naturopathydigest.com -- Acute Otitis Media: Correct Diagnosis and Treatment

buy microsoft office enterprise 2007

buy Microsoft Office 2003 Professional sp3buy autodesk autocad 2009

Acute Otitis Media: Correct Diagnosis and Treatment

By Jared M. Skowron, ND

Acute otitis media (AOM) is the most common childhood infection for which antibiotics are prescribed in the United States.

This is leading to an enormous increase in antibiotic-resistant bacteria in our children's flora, altering their immune systems, increasing the incidence of asthma, and worsening their future health.
In 1995, the direct cost of treating AOM was $1.96 billion, with an additional $1.02 billion lost due to lost time from school or parents from work.¹ In 2000, there were 16 million visits for AOM, with 80 percent receiving antibiotics.² Conventional pediatricians are changing their treatment from constant antibiotic therapy to "watchful waiting" for most children. This is due to the fact that for most cases, antibiotics are not reducing symptoms or duration of AOM.
Naturopathic medicine offers far superior treatments to enhance the body's ability to heal, while also keeping watch on dangerous sequelae. Preventing repeat AOM is important since children with a history of multiple ear infections achieve lower scores on skills of alliteration, rhyme, expressive vocabulary and reading.¹³
Diagnosis
To diagnose AOM, the clinician should confirm a history of the following:

acute onset
signs of middle-ear effusion, and
middle-ear inflammation.

AOM is commonly misdiagnosed when a URI is present. Otalgia (ear pain), tugging on the ear lobe by an infant, irritability, and/or fever are common symptoms of both AOM and viral upper-respiratory infections. Cough, congestion and nasal discharge are also common symptoms with both conditions, leading to many incorrect diagnoses. Accordingly, clinical history alone is not enough; an appropriate physical exam is necessary.
Middle-ear effusion can be confirmed by pneumatic otoscopy. Many physicians do not use the insufflator bulb with their otoscope to assess tympanic membrane mobility, especially in a fidgety child. Middle-ear effusion also can be demonstrated by the presence of fluid in the external auditory canal with tympanic membrane perforation.
Fullness or bulging of the eardrum, with deviation of the cone of light suggest middle-ear effusion. Reduced or absent mobility of the eardrum during pneumatic otoscopy is additional evidence of fluid in the middle ear. A fluid line and cloudiness of the eardrum are other findings that suggest effusion.
Visualizing the tympanic membrane is essential in diagnosing AOM, with certainty to identify effusion and inflammation. This means cerumen in the canal obstructing visualization must be removed, and lighting must be adequate. Twenty-two percent of physicians overdiagnose AOM when cerumen is present in the external canal.¹²
Middle-ear effusion is a result of Eustachian tube inflammation. Environmental allergies, food sensitivities (especially dairy) or viral upper-respiratory infections can cause Eustachian tube closing. The now-enclosed space of the middle ear is a haven for organisms to thrive. Immune reactions and pathogen growth lead to pressure changes in the middle ear, causing bulging or retraction of the tympanic membrane and ear discomfort.
The most common bacterial pathogens cultured during AOM are Strep pneumoniae, H. influenzae and M. catarrhalis.⁵ The question is: Are these organisms normal flora, flourishing under ideal terrain when the Eustachian tube closes due to inflammation, or exogenous organisms contracted from family, school, day care, etc.? Viruses are a more common etiology, found in up to 75 percent of middle-ear effusion secretions, and are the obvious etiology when antibiotics do not remedy the condition.⁶ Newer studies indicate that it is the terrain flora of an enclosed space which lead to most cases.¹⁰
Concerns regarding antibacterial resistance and costs of medications have brought to question the judicious use of antibiotics. Mastoiditis is a possible result of untreated bacterial otitis media. However, the fear is greater than the risk. In a study of 4,860 Dutch children untreated for AOM, only one child developed mastoiditis (0.04 percent), which resolved quickly with antibiotics.⁴ Mastoiditis normally occurs in infants and may be the presenting symptom. In the same study, no children contracted bacterial meningitis. The reasoning behind prescribing antibiotics to prevent dangerous post-infections is now proved unfounded. Watchful waiting is a far better technique, as these dangerous conditions are easily treated with antibiotics once the symptoms present. Prevention with antibiotics for so few cases (<1 percent) is a poor choice.
Treatment
Conventional pediatricians and the American Academy of Pediatrics are now acknowledging the overprescribing of antibiotics and suggesting an "observation option," which defers antibiotic treatment for 48 to 72 hours. No antibiotics should be prescribed in all children over the age of 2 with nonsevere symptoms. Children between the ages of 6 months and 2 years also should avoid antibiotics with nonsevere symptoms and an uncertain diagnosis.
Placebo-controlled trials show most children get healthy without antibiotic therapy. Within 24 hours, 61 percent of children have decreased symptoms, and 75 percent have complete resolution within seven days. There is no statistically significant difference in symptom relief, clinical resolution, pain duration, suppurative complications or persistent middle-ear effusion when treated with antibiotics or "watchful waiting."³
Symptomatic improvement of irritability, sleeping and eating patterns should be watched as a guide to improvement. Physical exam after treatment should be done to ensure resolution. Middle-ear effusion remains in 60 to 70 percent of children for two weeks and after three months in up to 25 percent of children.³ Lack of tympanic membrane injection and inflammation, and improvement of mood and appetite indicate resolution of the infection, and antimicrobial therapy is no longer necessary. The effusion is a sign of incomplete drainage of the area. Lymph massage, contrast hydrotherapy, lymphagogues, and digital opening of the Eustachian tube are all effective.
Breastfeeding, supine bottle-feeding, reducing pacifier use after six months, and eliminating secondary smoke exposure, dairy and other food sensitivities are ways to prevent recurrent AOM. Overweight children have an increased risk for AOM, due to easier closing of the Eustachian tube from local adipose tissue.⁸
Since most cases of AOM arise from local flora, therapies should focus on opening the Eustachian tube, improving immune-system function and decreasing inflammation. Viral treatment is effective in the form of vitamin A.¹¹ I personally use 25,000 IU TID with meals for three days. However, probiotics do not prevent the occurrence of AOM, since most of the time, endogenous flora, not exogenous organisms proliferate.⁹ A study in JAMA indicated the flu vaccine has no efficacy in reducing AOM.⁷
Relieving pain is also a consideration, especially in infants. Research suggests Allium sativum, Verbascum thaspus, Calendula flores and Hypericum perforatum are effective in relieving otalgia.¹⁴ Homeopathics also were studied compared to antibiotics, decongestants, and antipyretics. Pain duration was less with homeopathics and fewer relapses occurred over the following year. Remedies given were aconite, apis, belladonna, capsicum, chamomilla, kali bic, lachesis, lycopodium, mercurius, okoubaka, pulsatilla and silicae.¹⁵
The majority of AOM cases resolve within a few days. Naturopathic medicine can decrease the duration of the infection by improving the immune system and opening and draining the closed space of the middle ear. Palliative therapies also improve pain, which is especially important with infants and their families. Encouraging fever will resolve the condition faster and put the child on the road to a longer, healthier life.
References

1 Marcy M, Takata G, Chan LS. AHRQ Pub No. 01-E010.
BcCaig LF, Besser RE, Hughes JM. JAMA 2002;287:3096-3102.
Rosenfeld RM, Kay D. Evidence-Based Otitis Media. Decker, 2003.
Van Buchem FL, Peters MF. BMJ, 1985;290.
Klein JO. Clin Infect Dis, 1994;19.
Heikkinen T, Thint M. N Engl J Med, 1999;340.
Hoberman A, Greenberg DP. JAMA, 2003;290.
Kim JB, Park DC, Cha CI. Arch Otolaryngol Head Neck Surg, 2007 Apr;133.
Hatakka K, Blomgren K. Clin Nutr, 2007 Mar 10.
Yokota S, Harimaya A. Microbiol Immunol, 2007;51(2).
Alagag I, Guven M. Int J Pediatr Otorhin, 2007 Apr;71(4).
Legros JM, Hitoto H. Arch Pediatr, 2007, May; 14(5).
Winskel H. Br J Educ Psychol, 2006 Dec;76.
Sarrell EM, Mandelberg A. Arch Pediatr Adolesc Med, 2001 Jul;155(7).
Friese KH, Kruse S. HNO, 1996 Aug;44(8).

About the Author: Dr. Jared M. Skowron is in private practice in Hamden, Conn., where he specializes in pediatrics and successfully treating children on the autistic spectrum. A graduate of NCNM, he is the senior naturopathic physician with Metabolic Maintenance and has formulated a vitamin/mineral/amino supplement therapy for autism, currently undergoing clinical trials. Dr. Skowron also is an adjunct professor at the University of Bridgeport, teaching pediatrics, CPD and EENT.