Articles

Otitis Media

Introduction

Otitis media is a nonspecific term describing inflammation of the middle ear, and is classified according to its clinical presentation. (1) Acute otitis media is characterized by rapid onset of symptoms, and episodes are more frequent in the first 3 years of life. Acute otitis media is the most frequent diagnosis in infants and children who visit physicians because of illness. (2) Acute otitis media occurs in adults, but with much less frequency. Otitis media with effusion (accumulation of liquid in the middle ear cavity) differs from acute otitis media in that signs and symptoms of acute infection are absent. Whether the type of effusion is serous, purulent, or mucous it is often difficult to determine due to the opacity of the tympanic membrane.

The middle ear and its functions are best described as an air-filled cavity that begins at the tympanic membrane and extends to the nasopharynx via the eustachian tube. Its primary functions are the regulation of atmospheric pressure between both sides of the tympanic membrane, protection from nasopharyngeal secretions, and draining secretions from the middle ear into the nasopharynx. In the adult, the eustachian tube lies at a 45° angle from the horizontal plane. In children that angle is only 10°. This may indeed help explain the increased rate of infection in infants and children, since the degree of angulation may cause improper drainage. Also, the tensor veli palatini, the muscle responsible for eustachian tube opening is less efficient.

Several risk factors contribute to the higher incidence and frequency of otitis media:

Season: Frequency of otitis media is greatest in the winter months and appears to parallel outbreaks of upper respiratory tract viral infections.

Malformations such as cleft palate, downs syndrome, and adenoid hypertrophy increase the likelihood of acute otitis media infections and recurrences.

Environmental Factors that increase the likelihood of infections are parental smoking, attending day care centers, and history of recurrent acute otitis media or respiratory tract infections in siblings.

Race: The incidence of acute otitis media is more predominant in Caucasians than Black Americans, and Native Americans and the Inuit seem to be particularly at risk. The differences among races are attributed to anatomic differences, living conditions, availability of medical care, and the generally small sample size of groups studied.

Age at first episode: The younger the child’s first episode of otitis media, the greater the likelihood of developing recurrent, more severe episodes.

There are basically two situations which may occur with middle ear disturbances. First, a pathogen, such as a bacteria, may get into the middle ear and, as it propagates, fluid is unable to drain due to swelling and inflammation. Potential causes of this may include head trauma from birth or from an accident, or Eustachian tubes congested from allergies or colds.

Secondly, some experts feel that chronic ear complaints may be initiated by food or environmental allergies. Allergies could cause a fluid buildup in the ear, which may create pain or pressure in the child, but it is not an infection. However, this buildup can become a ripe medium for pathogen invasion. The biggest food culprits are wheat, corn, and dairy. Other common problem foods include soy, eggs, citrus, and peanut butter. It is thought that sugar may have a negative effect on the immune system. (3) The bacteriology of middle ear infections has changed very little since the mid-1970's with the exception of emergence of b-lactam resistance in some strains of H. influenza and M. catarrhalis. Bacterial cultures generally yield Streptococcus pneumonia (35%), Haemophilus influenzae (25%), and Moraxella catarrhalis (10%). (4)

Statistic

The National Institute on Deafness and Other Communication Disorders, National Institutes of Health, 1999.

    It is estimated that medical costs and lost wages because of otitis media amount to $5 billion a year in the United States. Middle ear infections are the reason for up to 30% of pediatric office visits in American children. Otitis media is second in prevalence only to the common cold. About two thirds of children have at least one acute ear infection by the time they are three years old. About 17% of all children under two have recurrent ear infections, i.e., three or more episodes within a six-month period. Prevalence increased 44% between 1981 and 1988, with infants particularly affected. 38% of children with ear infections also had sinusitis. More than 70% of children received antibiotics before they were seven months old, and the most common reason for these medications was otitis media. 80% of children are cured by two weeks without any treatment at all; antibiotics cure about 95%.

Signs and Symptoms

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Not available

General

  • Rapid onset of symptoms
  • Otalgia (denoted by pulling of the ear in some infants)
  • Fever
  • Hearing loss (secondary to effusion)
  • Irritability, lethargy, anorexia or vomiting may also occur, especially in young children
  • Usually occurs in children who have had an upper respiratory tract infection for several days 
  • Should perform an otoscopic exam whenever fever is present because symptoms do not always occur

Treatment Options

Conventional

The goals of therapy include the control of pain, eradication of infection, prevention of complications, and avoidance of unnecessary antibiotics. (5) Supportive therapy with analgesics, antipyretics, and local heat is beneficial in the comfort of the child. (6)

A nonpharmacologic treatment used frequently in cases of recurrent otitis media is myringotomy and insertion of tympanostomy tubes. The placement of tympanostomy tubes reduces recurrent episodes of otitis media by 50% with an infection-free period of three months for most. (7) The insertion of tubes interrupts the cycle of infection, relieves the discomfort that causes irritability in children, and rapidly restores essential hearing for a short period.

Currently, in the United States, the use of antibiotics remains the mainstay of therapy. Selection should be based upon:

    Antimicrobial susceptibility Penetration into the middle ear fluid Clinical efficacy Compliance factors Adverse effects profile Cost

Amoxicillin remains the antibiotic of choice despite growing concern of resistance. When there is lack of clinical improvement within 24-48 hours, or evidence of regional resistance to b-lactam antibiotics, a b-lactamase resistant antibiotic should be chosen. Some good choices are trimethoprim-sulfamethoxazole (TMP/SMX), cefaclor, cefixime, cefuroxime, axetil, ceftibuten, cefprozil, proxetil, loracarbef, azithromycin, clarithromycin, and erythromycin-sulfisoxazole.

Nutritional Supplementation


Vitamin C

Vitamin C is a nutrient that is critical for proper functioning of the immune system. One small study reported that neutrophil dysfunction can be restored and long-lasting clinical remission can be achieved in children with recurrent middle-ear infections with the use of vitamin C therapy. (8) Another study reported using a combination of antioxidants including vitamin C, vitamin E, and vitamin A in children with middle ear inflammation with good results. (9) To date, no large-scale studies have examined vitamin C’s usefulness for otitis media.


Zinc

Zinc is a nutrient that plays critical roles in the proper functioning of the immune system. In an investigation of 28 children aged 10 months to 10 years with undue susceptibility to upper respiratory and/or inner ear infections, zinc and iron were the two minerals that were found to be most frequently deficient in these children. (10)


Thymus Gland Extract

Thymus Extract may be used to support the immune system. Thymus extract products contain small amounts of the immune components of the thymus gland. Thymus gland extracts have reportedly been useful in treating individuals’ chronic viral and bacterial infections. (11)

Herbal Supplementation


Echinacea

Echinacea is one of the most popular herbs in the world. It has non-specific stimulatory effects on the immune system. (12) Research has indicated that echinacea stimulates the alternate and complementary pathway, activating white blood cells to scavenge for bacteria and cellular debris. (13) It has been used to improve wound healing (14) and to help in the treatment of colds and flu. (15) Two recent studies were performed using echinacea products in colds and influenza. One study reported no significant advantage when using echinacea in management of colds and influenza. (16) The investigators used an alcohol extract (polysaccharides are precipitated in alcohol). The other study (randomized, double-blind, placebo controlled) reported positive benefits in managing colds and influenza when using echinacea (using the succus product). (17) Echinacea is reported to have a wide level of antimicrobial activity on bacteria, fungi, and viruses. (18) It has been used externally for a wound wash, eczema, burns, herpes, canker sores, and abscesses, as well as other conditions. (19)

There are several mechanisms which could explain echinacea's activity. Echinacea (more prominently E. purpurea) inhibits the enzyme hyaluronidase. (20) The active constituents in Echinacea inhibit the breakdown of collagen ground substance and stimulate fibroblasts to make more of the ground substance. Echinacea reportedly stimulates an alternate pathway for the immune system. (21) Inulin is the component responsible for this activity. Echinacea is claimed to activate and increase white blood cell activity and cell-mediated immunity. (22) The components of white blood cells most affected by this are T-lymphocytes, macrophages, and killer cells. Cell-mediated immunity provides resistance to a variety of pathogens and guards against the development of arthritis, allergies, and other potential pathologies. Echinacea is reported to increase interferon, tumor necrosis factor, and interleukin-1 production through stimulation of macrophage activity. (23)


Astragalus

Astragalus has been valued by the Chinese for centuries for its immune-enhancing and adaptogenic properties. As an adaptogen, it may modify and improve the body’s response to stress through action on the adrenal cortex. (24) , (25) Experiments have reported that astragalus promotes regeneration of cells in the bronchi after viral infection. The polysaccharides contained in astragalus relate to the improvement in natural killer (NK) cells and T-cell function, as well as interferon production by the immune system. (26) Studies have reported that administration of astragalus for 1 month increased phagocytosis by spleen cells, decreased T- suppressor cell function, and improved T-killer cell function. (27) Astragalus enhances the effects of interferon and may act not only to improve resistance to colds but also decrease the duration of a cold. (28)


Larch Arabinogalactan

Arabinogalactans are a class of long, densely branched polysaccharides of the 3,6-beta-D-galactan type with molecular weights ranging from 10,000-120,0002. Because of the immune-enhancing properties, LA is receiving increased attention as a clinically useful immunomodulating agent. (29) LA may be a good therapeutic choice for individuals with recurrent immune system problems, including colds and influenza, chronic fatigue, and viral hepatitis among others. LA has also been used with positive success in children, specifically in otitis media. (30)

LA is reported to enhance immunity by various methods. Studies report that LA stimulates natural killer cell cytotoxicity, enhances other functional aspects of the immune system, and inhibits the metastasis of tumor cells to the liver. (31) Mechanism of action of LA in immunomodulation include:

    Natural Killer (NK) Cytotoxicity: It has been reported that decreased NK cell activity may be linked to a variety of chronic diseases including cancer, (32) chronic fatigue syndrome (CFS), (33) , (34) prostate cancer, (35) autoimmune diseases such as multiple sclerosis, (36) and viral hepatitis. (37) Investigators reported that LA stimulated NK cell cytotoxicity against a tumor cell line in vitro. (38) The larch arabinogalactan-mediated enhancement of NK cytotoxicity does not appear to be initiated directly, but may be governed by the cytokine network. Generally, LA pretreatment induces an increased release of interferon gamma, tumor necrosis factor alpha, interleukin-1 beta, and interleukin-6. Results suggest the increase in interferon gamma was most responsible for the observed enhancement of NK cytotoxicity. Reticuloendothelial and Complement Activation: Low to middle molecular weight (5,000-50,000) arabinogalactan polysaccharides isolated from larch and non-larch sources have been reported to have immunostimulating properties, including the ability to activate phagocytosis and potentiate reticuloendothelial system action. (39) , (40) Several arabinogalactans (isolated from non-larch sources) have also been shown to have anti-complement activity. (41)


Olive Leaf

Olive leaf extract has been reported to be an effective antimicrobial agent against a wide variety of pathogens, including Salmonella typhi, Vibrio parahaemolyticus and Staphylococcus aureus (including penicillin-resistant strains), Klebsiella pneumonia and Eschericha coli, causal agents of intestinal or respiratory tract infections in man. (42) The component usually associated with olive leaf’s antimicrobial properties is oleuropein. (43) , (44) Oleuropein also has been reported to directly stimulates macrophage activation in laboratory studies. (45)

Olive leaf extract has reported antiviral activity, reportedly caused by the constituent calcium elenolate, a derivative of elenolic acid. (46) , (47) Recent laboratory studies in laboratory animals reported hypoglycemic and hypolipidemic activity. (48) , (49) The constituent with the activity was reported to be oleuropein, with a proposed mechanism of action being: (1) potentiation of glucose-induced insulin release, and (2) an increase in peripheral blood glucose uptake.

Homeopathic

Belladonna

Typical Dosage: 6X or 6C, 30X or 30CSudden onset, intense, throbbing pain; Fever; Hot, red face, especially right ear; Worse at night; Relieved by warmth

Chamomilla

Typical Dosage: 6X or 6C, 30X or 30CViolent pain with much suffering; Red cheeks; Very restless; Worse from warmth and at night

Mercurius solubilis

Typical Dosage: 6X or 6C, 30X or 30CSoreness of internal ear; Tearing; Shooting, drawing pains in the ear; Ear and auditory tube inflamed; Discharge

Acupuncture & Acupressure

Jin Yong treated chronic pyogenic tympanitis with acupoint catgut embedding therapy. Main acupoints used were Ting Gong (SI 19), Ting Hui (GB 2) and Yi Feng (TE 17), supplemented with Wai Guan (TE 5), Taixi (KI 3), and Taichong (LR 3). After locating the acupoint acutely, the catgut was embedded into it to an appropriate depth, followed by withdrawing the penetrating needle rapidly. Pressed the needle hole with an alcohol cotton ball to prevent bleeding and then the local needle hole was covered with a piece of plaster for 2 ~ 3 days. The treatment was conducted once every 30 days. Results showed that of the 56 cases, 43 fully recovered, 11 had significant improvement, and 2 cases had no improvement. The total effectiveness rate was 96%. (50)

Traditional Chinese Medicine

Otitis Media

Extensive information regarding the treatment of this health condition using Traditional Chinese Medicine is available through the link above.

Diet & Lifestyle

Allergy to milk and dairy products: Some children with recurrent otitis media infections are found to have food allergies. In one study of children between the ages of 1.5 to 9 years of age, 81 of 104 (78 percent) were found to have food allergies. An elimination diet led to a significant amelioration of serous otitis media in 70/81 (86 percent) of patients as assessed by clinical evaluation and tympanometry. The challenge diet with the suspected offending food(s) provoked a recurrence of serous otitis media in 66/70 patients (94 percent). (51) One of the most common conditions is an allergy to milk and dairy products. (52)

Clinical Lab Assessment

Some of the following laboratory testing can provide information necessary for diagnosis and treatment. In addition, the tests listed may also give insight to functional metabolism and functional nutrient status in the body.

CBC

A CBC may suggest the involvement of secondary infections, inflammation and/or nutrient deficiencies. Mean corpuscular volume (MCV) may not be sufficient to assess iron status. Analysis of serum iron, total iron binding capacity, and ferritin may be indicated. The CBC includes screening for leukopenia (low WBC) and thrombocytopenia (low platelet count).

Allergy and Food Sensitivity Response Assessment

The severity of allergic response correlates with an increase in stress levels. (53) Allergies may have considerable impact on inflammatory processes. Direct correlation of impaired digestion or food allergic response is controversial, though some case studies manifest improvements on food elimination diets.

Clinical Notes

Probiotics (Lactobacillus acidophilus and bifidobacteria): Children who experience recurrent ear infections have usually been treated to multiple rounds of antibiotic therapy in their lives. In the majority of cases, the parents have not been advised about the importance of using high-dose probiotics following a course of antibiotics in order to reestablish a healthy intestinal microflora. Thus, it is likely that these children will be suffering from dysbiosis, which is an unbalanced or toxic population of bowel microflora, containing yeasts such as Candida albicans and various species of unfriendly bacteria. This condition can result in a wide variety of intestinal health problems ranging from gas, belching, bloating, diarrhea, and problems digesting and absorbing nutrients. The toxins from these organisms also get absorbed into the body, can also cause a wide range of physical and psychological/emotional problems as well as a significant weakening of the immune system.

One of the most effective ways to treat this condition is for physicians to advise parents about products that can help clean out the intestinal tract. Various approaches can be used ranging from herbal and homeopathic products to antibiotic and anti-fungal products when appropriate. After cleaning out the intestinal tract, patients should then begin ingesting high doses of probiotics twice daily with meals for a minimum of two weeks to rebuild a healthy intestinal microflora. A recommended dosage range is 5 to 10 billion cfu (colony forming units) twice daily.

Sugar Consumption: Since dysbiosis is aggravated by sugar consumption, parents should consider reducing or eliminating refined sugar intake in children. Although this seems to be difficult for parents at first, manipulation of food intake can be achieved with moderate effort.

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