Earache after swimming? We can help!

Vacationing this weekend, I spent many hours in the water, both in the pool and at the beach.  After my first day I noticed that my ear was hurting a bit, which has prompted this blog entry on swimmer’s ear, or otitis externa.

Swimmer’s ear is an infection of the outer ear, primarily within the external auditory canal or ear canal.  This is a bony and cartilaginous structure which extends from the pinna, or ear you can see on the side of the head, down to the eardrum.  It is separated from the middle ear space by the eardrum. 

Infections in the ear canal are common.  They frequently come after a period of time at the beach, lake or in the pool.  The first presenting signs include pain, fullness in the ear, hearing loss, and drainage.  These infections can be very painful.  Frequently though, these infections do not get attention until they are severe.  Occasionally, over-the-counter ear remedies are tried.  These include medicated pain drops, alcohol, peroxide, and anti-inflammatory pain relievers.  These remedies can exacerbate the pain, particularly if the products contain alcohol. 

With these infections, the ear canal swells and, as a result, debris accumulates.  This makes the environment darker and moister and the infection continues to worsen.  The treatment of choice for otitis externa is ototopical antibiotic drops.  I prefer a drop with a steroid in it to help with the inflammation.  Occasionally, the drops are unable to make it into the ear canal.  This is a problem in that the drops actually have to make it into the ear canal to work.

This is where your otolaryngologist, or ENT, can help your child!  When the ear canal is too swollen to apply the antibiotic drops, sometimes this requires a debridement, or cleaning of the ear canal.  If the ear canal is still too swollen, a wick may be placed to help transfer the drops down the swollen ear canal.  This usually stays in for 3 days and is then removed for the remainder of the duration of antibiotic drop treatment.  If the infection is severe enough, with extension onto the face or into the bone of the ear, oral or possibly intravenous antibiotics may be required.  This is very uncommon. 

Remember swimmer’s ear when your child has ear pain after swimming.  This is common and is usually well treated with ear drops.  Avoid putting cotton swabs in the ears and do not wait too long to seek treatment.   Your ENT can help if routine treatment does not solve the problem.  For more information about this and other ear pathology visit the Children's Ear, Nose and Throat Associates webpage. 

I only use it on the outside…

When I ask parents on their initial visit with me if they use cotton swabs, this is frequently the response I get.  They insist that they only use cotton swabs on the outside of the ear and that they NEVER go into the ear canal.  I have even heard this and ended up pulling several cotton swab heads out of the ears. 

The reason people frequently use cotton swabs is to remove earwax, or cerumen.  Cerumen is normal in the appropriate amount.  It functions to protect the ear canal as a mechanical barrier and an anti-bacterial layer.  Normally, cerumen is worked naturally out of the ear canal with normal movements of the jaw and ear canal.

Occasionally, cerumen gets stuck in the ear canal.  This can cause problems on multiple levels.  The biggest concern is for resulting hearing loss.  A significant cerumen impaction can result in a 30-40 dB hearing loss.  Prolonged cerumen impactions can become severe enough to cause erosion of the ear canal.  A significant cerumen impaction can also allow water to get trapped in the ear canal.  This moist, dark environment is a perfect breeding ground for yeast, mold, and bacteria which can setup a significant infection of the ear canal, or otitis externa.

Cotton swabs frequently facilitate these deeper cerumen impactions as instead of removing the wax, they actually plunge the wax further down the ear canal.  Furthermore, they can cause microtrauma to the skin of the ear canal resulting in small injuries which can more easily become infected.

“But how do I clean my child’s ears?”  This is one of the more common questions I hear in the office.  The truth is, we should not have to do much to clean the ears; they are quite good at cleaning themselves.  Occasionally the cerumen will become too thick or dry to work out of the ear canal.  In these instances, using a drop or 2 of mineral oil in the ear canal once per week can soften the earwax and help get it out of the ear canal.  If this is not enough, your ear, nose and throat doctor can use specialized suctions and instruments to get the cerumen out SAFELY!

“What about over the counter remedies?”  There are numerous things sold over the counter that can be used to clean the ears.  Beyond mineral oil, I would not recommend any of these.  Ear candles, in particular are dangerous, with common injuries including burns and rupture of the eardrum.  In fact the FDA has expressed concerns over these as well.  However, there are no randomized studies of ear candles in the management cerumen impactions.  Other ear drops and remedies are not recommended unless used under the direct supervision of your doctor. 

So remember, nothing smaller than your elbow in your ear.  Cerumen impactions can cause significant issues for your child, so be aware of this as a source of hearing loss, ear pain, and infections. 

You put what...where???

As September approaches, most of our children have returned to school to begin another year of learning and fun.  Younger children tend to have a lot of arts and crafts time and are fascinated with all of the beads, beans, pompoms and foam shapes with which they get to play and craft.  Children, for some reason, also have a fascination with placing these things in their ears and nose.

Frequently, objects in the ear will not be noticed until either the child says they put something in their ear, or until they are being seen by their pediatrician for a well-child or sick visit.  While objects like beads and erasers and so forth don’t interact with the ear much to cause significant inflammation; other items, like vegetable matter (popcorn kernels, beans), can cause a significant amount of inflammation and swelling.  This could result in pain, swelling, and drainage from the ear.  Further problems including ear drum perforation or hearing loss can result. 

Objects in the nose are more often easier to detect.  This is likely secondary to the nature of the lining of the nose being able to produce mucus.  When a foreign body is placed in the nose, there is usually an inflammatory response which results in excessive mucus production and may actually be diagnosed as sinusitis.  Failure to recognize a foreign body in the nose may result in scarring, bleeding, and potentially, if the object is large enough, an injury to the septum, or cartilage in the middle of the nose.

The treatment for a foreign body in the ear or nose seems simple: just take it out.  In reality these can be some of our most challenging cases.  For objects in the ear, particularly ones that can swell, they can enlarge enough to get stuck on the bone of the ear canal and become unable to be removed in their entirety.  For objects in the nose, they can be stuck between the turbinate and the septum and be quite far back and difficult to see.  It is about 3 inches from the tip of the nose to the back of the nose so there is a lot of room for things to hide. 

Your ear, nose and throat doctor can use a variety of tools to help remove these objects.  Frequently, microscopes, endoscopes, specialized suctions and forceps have to be used.  This can require a high level of expertise and experience to be successful and prevent injuries to surrounding structures.  Most of the time, though, we are able to get these objects out in the office without a trip to the operating room.

So, keep a foreign body in mind if your child unexpectedly starts complaining of ear pain or having drainage from just one side of the nose.  Get your child evaluated and visit an ENT specialist to help solve your problem.  Finally, encourage your children to not put things in their ears and noses!

God made dirt…and dirt don’t hurt!

This popular saying has justified how we have encouraged our children to not be afraid to get dirty.  Whether on the little league field sliding for home or scooping out worms to go fishing with grandpa, getting dirty has always been synonymous with growing up. 

While exposures to dirt seem harmless enough, as the evidence frequently washes off with a little soap and water, there can be things lurking in the dirt that can cause problems for your kids.  Atypical, or nontuberculous, mycobacteria are organisms that live in our water and soil.  Younger children are affected most commonly by these organisms, particularly during the teething years.  This is felt to be secondary to the amount of time these children spend with their hands in their mouths.  Unfortunately, the kids aren’t washing their hands before they put their dirty hands in resulting in potential exposures.

The organisms of concern are from the same family of organisms that cause tuberculosis.  Don’t worry!  They do not cause the same type of infection as tuberculosis.   M. avium has replaced M. scrofulaceum as the leading cause of infections in children.  These infections typically cause a swelling of the lymph nodes (glands) in the neck.  The typical course of the infection after exposure is a gradual swelling of the lymph nodes of the neck.  Other systemic features are rare.  In a study from Australia, the incidence of infection was less than 1 in 100,000 children.  The route of transmission is thought to be from a cut or break in the skin or mucosa.

These infections typically progress because they do not cause a lot of systemic symptoms.  There is usually no fever and, until the neck lymph nodes get really large, they are typically not observed.  Some infections present with a discoloration of the skin, and some even present with a wound in the skin with a cottage cheese consistency drainage.

Treatment usually involves multiple components.  If the infection is caught early, antibiotics (clarithromycin/Biaxin) may be enough to treat the infection.  Frequently, though, surgical intervention is needed.  Studies suggest curettage and surgical excision are the 2 primary modes of treatment.  The recurrence rate is high with reports as high as 23%.  In the literature, surgical excision is preferred if possible to remove the node and not injure important surrounding structures.

Keep this in mind if you see swelling of the lymph nodes which doesn’t go away after a cold.  Ask your doctor about the possibility of this, and, if a neck lymph node persists, consider an evaluation by your local pediatric ear, nose, and throat doctor.  We work together with our infectious disease doctors to give you a team approach to the care of your child.

While it is impossible to keep your child’s hands out of their mouth, particularly during teething time, fortunately these infections are rare.  Try to keep their hands clean, but kids will be kids.  

Five little monkeys jumping on the bed...

In the book Five Little Monkeys Jumping on the Bed by Eileen Christelow, the mischievous monkeys carelessly take to jumping on the bed against their doctor’s orders.  While the story is entertaining, and all is well that ends well, when this happens in real life, significant injuries can occur.

Penetrating palate trauma from kids jumping on the bed with an object in their mouth, or even just running around is a common cause for a visit to the emergency department.  While the great majority of these cases result in little more than a laceration or contusion (bruise) to the soft palate, significant problems can arise from such an injury. 

Because of the shape of the palate and the fact it has both a bony (hard palate) and muscular (soft palate) component, objects tend to be directed to the back of the throat.  Here, the soft tissue of the soft palate is easily penetrated by these objects which range from wiffle ball bats to pens and pencils.  Obviously, if the object is sharp, it is likely to penetrate into these structures more deeply.

Fortunately, the lining of the back of the throat includes firm layers of fibrous tissue (fascia) in front of bone (spine) and are infrequently significantly injured.  Unfortunately, penetrating injuries to the soft palate can result in a defect which goes into the nose.  This can, if not treated properly, result in a hole between the 2 cavities (oro-nasal fistula).  This can end up causing a change in voice and reflux of things through the nose when eating and drinking.  Furthermore, it can be very challenging to repair.

More concerning, however, are the structures which lay to the sides of the throat.  Large blood vessels which come from the heart (the carotid arteries) travel right along side the throat.  While they do sit a little deeper in the neck, and, as a result, are infrequently penetrated by the object, the carotid arteries can be bruised by the object resulting in the formation of a blood clot.  This can alter blood flow and potentially travel to the brain and cause a decrease in blood flow or stroke.  While this is very uncommon, with only 32 reported cases through 2006, this injury can be prevented by good supervision of children and early education not to run, jump, or play with objects in their mouths.

The treatment for most injuries involves observation, primarily of the child’s mental status after the injury.  If the wound is far enough away from the midline, your doctor may recommend a CT scan to look at the structure of the arteries.  Surgery is needed only if the laceration is very large, there is a flap of tissue present, a through-and-through injury is suspected into the nose, or there are retained foreign bodies within the wound.  

So while the five little monkeys all ended up at the doctor thanks to quick action by their ‘mama’, everyone survived without significant injury, and fell fast asleep.

Welcome to our blog!

Children's Ear, Nose and Throat Associates (CENTA) is pleased to announce the development of our first blog, highlighting issues in the care of children with disorders of the ear, nose and throat.  The blog will be written by physicians specializing in pediatric otolaryngology (ENT).  We will highlight topics that come up in our practice on a day-to-day basis, as each day provides a learning experience for us.  Our hope is to turn our experiences into education for parents and families and to heighten awareness of issues facing children with regard to the ears, nose or throat.  Please be sure to visit our homepage for more information about our practice.  You can also follow us on Facebook and Twitter. We look forward to sharing our experiences and will be posting to you soon!