It’s a rare parent who hasn’t had to deal with ear problems at one point or another. In some cases, they can be a chronic issue that can make an otherwise healthy child miserable. The most common symptom you’ll see relating to the ear is pain, usually due to an infection. The easiest way to prevent this is to carefully use cotton swabs moistened with rubbing alcohol to dry the ear canal after swimming or excessive sweating. Forceful use of a cotton swab, however, should be avoided; trauma may occur that damages internal structures. Normally, you shouldn’t place anything in the ear canal sharper than your elbow.
The ear is divided into 3 chambers, the outer, middle and inner ear. Inflammation of the ear is called “otitis”. The most common ear infections will be in the external and middle ear chambers. The external canal can be examined with special instruments that allow visualization of the entrance to the middle ear; commonly known as the tympanic membrane or “ear drum.”’
USING AN OTOSCOPE
Evaluation of the ear canal and eardrum is performed with a special instrument known as an “otoscope”. Always hold the otoscope in the left hand if you’re looking in the left ear, the right hand for the right ear. Holding the otoscope like you would a hammer seems to work best, as it allows you to gently rest your knuckles against the side of the head. Alternatively, you could hold the otoscope as you would a pencil.
The external ear canal is about 2-5 cm long in adults, shorter in kids. In children, it’s relatively straight. in adults, it isn’t; you’ll need to pull the top of the ear upwards and backwards to get a better view of the ear drum (also known as the “tympanic membrane”).
If you’re using the otoscope on a child, always start by explaining the process. Let them know that it might feel “weird”, but shouldn’t hurt. Choose an otoscope end attachment (called a “speculum”) of appropriate size for a child. They often come in sets of different sizes.
Examine the normal ear first. This will allow you to see what the anatomy should look like. It will also prevent you from transferring the infection to the healthy ear. Be sure to have the light at high intensity.
You will first see the external canal wall. Is there redness or swelling compared to the normal ear? Is there debris, excessive wax, or even a foreign object? Don’t be surprised if you see small hairs; this is normal.
Now look for the eardrum at the end of the canal. A normal eardrum will appear pearly gray, shiny, and translucent. A dull yellowish color usually indicates fluid behind it, a classic sign of infection; in the worst cases, the eardrum will appear to bulge out towards you due to pressure from within.
Otitis Externa, also known as “Swimmer’s Ear” is an infection of the outer ear canal, and most commonly affects children aged 4 -14 years old. Cases peak during summer months, when most people go swimming. Bacteria accumulates in water or sweat and, once trapped in the ear canal, inflammation and discomfort ensue. Other causes may be due to inflammation from skin conditions like seborrheic dermatitis (discussed in the section on skin) and allergies.
Symptoms of Otitis Externa include:
Earache (worsened by pulling on the ear)
Itching in the ear
Ringing, roaring, or buzzing in the ears (tinnitus)
A “full” sensation in the ear canal with swelling and redness
Thick drainage from the ear
Standard treatment may include a warm compress to the ear to help with pain control. An antibiotic/steroidal ear drop like tobramycin/dexamethasone (Tobradex) will be useful, and should be applied for 7 days. In order to get the most effect from the medicine, place the drops in the ear with the patient lying on their side. They should stay in that position for 5 minutes to completely coat the ear canal. If ear drops aren’t available, oral antibiotics may be used although they are reserved, in normal times, for severe cases that spread beyond the ear canal.
Preventive strategies include use of earplugs while swimming, low-setting hair dryers, and head tilting to remove water from the ear canal. Discourage scratching the area.
A popular natural remedy for otitis externa is a 50/50 mix of apple cider vinegar and rubbing alcohol. Rubbing alcohol helps evaporate water trapped in the canal; the acidity of the vinegar decreases bacteria. Place 3-4 drops in the ear and wait 5 minutes before allowing to drain out. This is also a preventive strategy in those with frequent infections.
The most common cause of earache is an infection of the middle ear called “otitis media.” Normally, the eardrum is shiny and pearly-gray in appearance. When there is an infection in the middle ear canal, the eardrum will appear dull when examined with an otoscope. This is because there is pus or inflammatory fluid behind it. The resulting pressure is what causes the pain. Standard treatment often includes oral antibiotics and ibuprofen, especially in adults with the infection. If caused by a viral infection like the common cold, however, it should resolve on its own.
Otitis media is most common, however, in infants and toddlers. This is why mothers are always cautioned against bottle or breast-feeding with their baby lying flat. You can expect otitis media to present with one or more of the following:
Pain, more so when lying down
Crying and irritability in infants
Loss of appetite
Loss of balance
Holding or pulling the affected ear
Drainage of fluid from the affected ear
Difficulty hearing from the affected ear
“High-dose” Amoxicillin is the antibiotic of choice: In children, use 80-90 mg per kilogram per day in two divided doses for ten days will be effective in infants 6-23 months. 5-7 days of treatment is usually enough in children over two years of age. In penicillin allergies, clindamycin 30–40 mg per kilogram per day in 3 divided doses is an option. It should be noted that some pediatricians treat with antibiotics only in prolonged or severe cases; for example, when there is a high fever. Adults may be given Azithromycin 250 mg twice on the first day of therapy, followed by one tablet daily for 4 days.
Pain relief may be required for otitis patients. A number of natural remedies are available. Follow this procedure:
Mix rubbing alcohol and vinegar in equal quantities, or alternatively, 3% hydrogen peroxide.
Place 3-4 drops into affected ear.
Wait 5 minutes; then, tilt head to drain out the mixture. Next, use either plain warm olive oil, or add 1 drop of any one of these essential oils to 2 ounces of the olive oil: tea tree, eucalyptus, peppermint, thyme, lavender, garlic, or mullein.
Warm the oil slightly and place 2-3 drops into the ear canal. This does not have to be drained or removed.
A cotton ball with 2 drops of eucalyptus oil may be secured to the ear opening during sleep.
Some patients find a heat source soothing to a painful ear. If you’re off the grid, dip a sock or other absorbent material into heated water. Wring it out and place it on the outside of the affected ear.
VERTIGO AND OTITIS INTERNA
Inner ear canal issues often cause “vertigo”. It usually presents as a spinning sensation even when perfectly still. This differs from simple lightheadedness (dizziness) in that there is a feeling of rotational motion. Sometimes, vertigo is caused by an inflammation in the inner ear known as “Otitis Interna”. These patients commonly feel nauseous as well. Amoxicillin 500 mg three times a day for 7 days (adults) is an appropriate antibiotic therapy in infection-related cases.
To determine which inner ear is affected:
Have the patient sit so that when they lie down, their head hangs slightly over the end of the bed.
Turn the patient’s head to the right and have them lie back quickly.
If the symptoms worsen after a minute, the right ear is affected.
If no dizziness occurs, sit the patient back up and wait a minute or so.
Turn the patient’s head to the left and have them lie back quickly.
If the symptoms worsen after a minute, the left ear is affected.
Treatment for vertigo involves having the patient lie still in a quiet, darkened room. This tends to decrease nausea and reduce the sensation of spinning. Oftentimes, vertigo will go away by itself after a short time, but certain oral medications may be used for prolonged episodes:
Meclizine (Antivert): 12.5 to 50 mg orally every 4 to 8 hours (non-prescription)
Dimenhydrinate (Dramamine): 25 to 100 mg orally every 4 to 8 hours (non-prescription)
Diazepam (Valium): 2 to 10 mg orally every 4 to 8 hours
Lorazepam (Ativan): 0.5 to 2 mg orally every 4 to 8 hours
Metoclopramide (Reglan): 5 to 10 mg orally every 6 hours
A low-tech therapy for vertigo is called the “Epley maneuver”. If symptoms of vertigo occur from the right side, have your patient:
Sit on a bed.
Turn their head 45 degrees to the right.
If vertigo is related to the left ear, processed is reversed:
The patient sits on a bed.
Turn their head 45 degrees to the left.
Lie down quickly, keeping the head turned and slightly extended (chin up). Wait 30 seconds.
Turn their head 90 degrees to the right, without raising it. They should now be looking 45 degrees to the right. Wait another 30 seconds.
Turn your head and body another 90 degrees to the right, into the bed. Wait another 30 seconds.
Sit up on the right side of the bed for 15 minutes.
Most feel better right away after performing the maneuver, but some have to repeat several times to see an effect. They should continue to perform it three times a day until symptoms have been gone for 24 hours.
Joe Alton MD
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