Category Archives: Ear care

Help For Chronic Ear Infections In Infants

ear infection infantEar infections, a fairly common occurrence in infants, are caused when there is an inflammation of the middle ear which is the cavity behind the ear drum.  When an ear infection does not heal in time or if the infection continues to reoccur (recurring), it is said to have become chronic. Chronic ear infections are called chronic otitis media.

What causes Chronic Ear Infections

The middle ear produces secretions which usually drain out through the eustachian tube to the throat. The eustachian tube is also critical for maintaining airflow through the ear and equalizing air pressure, which is essential for balance. When the fluids don’t drain properly, the bacteria present in the fluid gives rise to an infection.

Children are more likely to suffer from ear infections because the tubes are smaller and at a similar horizontal level hampering drainage, most often when the tubes are swollen or blocked with mucus from other illnesses like the flu. The ear infections typically occur with regularity in children under the age of 3 years.

Treatment of Chronic Ear Infections In Children

Doctors today usually have a wait-and-watch approach towards ear infections in infants with symptomatic relief since the infection often clears up on its own. When this condition continues, specific treatment for the infection needs to be undertaken.

For treating chronic infections, the doctor may prescribe a course of antibiotics.  When the infection fails to responds to the antibiotics, fluid builds up in the middle ear remains for longer time or hearing loss begins , a minor surgical procedure  (Myringotomy)is advised.

Myringotomy the surgery is especially recommended for infants since having persistent fluid in the ear might impact their hearing and speech development.

Under this surgery, a small ventilation tube or grommet, made of metal, plastic or Teflon, is placed in the eardrum to help drain the fluid. The tube releases pressure and acts as a vent until the eustachian tube returns to normal functioning.

Myringotomy is simple, low risk and takes less than half an hour. The surgeon makes a small incision in the eardrum, drains the liquid and then places tiny tube connecting the middle ear and the outer ear. The surgery is usually done in both ears and is called bilateral myringotomy.

The surgery significantly reduces the pain, the severity of symptoms experienced, and over time reduces the infection and its reoccurrence. Any loss in hearing is often restored. The tubes, which are invisible, stay for six to nine months and usually fall out by themselves.  At times, the infection reappears in which case the procedure would need to be repeated.

If left untreated for long, chronic ear infection may, in addition to causing hearing loss, also affect other areas of the ear such as the small bones in the middle ear or the eardrum itself. Surgical procedures are also needed in these cases to repair them.

Hyperacusis: Intolerance to sound

Hyperacusis is a condition characterized by over-sensitivity to everyday environmental sounds which may be unpleasant or painful to the ear as a result of damage sustained to the Auditory system. Hyperacusis can be due to damage to the brain or the neurological system, In these cases, there is processing problem specific to how the brain perceives sound. .

Individuals with hyperacusis have difficulty tolerating normal sounds which are not loud to others such as sound from running water in the kitchen sink, ringing phones, shutting doors, shuffling paper, placing dishes on table, TV sound etc.

40% of patients with tinnitus complain of mild Hyperacusis and around 86% of Hyperacusis sufferers have tinnitus.

Tinnitus is the perception of sound within the human ear such as ringing sensation, when no external sound is present.

Hearing Loss with low tolerance to sound is different term known as recruitment, In Hyperacusis usually hearing is normal.

Hyperacusis may be caused by overexposure to excessively high loudness levels, head injury, stress, and genetic differences or by abnormal responses in the ear muscles, which protects the ear from loud sounds. Other causes may include adverse reactions to medicine or surgeries, chronic ear infections, autoimmune disorders, migraine and some forms of epilepsy.

In cochlear Hyperacusis, the symptoms are ear pain, annoyance and general intolerance to everyday sounds.

In some conditions, wherein the vestibular system is involved is called as Vestibular Hyperacusis. In this condition, the sufferer may experience feelings of dizziness, nausea or a loss of balance when sounds of certain pitches are present at certain level.

AnxietyStress and Phonophobia (fear of loud sounds) may be present in Hyperacusis. Sufferer may result in developing avoidant behavior in order to avoid a stressful sound situation or to avoid embarrassing themselves in a social situation which involves noise. This might lead the sufferer stay away from the society.

Understanding the mechanism of Hyperacusis is often challenging. People who develop Hyperacusis should have a thorough Evaluation by otorhinolaryngologist (Ear, Nose and Throat doctor) and a detail Audiological evaluation to determine the state of the Auditory- Vestibular system.

Although a corrective medical or surgical approach for treating Hyperacusis is not available at this time, there are therapies that can help sufferer to reduce fears and anxieties towards sensitivity of sounds under guidance of an ENT Specialist and supervision by a Clinical Audiologist.

Antidepressant medicines and treating migraine may help.

Retraining Therapy

Retraining therapy consists of counseling and acoustic therapy. The aim is to reduce the patient’s reactions to Hyperacusis. Counseling is designed to help a patient better cope, while acoustic therapy is used to decrease a patient’s sensitivity to sounds and to teach them to view the sound in a positive manner.

Sound Generators

This treatment approach uses the sound of music or broadband noise or music produced via a body-worn system or a small device that looks like a hearing aid, which produces steady and gentle sounds. The theory is that, by listening to a sound at a low level for a certain amount of time each day, the auditory nerves and brain centers will become desensitized and able to tolerate normal environmental sounds again.

Constant use of earplugs/ earmuffs is not recommended because constant or frequent blocking of the ears may further alter the brain’s calibration of loudness which may lead the brain to further restrict its comfort range for sounds.

What to do in hyperacusis ?

1 .Avoid exposure to loud noise

  1. Avoid caffeine, chocolate, smoking , alcohol, MSG
  2. Avoid ototoxic medicines (medicines that might damage ear) such as aspirin, quinine)
  3. Daily exercise
  4. Adequate rest
  5. ENT & Audiological evaluation

Read more about Hyperacusis  http://www.tinnitus.org.uk/hyperacusis

What causes Ear Pain – How to get relief?

Edited my old blog post  ear pain

Earache (or Ear pain) in adult and children is one of the most common reasons for visiting ENT specialist and common reason my clinic gets calls on the helpline during Sundays, nights and other emergencies.  

The most common cause of ear pain is swelling or infection within the ear itself and diagnosis is simple. However, sometimes the cause is not in the ear, but in remote areas, known as referred earache. Therefore, finding out the cause of referred ear ache is real challenge and requires thorough examination by ENT doctor.

ear-pain treatment by ENT

 Causes of Ear Pain-

Common causes of earache are Outer ear infection (otitis externa), Middle ear Infection (acute otitis media), eustachian tube blockage and impacted wax.  

  1. Causes of ear pain within the ear
  •  Outer Ear and Ear-canal– Outer ear canal infection (Otitis externa), impacted wax, boil, Herpes Zoster
  • Middle ear– Infection (Acute otitis media), Eustachian tube blockage, Glue ear, travel by flight
2. Causes of ear pain outside the ear (Referred Earache)– 
  • Carious tooth, impacted wisdom tooth
  • TMJ (Jaw joint) disorder
  • Oral cavity and tongue-ulcers
  • Mumps/ Parotitis
  • Base of tongue- ulcer, tumor
  • Sore throat (Pharyngitis), tonsillitis, after tonsillectomy surgery
  • Elongated styloid process stretching nerve

  Common reasons and treatment of Ear Pain:

External ear infection (Otitis Externa)– Moisture may be trapped inside the canal while bathing or injury may occur in the skin of the ear canal while using ear buds to clean the ear. Consequently outer ear and ear canal infection develops.  Further, it may lead to fungal infection of the skin of outer ear.

Ear pain of otitis externa worsens on touching the ear and there may be swelling of the ear and blocked ear feeling.

Treatment Outer ear infection is treated with combination antibiotic and steroid ear drops for 7-10 days.

If ear swelling is severe a wick/ear dressing soaked with ear drops or ointment is placed in the canal. Oral antibiotics and analgesics are prescribed.

Furthermore if pus accumulates, incision and drainage may be required.

Impacted wax and foreign bodies–  Ear wax is not a disease rather it makes a protective layer in the ear canal. It may be a reason of ear pain; also attempts to clean the wax at home may hurt the skin, as a result ear infection develops.

Removal of Impacted ear wax causing obstruction and ear foreign bodies is done by an ENT Specialist by instruments or syringing.

If wax is hard then wax-softening ear drops may be prescribed for 5-7 days and ear cleaning is done after wax becomes soft.

Eustachian-tube block and glue ear Eustachian tube connects the middle ear with the nasopharynx. It helps with ventilation of the middle ear and drainage of fluid from the middle ear.

Cold, allergy, sinusitis, adenoids or sore throat may cause blockage of the tube therefore resulting in ear pain.

Tube blockage creates negative pressure in the middle ear, which in turn leads to fluid accumulation in the middle ear (Glue ear). Subsequently, increasing pressure in the middle ear may cause pain in the ear.

Treatment of Eustachian tube blockage is oral decongestants and nasal drops. Antibiotics may be given for glue ear.

If the fluid persists for more than 3 months, then a tiny tube (Grommet) may be placed into ear drum.

Otitis media– Otitis media is infection of middle ear which often spreads from cold, flu, sore throat or allergy.  

Treatment -Visit to an ENT clinic is required for proper diagnosis and suitable antibiotics prescription by an ENT doctor. Additionally pain killer, oral or nasal decongestants and antibiotic ear drops may be advised.

  Home remedies for ear pain-

  •  You can apply a cold pack or warm compresses to the ear to reduce pain.
  • Some safe over the counter pain-relievers can be used to ease the ear pain.
  • Do not use ear buds/q tips to clean the ear.
  •  Avoid putting oil, water or any other thing in the ear

Earache may be because of a myriad of reasons. Most common causes are impacted, wax, minor injury while ear cleaning, Eustachian tube blockage and ear infection due to cold.

If Ear pain is severe, continuous or associated with hearing problem, dizziness, headache, fever or is simply unexplainable you should visit your ENT specialist for timely treatment.

What to do if you have piercing /shooting ear Pain?  —Contact ENT clinic, Vashi, Navi Mumbai

 

Holi , Ear care & Ruptured Ear Drum:

Holi , Ear care & Ruptured Ear Drum:

 While playing Holi people often neglect their Ear. Chemical colours and water may enter inside the ear resulting in ear itching, irritation, ear blockade and ear pain.  Water filled balloons can be dangerous and if hits the ear could cause ruptured ear drum.

 Ruptured Ear Drum:

A ruptured ear drum or perforated Tympanic membrane is a tear or hole in ear drum- a thin membrane which separates ear canal from middle ear.

Ear drum has two roles:

Hearing- Transmission of sound from ear canal to middle ear

Protection- Covers & protects delicate structures of middle and inner ear

 A ruptured eardrum can cause hearing loss, ear pain, or ear infections.

A ruptured eardrum usually heals within a few weeks without treatment. Sometimes, however, a procedure or surgical repair is required.

Symptoms of ruptured ear drum:

Symptoms of a ruptured eardrum may include:

  • Ear pain
  • Drainage from your ear, may be boody
  • Hearing loss
  • Ringing in ear (tinnitus)
  • Air escapes out of the ear on blowing of the nose producing whistling sound
  • Spinning sensation

Diagnosis of ruptured tympanic membrane:

Video Otoscopy by ENT Specialist:

Tear in the ear drum, irregular in shape, and surrounded by blood clots.

Hearing tests:

Tuning fork tests and PT Audiometry may show conductive hearing loss.

 Complications:

  • Ear Infections Otitis media
  • Permanent drum perforation
  • Middle ear Ossicle dislocation
  • Cholestaetoma  (read more)

 Other Causes Of ruptured ear drum:

1.Indirect trauma: Due to rapid pressure changes:

  • A blow on the ear (commonest)
  • Otitic barotrauma
  • Blast injury (explosion)
  • Jumping in swimming pool
  • Forcible nose blowing

2. Direct trauma:

  • Foreign body in ear
  • Self-inflicted e.g. by a hairpin
  • Ear wash or instrumentation
  • Head injury, Fracture of temporal bone

 Treatment of Ruptured Ear drum:

Conservative treatment:

Most of the traumatic perforation of tympanic membrane heals spontaneously within a month. Early surgery is not indicated and waiting for three month should be allowed for healing. However close follow up visit to ENT doctor and repeat Audiometry is required to check any urgency of operation.

 Treatment and precautions includes:

  • Prophylactic antibiotic therapy
  • Decongestant nasal drops
  • Avoid ear contamination.
  • Do not wash the ear.
  • Do not use ear drops.
  • Do not blow the nose forcibly.

Eardrum patch:

If the hole in  the eardrum doesn’t close on its own, a patch can be used to seal it. It is an OPd/office procedure, an ENT specialists apply chemical to the edges of the tear to stimulate growth and then apply a patch over the hole. The procedure may need to be repeated more than once before the hole close

Surgical treatment:

Surgery is recommended –

If Perforation fails to heal after three months, there is no healing by a patch or hole is not likely to heal with a patch,

If there is disruption of the ossicular chain, or  if injuries affecting the inner ear ssurgery can be recommended earlier.

Myringoplasty or tympanoplasty is repair of tympanic membrane perforation by a graft taken from patient own tissue.

Noise Induced Hearing Loss

A teenage girl visited ENT clinic with her mother with ringing in the ear and felt like cotton in the ear. Previous night,  Diwali Night she had spent several hours setting off the fire crackers.

Her ear were normal on video otoscopy and Audiogram showed  35 db at 4000 and 8000 hertz, Several days later, her hearing had returned to normal.

This patient is an example of a “temporary threshold shift.” Or Reversible Hearing Loss by exposure to an intense “impulse” sound such as fireworks or loud rock concert.

If sound is too loud or duration of exposure is long enough, such as noise generated in a woodworking shop it may lead to permanent threshold shift.  This condition is called Noise Induced Hearing Loss which has no cure.

Acoustic trauma occurs when excessive sound energy strikes inner ear. When we are exposed sounds that are too loud or loud sounds that last a long time—small sensitive structures in our inner ear, called hair cells, can be damaged, Hair cells convert sound energy into electrical signals that travel to the brain. The louder the sound, the shorter the time period before NIHL can occur.

Sound is measured in units called decibels. Continual exposure to more than 85 decibels (dB) is dangerous to the ears. Firecrackers emit sounds from 120 to 160 decibels. Sound with 140dB can cause ear ache. A very high intensity sound (above 160 dB) may also damage the ear drum and can cause dislocation of middle ear ossicles.

An even higher intensity may cause leakage of inner ear fluid leading to permanent hearing loss associated with dizziness.

Symptoms

  • Hearing loss
  • Sense of fullness  the ear
  • Noises, ringing in the ear
  • Earache
  • Bleeding from the are
  • Dizziness,

Signs and tests

Acoustic trauma is suspected if hearing loss occurs after noise exposure. Audiometry may determine how much hearing has been lost. Audiogram has typical “notch” at 4000 hz, with better hearing at both lower and higher frequencies. Otoacoustic Emisson (OAE) testing is very sensitive to noise induced hearing loss.

Treatment

The hearing loss may not be treatable. The goal of treatment is to protect the ear from further damage. Hearing aid is prescribed for communication needs. If ear Drum is ruptured, surgery to repair ear drum may be needed.

Ear protection using noise protector ear plugs or ear muffs may prevent the hearing loss from getting worse.

Noise exposure, whether occupational or recreational, is the leading preventable cause of hearing loss. It can be prevented by avoiding “too loud” or “too long” Noise exposure and use of hearing protection when necessary.

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It’s a Noisy Planet. Protect Their Hearing campaign, a program of the National Institute on Deafness and Other Communication Disorders (NIDCD).
NIDCD

Proper Way Of Using Ear Drops

Sometimes in our opd we keep patients aside and talk about ear drops (we means ENT specialist and Patients relatives ) and this talk is very frequent next only to how to clean our ear).

People having minor itching in the ear to the people hearing less- everybody want to quick fix the things with magical ear drop. If I mildly, jokingly or sometimes with force refuse the request to write the ear drops for relatives there is always a helping chemist to amuse them with the one perfect for the need.

So there are things which really don’t need an ear drops but at times it is absolutely necessary to talk about ear drops not to just prescribe the one.

Almost every one will agree that to be effective medicine should reach to the site of infection, so ear drops must also be delivered to the site of infection which is external ear canal in case of otitis externa & wax and middle ear in case of otitis media. Almost all cases of ototopical therapy failure are due to inadequate drug delivery.

Topical drug delivery can be improved in a number of ways–

Steps followed by the ENT professionals-

Hands should be cleaned with disinfectant.

Careful cleaning of ear (aural toilet) is prerequisite. The external auditory canal should be mopped dry prior to instillation of ear drops.

If too much of thick secretion is present irrigation of the external auditory canal with a small bulb syringe can be done before instillation of ear drop.

In case of refractory acute otitis media with tympanostomy tube fenestrated otowicks may be used to allow drainage and ventilation of the middle ear. Ear wicks of ribbon gauze may also be used in case of otitis externa.

In cases of failure to respond to drug health care provider should always keep in mind the possibility of diabetes, mastoiditis, cholesteatoma or MRSA ( methcillin resistant ) or immunocompromized status.

Steps to be explained to the patients

1. Wash hands with soap and water.

2. Clean outer part of the ear very gently ( do not use cotton buds inside the canal)

3. Shake the bottle well for 10 seconds to thoroughly mix

4. The patient should preferably be lying down with the affected ear up

5. Ear should be gently pulled backward and upward to straighten the canal to provide a linear path into middle ear (child younger than 3 years of age, pull backward )

6. Instill the number of drops in the ear as recommended.

7. Shake the ear and by one finger repeatedly press and release the tragus (small elevated part in front of the ear) to help better delivery of ear drops.

8. Keep the treated ear in the upright position for an average of 5-10 minutes (the longer, the better) after ear drops are instilled.

One thing I never fail to warn my patient with ear wax not to try to clean the wax by themselves after putting the drops however tempting it may be as wax may be further pushed inside and become impacted.

In case you experience pain or giddiness following an use of ear drop report to your doctor.

Winter Worries of Mother-Crying Child with ?Ear Infection (When To Use Antibiotic?)

With onset of winter season ENT clinic are flooded with children with ear pain, because upper respiratory infections and ear infections in children are most common with colder temperature during the winter months. An anxious Mother of 3 year-old boy with fever says he has cold and his ear hurts, she than inquires with concern does he need an antibiotic?

To decide we need to make a diagnosis first…


Otitis media is the second most common reason after the common cold for visits to doctor and the most frequent reason for prescribing antibiotics to children. About 90% of children have OME (Otitis Media with effusion) at some time before school age and 75% of children have at least one episode of AOM (Acute Otitis Media) by the age of 2 years which usually resolves spontaneously
Appropriate treatment of children with “ear infection” requires distinguishing AOM from OME by careful history and pneumatic otoscopic examination (single most important tool).
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To understand the definitions- What is AOM and OME?

Acute otitis media AOM – an acute bacterial infection of the middle ear of less than 6 weeks duration

There is usually pain in the ear and fever. If ear drum ruptures there may be pus discharge (Otorrohea) from the ear with rapid relief of pain. Pus may be mixed with blood.

Chronic suppurative otitis media (CSOM) – If ear drum infection persists for more than 3 months and is associated with a chronic perforation of the tympanic membrane.

Otitis media with effusion (OME) – Fluid in the middle ear without signs or symptoms of inflammation

It can occur just prior to AOM or persist after AOM for a few days or up to many weeks.

How we decide about giving antibiotic?

Age and severity of symptoms are deciding factors but most important is correct diagnosis.

  • If it is OME antibiotics are unnecessary.
  • Uncomplicated AOM in an otherwise healthy child above 2 years of age where we are assured that parents will be coming for follow up visit can be considered for observation without use of antibiotic.
  • If child is less than 6 months of age antibiotics are to be given even if diagnosis is not certain. (Contrary to parent’s belief that small kid should not be given antibiotics).
  • Most controversies exists in treating child above 6 months but less than 2 years of age where current guidelines by the AAP (American Academy of Pediatrics) and AAFP (American Academy of Family Physicians) advises to avoid antibiotic for uncertain diagnosis or if illness is mild.

So How Do We Diagnose Ear Infection?

Distinguishing OME (Otitis Media with Effusion) and AOM (Acute Otitis Media)

OME is usually caused when the eustachian tube is blocked or mucus production is more and fluid becomes trapped in the middle ear. This often occurs after a common cold or viral infection, but it can also occur after an episode of AOM.

It is common in a child because eustachian tubes are shorter and more horizontal as compare to adults and muscles to close the tube are not properly developed in children.

Symptoms – The child with OME does not have ear pain or draining ear. He may have slight hearing impairment. There may be history of frequent URTI & mouth breathing.

Examination of Ear by Pneumatic otoscope– Single most important diagnostic tool –

  • Tympanic membrane may be dull looking, Pulled in (retracted) and immobile.
  • Ear drum is not red or bulging as it is in AOM.
  • Air Fluid level seen as bubbles

Tympanometry can be advised to confirm the diagnosis of OME

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AOM occurs when fluid in the middle ear becomes infected, usually following a common cold or viral upper respiratory infection.

Symptoms – Child usually have fever and sudden ear pain after a common cold or stuffy nose. Infant may be irritable with pulling of ear. If tympanic membrane gets ruptured liquid may be coming out from ear (Otorrhoea/ear discharge).

Examination of ear–  symptoms alone are not enough to diagnose AOM and examination of ear drum with otoscope to see the signs of inflammation (redness or erythema) and pneumatic otoscopy to conform the fluid in the middle ear is necessary. (Opacification & Bulging of ear drum with reduced mobility)

If tympanic membrane is ruptured Ear discharge may be present, and hole (Perforation) in the ear drum may be seen

Audiogram may show mild to moderate conductive hearing impairment.

Tympanogram may show type “B” curve

How to treat AOM and OME?

Management of children with OME

  • Aim is resolution of fluid, restoration of ear drum mobility and restoration of hearing
  • As OME usually resolves without treatment for 3 months it is just wait and watch.
  • Antihistamines and decongestants are not effective and antibiotics are not recommended for routine management.
  • Steroids with beta lactame antibiotics are proven to be beneficial in few studies and and no benefit in others.
  • Children with persistent effusion reexamined at 3-6 months interval till it resolve.
  • Hearing testing is done if OME persists for more than 3 months or if Child is at risk of speech or language delay.
  • If the effusion persists for more than 3 months and/or hearing loss exceeds 20 dB surgery Tympanostomy tube (Grommet) insertion is done.
  • Adenoidectomy is done if indication for surgery is present.

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Management of Children with acute otitis media

Aim is to relieve pain and fever, to treat infection and restore hearing along with prevention of recurrence.

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) clinical practice guideline for OME emphasizes the management of pain as a major management goal.

  • Analgesics are usually prescribed to provide relief from pain; acetaminophen and ibuprofen are commonly given medicines.
  • Uncomplicated AOM in an otherwise healthy child above 2 years of age or very mild infection in children below 2 yrs but more than 6 months of age where we are assured that parents will be coming for follow up visit can be considered for observation without use of antibiotic or amoxicillin can be used.
  • If there is no response within 2-3 days antibiotic is to be started or antibiotic is changed.
  • Ear drops (Ototopical formulations) antibiotic with or without steroid are prescribed if ear drum is ruptured as steroid reduces inflammation and antibiotic improves infection eradication.
  • Tympanic membrane perforation in children usually heals spontaneously in 1-2 months. During this time child should come for periodic follow to visits to assess the healing process, water entry in the ears should be avoided and all possible preventive measure to reduce chances of catching common cold are to be taken.

Role of Surgery in brief

Surgical management of otitis media is indicated for recurrent AOM, AOM with complications, chronic suppurative otitis media (CSOM) and otitis media with effusion where chances of hearing and speech problem are predicted

Most common surgical procedure is placement of tympanostomy tubes (Grommets).

Tympanostomy tubes allow drainage of fluid in the middle ear and ventilaton of middle earspace. Grommets usually fall out of the tympanic membrane within 6-14 months.

Coming Back to original question

It is important to distinguish between the presence of middle ear fluid (OME) and the presence of middle ear fluid with infection (AOM) by pneumatic otoscopy. If wax is obscuring the view of ear drum it has to be removed.

OME does not benefit from antibiotic therapy; child should be carefully monitored for recurrent AOM and hearing loss, which, if chronic, can impair speech and language development. AOM, if it does not resolve spontaneously, can result in serious complications, and benefits from antibiotic therapy.

So with utmost patience and gentleness we examine the crying 3 year old of worried parents and find that ear drum is red and bulging, our diagnosis is AOM.

So again the question of mother – Is Antibiotic Required?

We reassess the situation, explain the risk and benefit of antibiotic and we feel parents are anxious but motivated to come for follow up visit after 2 days, we give symptomatic treatment and avoid antibiotic.

Child of more than 2 years age observation without use of antibiotics is an option for treatment of acute otitis media but children must be followed carefully and antibiotics should be prescribed if spontaneous resolution does not occur.

Child if less than 2 years but more than 6 months of age and diagnosis of AOM is certain I usually prefer to give appropriate antibiotics in proper dose after explaining to parents as usually child has already waited or took treatment with family doctor or pediatrician with pain medicines and because there is chance of ear drum rupture unless parents are concerned about use of antibiotics or it is first day of onset of symptom which are mild. We keep a strict watch and wait in these children with assurance of prompt visit in case of worsening symptoms, fever, or drainage from the ear.


Special consideration

Antibiotics should be prescribed if child is —

  • Less than 6 month of age
  • Cleft palate
  • Downs syndrome
  • Immunodeficiency
  • Cochlear implant


Summary

Most of the parents usually scared of the word ‘antibiotic’. Antibiotic does have side effects like loose stools or stomach upset but most feared side effect is development of resistance means antibiotic becomes ineffective to kill the bacteria.  Thus when there is nothing to fix it should not be fixed but parents should be given time in busy opd hours and explained to understand what doesn’t need to be done and why?

During the winter months, viral upper respiratory infection is the most common cause of Eustachian tube dysfunction and ear infection in children. Adenoids may also cause obstruction.

Though this winter is prolonged and there are more number of children with ear infection but in general awareness about preventive measures and vaccination against influenza and pneumococcus have decreased the incidence of winter AOM.

According to current guidelines by the AAP (American Academy of Pediatrics) and AAFP (American Academy of Family Physicians for use of antibiotics –

“Otitis Media with effusion does not require antibiotics and Acute Otitis Media does not always require antibiotics“.

Home Care for Benign Paroxysmal Positional Vertigo

You can read my older post about Benign Paroxysmal Positional Vertigo (B.P.P.V.)

Important–If diagnosis of BPPV is established Epley maneuver is first line of treatment.

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Benign Paroxysmal Positional Vertigo and other non specific peripheral vestibular disorders where etiology is unknown can be managed by following protocol

  • Reassurance (Wait and watch) with home care
  • Vestibular Rehabilitation Exercises (physical therapy)
  • Medicines (pharmacotherapy)
  • Surgery

Reassurance and Home care Benign Paroxysmal Positional Vertigo

Peron with acute vertigo is anxious and afraid of stroke or tumor.  Most of the patients develop emotional reaction to vertigo which may result in aggravation of the symptoms. These patients need strong reassurance.

As BPPV is not intrinsically life threatening and symptoms usually reduce in a week’s time and disappear in about 4-6 weeks thus patient should be explained about the benign and self limiting nature of the disorder.

Nature has marvelous capacity for compensation of imbalance which can be accelerated by certain exercises.

Self Home care while waiting for nature’s compensation of imbalance

  • Take proper bed rest
  • Avoid sudden jerky head movements and body position changes.
  • Avoid sleeping on the “bad” side.
  • Get up slowly and sit on the bed for a minute before getting out of the bed.
  • Avoid bending down and extending the head
  • Avoid driving, working at heights or with machinery during acute attack of vertigo.
  • Cawthorne Cooksey exercises (see details below)
  • Positional exercises of Brandt and Daroff (see details below)
  • Home Epley Maneuver (See detail below)

Cawthorne Cooksey exercises

Positional exercises of Brandt and Daroff

    1. Sit on the edge of the bed near the middle, with legs hanging down. (position 1)
    2. Turn head 45° to right side.
    3. Quickly lie down on left side, with head still turned (angled upwards), and touch the bed with portion of the head behind the ear. (Position 2)
    4. Maintain this position and every subsequent position for about 30 seconds or till the dizziness disappears.
    5. Sit up again. (Position 3) stay for 30 seconds
    6. Quickly lie down to right side after turning head 45° toward the left side. (Position 4)
    7. Sit up again.
    8. Do 6-10 repetitions, 3 times per day for 2 weeks

The Brandt-Daroff Exercises are a home method of treating BPPV, usually used when the side of BPPV is unclear. They succeed in 95% of cases but may take longer than the other maneuvers. In approximately 30 percent of patients, BPPV will recur within one year.

Caution–When performing the Brandt-Daroff maneuver, person should immediately visit his physician if he feels weakness, numbness or visual changes.

HOME EPLEY MANEUVER Home Epley Left

The Epley and/or Semont maneuvers as described in my previous post can be done at home every night for a week.

The method (for the left side) is performed as shown on the figure. One stays in each of the lying down positions for 30 seconds, and in the sitting upright position (top) for 1 minute. Thus, once cycle takes 2 1/2 minutes. Typically 3 cycles are performed.

Caution Before doing home Epley maneuver diagnosis of BPPV should be confirmed, and one should know the affected or “bad” side. It is safer to have the first Epley performed in a doctor’s clinic which can be followed at home.

Spinning world: Benign Paroxysmal Positional Vertigo

Dizziness, a common cause of referral to otolaryngology clinic, includes a broad range of sensations from severe vertigo to momentary light-headedness , and Vertigo most common of dizziness  is an illusion of movement of the body or environment.

Vertigo may be because of otologic, neurologic, or systemic reasons.

Causes of Otologic dizziness

  • Benign paroxysmal positional vertigo) – about 50% of otologic, 20% all
  • Meniere’s disease – about 20%
  • Vestibular neuritis and related conditions (15%)
  • Bilateral vestibular loss (about 1%)
  • SCD and Fistula (rare)

What is Benign Paroxysmal Positional Vertigo?

Benign paroxysmal positional vertigo (BPPV) is the most common underlying cause of vertigo accounting for about 20% of all dizziness and 50% of otologic dizziness.

Benign paroxysmal positional vertigo is defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo.

Positional vertigo means a spinning sensation produced by changes in head position relative to gravity.
Benign means not due to any serious brain or CNS (Central Nervous System)disorder  and the overall prognosis for recovery is favorable. (However, undiagnosed and untreated BPPV may have health, and quality-of-life impacts).
Paroxysmal—  means Rapid and sudden onset of the vertigo

Symptoms of BPPV-

Dizziness, Imbalance, Nausea, light-headedness

That is

  • Brief and strong
  • Provoked by change of head position
  • Definitively diagnosed by Hallpike test
  • Many patients wake up with the condition, noticing the vertigo while trying to sit up suddenly.
  • People do not usually feel dizzy all the time. Dizziness attacks triggered by head movements (classically with lying down or rolling over in bed) and between episodes patients usually have few or no symptoms.
  • Classic BPPV is usually triggered by the sudden action of moving from the erect position to the supine position while angling the head 45° toward the side of the affected ear.

The pathophysiology of BPPV –

Normal Ear Anatomy

The labyrinth of the inner ear is composed of the vestibule (utricle and saccule) and the 3 semicircular canals. These are filled with fluid called endolymph and have receptors to inform the brain about the head’s position in space.

Inner Ear

Utricle contains small calcium oxalate crystals called otoliths or otoconia for gravity and position receptors for linear acceleration.

Similarly, angular acceleration receptors are located in the cupula of the semicircular canals. When head turns, these receptors inform the brain via vestibular nerve that the head is turning. Once the head stops turning, the endolymph stops moving, the receptors stop firing, and the brain now knows that the head has stopped turning.

Inner ear semicircular canals-BPPV

In BPPV, the otoliths become dislodged from normal position and accumulate in wrong place in one of the semicircular canals (most commonly in the posterior semicircular canal since it is at the most dependent position)

When the patient turns his head, otoliths move, and trigger faulty signals even after head stops moving. The eyes, however, inform the brain that the head has stopped moving. Brain Receives conflicting information causing brief but intense sense of spinning.

Diagnosis of BPPV—

Comprehensive History is most important aspect. Patient describes his complaints in his own words and a specific set of leading questions specially onset of symptoms, duration, associated eye,  ear and neurologic systems, history of any ear/head trauma, medical disease or medication  are asked by health care provider. While talking to patient usually a diagnosis is established.

Basic ENT and Ear examination is done for concomitant ear problem.

Neurological examination to rule out any CNS lesion is carried out.

Neurotologic examination Evaluation of static disturbances (with head still) and dynamic disturbances (with head motion)

Dix-Hallpike maneuver– Standard clinical test for BPPV


This test is performed by rapidly moving the patient from a sitting position to the supine position with the head turned 45° to the right. After waiting approximately 20-30 seconds, the patient is returned to the sitting position. If no nystagmus is observed, the procedure is then repeated on the left side.

The finding of classic rotatory nystagmus with latency and limited duration is considered pathognomonic. A negative test result is meaningless.

Classic BPPV is the most common variety of BPPV. It involves the posterior Semi Circular Canals.

Diagnostic criteria for posterior canal BPPV
  • History – Patient reports repeated episodes of vertigo with changes in head position.
  • Physical examination each of the following criteria are fulfilled:–
  • Vertigo associated with nystagmus is provoked by the Dix-Hallpike test. There is a latency period between the completion of the Dix-Hallpike test and the onset of vertigo and Nystagmus, Geotropic (means towards earth-refer to upper half of the eyes nystagmus with the problem ear down
  • The provoked vertigo and nystagmus increase and then resolve within a time period of 60 seconds from onset of nystagmus.
  • Reversal upon return to upright position
  • Response decline upon repetitive provocation
Nystagmus is involuntary eye movements (usually triggered by inner ear stimulation) named by the direction of the fast phase. Thus, nystagmus may be horizontal (right beating, left beating, up-beating), vertical (down-beating), or rotational (geotropic-towards earth and ageotropic).


Workup for BPPV

Laboratory Studies

  • Laboratory tests are not needed to make the diagnosis of benign paroxysmal positional vertigo (BPPV).
  • Tests may be advised for other associated inner ear pathology.
  • Blood sugar and routine complete blood count may be done to rule out hypoglycemia and anemia.
  • Electrolyte level may be done if patient had severe episodes of vomiting

Imaging Studies

Imaging studies (CT scan and MRI) are not routinely required for patient with BPPV. In cases of doubt it may be advised.

Other tests

  • Audiogram – simple test which may be done for concomitant ear pathology
  • Caloric test
  • Electronystagmography (ENG)
  • Posturography

Differential diagnoses for benign paroxysmal positional vertigo (BPPV)

  • Ménière disease
  • Inner ear concussion
  • Alcohol intoxication
  • Vestibular labyrinthitis
  • Vascular loop syndrome
  • Lesion of the nodulus from stroke, multiple sclerosis, Arnold-Chiari malformation, ischemia, cerebellar degeneration, and intoxication.
  • Posterior fossa lesion such as acoustic neuroma or meningioma.
  • Vertebral artery insufficiency
  • Cervical vertigo, or head extension vertigo,
  • Orthostatic hypotension,
  • Medication side effects
  • Anxiety or panic disorder
  • Migraine related vertigo
  • Management of BPPV

    Epley Maneuver— Initial and most important management strategy is Canalith repositioning maneuver or CRP or Epley maneuver. ( for details read previous post Canalith repositioning maneuver for BPPV)

    Vestibular Rehabilitation Exercises Vestibular rehabilitation is an exercise program to help compensate for a loss or imbalance within the vestibular system either self-administered or with a clinician.

    Cawthrone cooksey exercises and Brand  Daroff exercises for BPPV are beneficial for hastening of restoration of normal balance.

    Observation – wait and watch with reassurance and follow-up visits as symptoms resolve in 1-2 month time.

    Medical TherapyVestibular suppressant medications can be used but many times not effective and masks the problem.. Adverse effects of grogginess and sleepiness ca occur.

    Health Education – Patients are counseled regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up.

    Surgical Care

    Surgery is reserved for those in whom CRP fails. There is possibility of complications such as hearing loss and facial nerve damage.

    The most viable surgical option is posterior canal occlusion. The aim is to stop the benign positional vertigo by collapsing the posterior canal, immobilizing the movement of particles through the canal.

    Benign Paroxysmal positional vertigo usually is not due to any serious neurological disorder and the overall prognosis for recovery is favorable; however, undiagnosed and untreated BPPV may have safety concerns and quality-of-life impacts.

    Proper Diagnosis and treatment of patients with BPPV may lead to significant health care quality improvements thus it is very important to implement a well-constructed clinical practice guidelines.

    Canalith Repositioning Procedure for Vertigo: Active treatment of BPPV

    Update — in my other posts read more about Benign Paroxysmal Positional Vertigo

    and Home care of vertigo


    Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of dizziness, most often experienced when patients lies down.

    Because BPPV is not intrinsically life threatening and symptoms are usually self limiting patient is usually kept under watchful wait but as BPPV can last for much longer than 2 months, it is better to treat it actively by Epley maneuvers or Semont Maneuver. The Semont and Epley maneuvers may improve or cure benign paroxysmal positional vertigo (BPPV) with only one procedure however some people may need multiple sittings.

    CRP / Epley maneuver/  Canalith repositioning procedure


    The Canalith Repositioning Procedure (CRP) or epley’s maneuver is a rehabilitation treatment for Benign positional vertigo.  CRP is very effective, with an approximate cure rate of 80%. The recurrence rate for BPPV after these maneuvers is low. However, in some instances additional treatment may be necessary.

    Canalith/otolith/or otoconia are small crystals of calcium carbonate attached to the otolithic membrane in the utricle of the inner ear. Because of trauma, infection, or aging, canaliths can detach from the utricle and collect within the semicircular canals. Here these canaliths shift with the head movement  and stimulate sensitive nerve endings to cause dizziness.

    Epley’s maneuvers involve a series of specifically patterned head and trunk movements performed by a trained professional. This head position change, moves the canaliths from the problematic location in one of the semicircular canal to the utricle.

    Procedure: The procedure takes approximately 20-30 minutes.

    You will be placed on a table and then laid back with your head hanging over the end of the table.
    If you have a “positive” response in this position you will then be moved through the procedure.

    A. Patient is placed in sitting position on the edge of the examination table (Position A).

    B. Head is rotated 45° towards the affected ear, and the patient is swiftly placed in lying position with the head hanging 30° below the horizontal over the table edge (Position B). Positive response (primary stage nystagmus) is observed position is maintained for 1-2 minutes.

    C. The head is rotated 90° towards the opposite ear while maintaining the head hanging position. (Position C)

    D. Patient is turned further 90° towards the unaffected side to face the floor. (Position D)

    The patient’s eyes are observed for secondary-stage nystagmus, it should be in the same direction as the primary-stage nystagmus.

    E. Position is maintained for 30 to 60 seconds, and then again laced in sitting position (Position E). Upon sitting, there should be no vertigo or nystagmus in a successful maneuver.

    Instructions Following the Canalith Repositioning Procedure

    Wait for 10 minutes after the maneuver is performed before going home. Don’t drive yourself home.

    For first 48 hours

    1. Do not tip your head up or down or bend at the waist. Use of the cervical collar will help prevent you from tipping your chin down.
    2. Do not visit the places that require you to lie down or tilt your head (hairdresser, dentist, chiropractor or barber).
    3. Avoid tipping your head up or down when brushing teeth, shaving or washing your hair.
    4. Sit down and get up from chairs while keeping your back straight, without bending forward and avoid tilting your head forward.
    5. Housework such as cooking or cleaning should be avoided for the next 48 hours.
    • Do Not Lie Flat in Bed:

    Sleep semi-recumbent for the next night. This means sleep with your head halfway between being flat and upright (a 45 degree angle) by using a recliner chair or by using pillows arranged on a couch

    The Following Week:

    • Do Not Sleep on your treated side
    • Use two pillows when you sleep.
    • Avoid sleeping on the “bad” side.
    • Don’t turn your head far up or far down

    (Like head extended positions at the beauty parlor, dentist’s office, and while undergoing minor surgery).

    • No “sit-ups” for at least one week and no “crawl” swimming.

    After 1 week you can resume your daily activities without any restrictions. Move around as you wish.

    Update–

    Contraindications to perform Epley Maneuver

    • Unstable heart disease
    • High grade carotid stenosis,
    • CNS disease (stroke or Transient Ischemic Attack),
    • Physical limitation– neck disease (rheumatoid arthritis, cervical radiculopathies, ankylosing spondylitis, cervical spine fracture or surgery)
    • Pregnant women beyond the 24th week of pregnancy

    Semont Maneuver

    The Semont maneuver (liberatory” maneuver) involves a procedure whereby the patient is quickly moved from lying on one side to lying on the other side.

    © Liberatory manoeuvre of Semont (right ear)Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003:169:681-693.

    Position 1. Patient is made to sit on the examination table with legs hanging over the edge and head turned 45 degrees horizontally towards the unaffected ear.

    Position 2. While maintaining head rotation patient’s upper body is swiftly moved to side lying position on the affected side with head resting on examination table and nose pointed upwards. Position is maintained for 3 minutes or till vertigo and nystagmus subsides. This step moves the debris to the apex.

    Position 3. Patient is rapidly moved through the sitting position (Position 1) to lying on the opposite or unaffected side (maintaining same head rotation) with nose pointed to the ground. Position is again maintained for 3 minutes or till the vertigo and nystagmus subsides. This maneuver moves the debris towards exit of the canal.

    Idea is to move the debris into the utricle where it will no longer cause vertigo.

    Semont maneuver is 90% effective after 4 treatment sessions

    Update — Next post–Read more about BPPV (Spinning world–Benign Paroxysmal Positional Vertigo)

    and Home care of Vertigo