific precautions (e.g. ear plugs, headbands), in most cases.
  2. If an infection develops, drops alone can be used to treat the infection, eliminating the additional need for oral antibiotics.

If you are still uncertain whether or not your child should have tubes, ask your pediatrician. Your pediatrician knows you and your child and can steer you in the right direction.


What To Do About Draining Ears

I am on call this weekend and have received a couple of calls about draining ears. Here’s the quick scoop on when you see stuff coming out of your kid’s ears.

First question is what is coming out of the ear? Is it just wax? Wax is usually a dark brown and sticky. There is no pain associated with wax. However, if it is pus, now we’re talking infection. Pus is white or yellow, creamy in consistency, and has a foul odor. Almost all cases of pus draining out of the ear come from one of two ways. First, pus can drain out if there is a tympanostomy tube (in fact, that is what they are designed to do). Second, pus drains out if the ear drum is ruptured. When that happens, sometimes the drainage will have a little blood in it.

When people refer to “ear infections,” they are usually referring to the middle ear (the medical term is “otitis media”—meaning ear, inflammation, middle). So when pus drains out of an ear, it means the pressure in the middle ear has gotten so great that the infection is draining out of the ear (normally it gets trapped behind the ear drum). If the ear infection is severe or goes on for a while, this complication will commonly happen.

Draining ears are treated with either antibiotic ear drops, oral antibiotics, or both. Your doctor will help determine what is best based on your child’s circumstances. Don’t be surprised if your doctor requests a follow up appointment after treatment to ensure the ear drum has healed properly. The silver lining to this whole situation is that often when the ear drum ruptures, the pain is greatly relieved because of the release in pressure. So if you have a draining ear, call your doctor, you’ll need to be seen.