• Acute otitis media:
Earache or irritability
History of recent upper respiratory tract infection or allergy
Red, opaque, bulging eardrum with loss of the normal features
Fever and chills
• Chronic or serous otitis media:
Painless hearing loss
Dull, immobile tympanic membrane
An acute ear infection is usually preceded by an upper respiratory infection or allergy. The organisms most commonly cultured from middle ear fluid during acute otitis media include Streptococcus pneumoniae (40–50%), Haemophilus influenzae (30–40%), and Moraxella catarrhalis (10–15%).
Chronic ear infection—also known as serous, secretory, or nonsuppurative otitis media; chronic otitis media with effusion; and “glue ear”—is a constant swelling and fluid accumulation in the middle ear.
Nearly two-thirds of American children have a bout of acute otitis media by two years of age, and chronic otitis media affects two-thirds of children younger than the age of six. Otitis media is the most common diagnosis in children and is the leading cause of all visits to pediatricians. It is the main reason for antibiotic and surgical interventions during childhood. Children diagnosed with otitis media during infancy are also at greater risk for developing allergic eczema and asthma during school age. The more frequent the ear infections, the stronger these associations.1 A conservative estimate is that approximately $4 billion to $8 billion is spent annually on medical and surgical treatment of otitis media in the United States.
Standard Medical Treatment
The standard medical approach to an ear infection in children is antibiotics, pain relievers (acetaminophen or ibuprofen), and/or antihistamines. If the ear infection is long-standing and unresponsive to the drugs, surgery is performed. The surgery involves the placement of a tiny plastic myringotomy tube through the eardrum to assist the normal drainage of fluid into the throat via the eustachian tube. It is not a curative procedure, as children with myringotomy tubes in their ears are in fact more likely to have further problems with otitis media.
Myringotomies are currently performed on nearly 1 million American children each year. It appears that the unnecessary surgery of the past, the tonsillectomy, has been replaced by this new procedure. In fact, there is a direct correlation between the decline of the tonsillectomy and the rise of the myringotomy. More than 2 million myringotomy tubes are inserted into children’s ears each year, and 600,000 tonsillectomies and adenoidectomies are done. These surgeries are unnecessary for most children.
A 1994 evaluation of the appropriateness of myringotomy tubes for children younger than 16 years of age in the United States found that only 42% were judged as being appropriate.2 These results mean that several hundred thousand children are subjected to a procedure that will do them little good and possibly significant harm.
A number of well-designed studies have demonstrated that there were no significant differences in the clinical course of acute otitis media when conventional treatments were compared with a placebo. Specifically, no differences were found between treatment other than antibiotics, ear tubes, ear tubes with antibiotics, and antibiotics alone.3–7 Interestingly, in some studies, children not receiving antibiotics had fewer recurrences than those receiving antibiotics. This reduced recurrence rate is undoubtedly a reflection of the suppressive effects antibiotics have on the immune system, and of the fact that they disturb the normal flora of the upper respiratory tract.8
Since in most children with acute otitis media (70 to 90%) the infection clears up by itself within 7 to 14 days, antibiotics should not routinely be prescribed initially for all children.7 Extensive review of the scientific literature on the value of antibiotics in the treatment of otitis media over the past 30 years has led to the following conclusions:
• The benefit of routine antibiotic use for otitis media, judged by either short-term or long-term outcomes, is unproved.
• Existing research offers no compelling evidence that children with acute otitis media routinely given antibiotics have a shorter duration of symptoms, fewer recurrences, or better long-term outcomes than those who do not receive them.
• Antibiotics did not improve outcome at two months, and no differences in rates of recovery were found for either the type of antibiotic given or the duration of treatment with the antibiotic.
While these results have been accepted by some U.S. pediatricians, others still rely heavily on antibiotics to treat otitis media. Instead of antibiotics, the recommendation from this group of experts was to use pain relievers and have the parent observe the child closely. Results from clinical trials have shown that more than 80% of children with acute otitis media respond to a placebo within 48 hours. Although pain relievers may help relieve the child’s discomfort, they have their own toxicity profile. Therefore, we recommend other proven pain-relieving options such as botanical eardrops (discussed later).
In addition to antibiotics’ lack of effectiveness in otitis media, the widespread use and abuse of antibiotics is becoming increasingly alarming. Risks of antibiotics include allergic reactions, gastric upset, accelerated bacterial resistance, and unfavorable changes in the bacterial flora in the nose and throat. Antibiotics not only fail to eradicate the organisms but can induce middle ear superinfection. Moreover, prescribing antibiotics can increase return office visit rates.9 Additionally, studies on concomitant antibiotic and steroid treatment have revealed a lack of long-term efficacy in chronic otitis media.10
Antibiotics are encouraging the near-epidemic proportion of chronic candidiasis, as well as the development of “superbugs” that are resistant to currently available antibiotics. The American Academy of Otolaryngology—Head and Neck Surgery states that there is no evidence to indicate that systemic antibiotics alone can improve treatment outcome and recommends that they should not be used except when there is an underlying systemic infection.11 According to many experts, as well as the World Health Organization, we are coming dangerously close to arriving at a “postantibiotic era” in which many infectious diseases will once again become almost impossible to treat because of our overreliance on antibiotics.12
The bottom line is that otitis media is normally a self-limiting disease, clearing up on its own, regardless of treatment. Three meta-analyses independently found that approximately 80% of children with acute otitis media had spontaneous relief within 2 to 14 days. Some studies of children younger than two years do suggest a lower spontaneous resolution of about 30% after a few days.9
The risks and failure of antibiotics, when coupled with the high rate of spontaneous resolution and the high rate of recurrent otitis media following insertion of ear tubes, suggest that conservative (nonantibiotic, nonsurgical) treatment alone would reduce the frequency rate and decrease the yearly financial costs of otitis media. To examine this concept, in one study the parents of children with acute otitis media were given a “safety prescription” of antibiotics to be filled only if there was no improvement within two days. This wait-and-see method reduced antibiotic use by 31%.13
Although standard antibiotic and surgical procedures may not be statistically effective, each child must be evaluated individually, and appropriate follow-up including physician-family communication should be planned before a decision not to use these procedures is made. A special need to prevent hearing-loss-induced developmental delays may indicate a more appropriate use of ear tubes.
Finally, pneumococcal and viral vaccines have been designed but have also shown little benefit, probably owing to the multifactorial nature of this condition.9 Given the inherent risks and complications, vaccinations do not appear to be warranted at this time.
Causes
The primary risk factors for otitis media are food allergies, day care attendance, wood-burning stoves, parental smoking (or exposure to other sources of secondhand smoke), and not being breastfed. Besides day care, all of the other factors have something in common: they lead to abnormal eustachian tube function, the underlying cause in virtually all cases of otitis media. The eustachian tube regulates gas pressure in the middle ear, protects the middle ear from nose and throat secretions and bacteria, and clears fluids from the middle ear. Swallowing causes active opening of the eustachian tube due to the action of the surrounding muscles. Infants and small children are particularly susceptible to eustachian tube problems since their tubes are smaller in diameter and more horizontal.
Obstruction of the eustachian tube leads first to fluid buildup and then, if the bacteria present are pathogenic and the immune system is impaired, to bacterial infection. Obstruction results from collapse of the tube (due to weak tissues holding the tube in place, an abnormal opening mechanism, or both), blockage by mucus in response to allergy or irritation, swelling of the mucous membrane, or infection.
Diagnostic Considerations
Recurrent ear infection is strongly associated with early bottle-feeding, while breast-feeding for a minimum of three months has a protective effect.14,15 Whether this is due to cow’s milk allergy or to the protective effect of human milk against infection has not yet been conclusively determined. It is probably a combination.
In addition, bottle-feeding while a child is lying on his or her back (bottle-propping) leads to regurgitation of the bottle’s contents into the middle ear and should be avoided.
Whatever the causative organism in otitis media—viral (respiratory syncytial virus, rhinovirus, or influenza A) or bacterial (S. pneumoniae, M. catarrhalis, or H. influenza)—human milk offers protection because of its high antibody content, which helps to inhibit infectious agents.16 Breastfed infants also have a thymus gland (the major organ of the immune system) roughly 20 times larger than that of formula-fed infants.17
The role of allergies as the major cause of chronic otitis media has been firmly established in the research literature.18–23 Most studies show that 85 to 93% of these children have allergies: 16% to inhalants only, 14% to food only, and 70% to both.
Another way in which prolonged breast-feeding prevents otitis media may be by the avoidance of food allergies, particularly if the mother avoids sensitizing foods (i.e., those to which she is allergic) during pregnancy and lactation. In addition to breastfeeding, also of value is the exclusion or limited consumption of the foods to which children are most commonly allergic—wheat, egg, peanuts, corn, citrus, chocolate, and dairy products—particularly during the first nine months.
Because a child’s digestive tract is quite permeable to food antigens, especially during the first three months, careful control of eating patterns (no frequent repetitions of any food, avoiding the common allergenic foods, and introduction of foods in a controlled manner, one food at a time, while carefully watching for a reaction) will reduce or prevent the development of food allergies.
The allergic reaction causes blockage of the eustachian tube by two mechanisms: inflammatory swelling of the mucous membranes lining the tube and inflammatory swelling of the nose, causing the Toynbee phenomenon (swallowing when both mouth and nose are closed, forcing air and secretions into the middle ear). The middle and inner ear are immunologically responsive, and this responsiveness includes food hypersensitivities.18 In chronic earaches, an allergic cause should always be considered, and the offending allergens determined and avoided.
Food Allergies in Children with Chronic Otitis Media |
||
FOOD |
NUMBER OF PATIENTS |
PERCENTAGE OF PATIENTS |
Cow’s milk |
31 |
38 |
Wheat |
27 |
33 |
Egg white |
20 |
25 |
Peanut |
16 |
20 |
Soy |
14 |
17 |
Corn |
12 |
15 |
Tomato |
4 |
5 |
Chicken |
4 |
5 |
Apple |
3 |
4 |
One illustrative study of 153 children with earaches demonstrated that 93.3% of the children (according to the RAST test for diagnosis) were allergic to foods, inhalants, or both. The 12-month success rate for 119 of the children, when they were treated with serial dilution titration therapy for inhalant sensitivities and an elimination diet for food allergens, showed that 92% improved. This result is significantly higher than that seen in the surgically treated control group (ear tubes and, as indicated, removal of the tonsils and adenoids), which showed only a 52% response.19
In another study, a total of 104 children with recurrent otitis media ranging in age from 18 months to 9 years were evaluated for food allergy by means of skin-prick testing, specific IgE tests, and food challenge.23 Results indicated a statistically significant association between food allergy and recurrent otitis media in 81 of 104 patients (78%). An allergy elimination diet led to a significant improvement of chronic otitis media in 70 of 81 patients (86%) as assessed by detailed clinical evaluation. The challenge diet with the suspected offending food provoked a recurrence of serous otitis media in 66 of 70 patients (94%).
Therapeutic Considerations
The primary treatment goals are to ensure that the eustachian tubes are unobstructed and to promote drainage by identifying and addressing causative factors. Supporting the immune system is also important. The recommendations that follow should be used along with the recommendations given in the chapter “Immune System Support.”
Naturopathic Ear Drops
In acute otitis media, naturopathic botanical ear drops have been shown to be as effective as either antibiotic or anesthetic drops24,25 and offer a much less toxic approach to pain management.
In a double-blind outpatient trial, one group from Israel studied 171 children ages 5 to 18 who were randomly assigned to receive treatment with naturopathic herbal extract ear drops or anesthetic ear drops (amethocaine and phenazone), with or without amoxicillin (a daily dose of 80 mg/kg per day).24 The plant medicine was a combination of Calendula officinalis flowers (marigold, 28%), Hypericum perforatum complete herb (Saint-John’s-wort, 30%), Verbascum thapsus flowers (mullein, 25%), and Allium sativum oil (garlic, 0.05%) in olive oil (10%), Lavendula officinalis (lavender oil, 5%), and tocopherol acetate oil (vitamin E, 2%) and the dose was 5 drops three times per day. All groups had a statistically significant improvement in ear pain over the course of the three days, with a 95.9% reduction of pain in the group treated with naturopathic drops alone. The group treated with naturopathic drops plus antibiotics had a 90.9% pain diminution. The anesthetic drops alone and anesthetic drops with antibiotics had 84.7% and 77.8% reductions, respectively.
Xylitol
Xylitol is a commonly used natural sweetener derived mainly from birch and other hardwood trees. It has demonstrated inhibition of S. pneumoniae. Two double-blind clinical trials illustrated xylitol’s ability to reduce acute otitis media incidence by 40%. In one study of 306 children in day care with recurrent acute otitis media, 157 children were given xylitol (8.4 g per day) chewing gum and 149 children were given a sucrose control gum.26 During the two months, at least one event of acute otitis media was experienced by 20.8% of the children who received sucrose compared with only 12.1% of those receiving xylitol. Significantly fewer antibiotics were prescribed among those receiving xylitol.
In a second randomized and controlled blinded trial,27 857 healthy children were randomly assigned to one of five treatment groups to receive control syrup, xylitol syrup, control chewing gum, xylitol gum, or xylitol lozenges for a period of three months. The daily dose of xylitol varied from 8.4 g (chewing gum) to 10 g (syrup). Although at least one event of otitis media was experienced by 41% of the 165 children who received control syrup, only 29% of the 159 children receiving xylitol syrup were affected. Likewise, the occurrence of otitis decreased by 40% compared with control subjects in the children who received xylitol chewing gum and by 20% in the lozenge group. Thus the occurrence of acute otitis media during the follow-up period was significantly lower in those who received xylitol syrup or gum, and these children required antibiotics less often than did controls.
Humidifiers are popular treatments for otitis media and upper respiratory tract infections in children. This may be justified, according to a 1994 study that evaluated the role of low humidity in this disorder.28 The study examined the effect of low humidity on the middle ear using a rat model. Twenty-three rats were housed for five days in a low-humidity environment (10 to 12% relative humidity), and 23 control rats were housed at 50 to 55% relative humidity. Microscopic ear examinations were graded for otitis media before testing and on test days three and five. The lining of the middle ear and eustachian tube was examined by biopsy. Significantly more effusions (fluid in the eustachian tubes) were observed in the low-humidity group on both day three and day five, but biopsy results were similar in both groups.
QUICK REVIEW
• Since an ear infection can be quite serious, it is necessary that anyone with symptoms of acute ear infection be seen by a physician.
• Ear infections are extremely common in children under the age of six years.
• Acute otitis media is usually preceded by an upper respiratory infection or allergy.
• A number of well-designed studies have demonstrated that there are no significant differences in the clinical course of acute otitis media when conventional treatments were compared with a placebo.
• The primary risk factors for otitis media are food allergies, day care attendance, wood-burning stoves, parental smoking (or exposure to other sources of secondhand smoke), and not being breastfed.
• Recurrent ear infection is strongly associated with early bottle-feeding, while breastfeeding (for a minimum of three months) has a protective effect.
• The role of food allergy as the major cause of chronic otitis media has been firmly established in the medical literature.
• Elimination of food allergens has been shown to produce a dramatic effect in the treatment of chronic otitis media in more than 90% of children in some studies.
• In acute otitis media, naturopathic botanical ear drops have been shown to be as effective as either antibiotic or anesthetic drops.
• Two double-blind clinical trials illustrated xylitol’s ability to reduce acute otitis media incidence by 40%.
This study indicated that low humidity may be a contributing factor in otitis media. Possible explanations are that low humidity may induce nasal swelling and reduce ventilation of the eustachian tube, or that it may dry the eustachian tube lining, possibly leading to an inability to clear fluid, as well as to increased secretions. The mast cells that reside in the lining of the eustachian tube may also come into play by releasing histamine and producing swelling.
Although preliminary, this research indicates that increasing humidity with the use of a humidifier may be helpful in the treatment of otitis media with effusion.
TREATMENT SUMMARY
The key factor in the natural approach to chronic otitis media in children appears to be the recognition and elimination of allergies, particularly food allergies, as well as support for the immune system and healthy digestive function. Because it is usually not possible to determine the exact allergen during acute otitis media, the most common allergic foods should be eliminated from the diet:
• Milk and other dairy products
• Eggs
• Wheat
• Corn
• Oranges
• Peanuts
• Chocolate
The diet should also eliminate concentrated simple carbohydrates (e.g., sugar, honey, dried fruit, concentrated fruit juice) because they inhibit the immune system. These simple dietary recommendations bring relief to most children in a matter of days.
• A high-potency multiple vitamin and mineral formula as described in the chapter “Supplementary Measures”
• Vitamin C: adults, 500 to 1,000 mg three times per day; children, 50 mg for each year of age every two hours
• Zinc: adults, 15 to 30 mg per day; children, 2.5 mg for each year of age per day (up to 30 mg)
• Xylitol: approximately 8 g per day as either chewing gum chewed throughout the day or 10 g syrup per day in divided doses
• Naturopathic ear drop formula: 5 drops in the affected ear three times per day
• If the otitis media is due to an upper respiratory tract infection, follow the recommendations in the chapter “Sinus Infections”
• Local application of heat is often helpful in reducing discomfort. It can be applied as a hot pack, with warm oil (especially mullein oil) dripped into the ear, or by blowing hot air into the ear with the aid of a straw and a hair dryer. These treatments help to reduce pressure in the middle ear and promote fluid drainage.