A friend presented the other day complaining of a fuzzy head, intermittent balance problems, noises in the ear and a ‘sniffly’ nose. By the time he had stopped talking I had the auriscope in my hand and 30 seconds later we had the diagnosis – a middle ear infection, or Otitis Media.
A friend’s child was also brought along with a painful ear, and as she has had a cough and cold recently, there were enough factors to satisfy all clinical diagnoses. Once again, the auriscope was the appropriate instrument and a very brief inspection of the offending ear drum showed the scarlet flare that results from infection behind the drum, in the middle ear.
Ear infections are actually very common in small children, much more than in adults, and most ear infections involve the middle ear. By the way, we usually examine the “good” ear first, as the child is not apprehensive with the doctor examining that one, as there is no pain in it. An old trick learned from many years of practice.
Babies and young children suffer more middle-ear infections than older children because the tubes connecting the middle ear to the throat (called the Eustachian tubes) are shorter and when the Eustachian tube is blocked, fluid does not drain very well from the middle ear to the throat, and air does not get up into the middle ear space as well as it should, providing an ideal breeding ground for all kinds of bugs.
Babies and toddlers will usually suffer intense ear pain and generally have a fever. There may also be vomiting, loss of appetite, decrease in energy and some loss of hearing. In some cases, the pus will break through the eardrum. This results in a thick yellow discharge from the ear. However, the child feels better when the ear discharges as the painful pressure is gone. The burst eardrum usually heals on its own, without any need for ear drum repair.
Going straight to the cause with these two patients was not a case of brilliant diagnosis (though the plaudits of the crowd are always accepted) but purely the result of many years of experience. In any young child with those symptoms, one must always suspect and exclude the middle ear problems. Children, in particular, will pull at the offending ear, there will be no doubts about which side has the infection.
I mentioned vomiting, as one of the symptoms. Why do they vomit with Otitis Media? Probably for the same reason that people get sea sick – disruption of the normal fluid workings of the inner ear. The inner ear is intimately involved with balance, which is why the adult gave balance problems as part of his symptoms. Whatever, it is always worth asking your vomiting, febrile child if he or she “hurts” anywhere. If they point to or pull at the ear then you are most likely on the right track.
Remember that the middle ear infection does not necessarily produce an ear discharge as an initial symptom. For that to happen, it means the pus and goo trapped in the middle ear has ruptured through the ear drum. This is what we call a perforation, generally shortened to “perf”.
The treatment is a swiftly administered appropriate antibiotic. If the ear is discharging, then a culture can be taken and the exactly appropriate antibiotic chosen. If not, then most doctors fly by the seat of their pants and prescribe a penicillin derivative or one of the newer drugs. Some paracetamol to ease any pain and lower the temperature completes the package and expect junior to be better in a couple of days.
With the adults you have to also treat any ongoing or chronic sinus infections, and if the patient is a smoker, cessation is the best thing they can ever do for their sinuses.
If your child gets recurrent middle ear infections, then you really should get this investigated – including an audiogram (hearing test) to ensure there is no lasting damage.
So just remember, Mums of the world, a temperature and vomiting may not necessarily mean an intra-abdominal problem. It could all be in the ears!
