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Introduction: This podcast forum is brought to you to share expertise and insights within our integrated delivery system. To help us improve the health of the people we serve and achieve world-class accessible care. This is Expert Insights. Here's your host. Melanie Cole.

Melanie Cole: Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole and today we're discussing otitis media. Joining me is Dr. Michael Novak. He's an Otolaryngologist with a subspecialty in Otology and he's with the Carle Foundation Hospital. Dr. Novak, it's a pleasure to have you join us today. First, give us a little working definition. What is otitis media and give us some of the subtypes as well. Please identify the three main types.

Dr. Novak: Otitis media essentially is any fluid and or inflammation in the middle ear defined as the space underneath the eardrum. Generally, there are several types. The most common probably is acute otitis media. This is the actual bacterial infection in the middle ear space, typically seen and very commonly seen by pediatricians, family medicine providers, in the acute setting when they take care of children. It seems some in adults, but not as often as children by any means. It's probably the most common thing seen by primary care providers who take care of children. Then there's just the serious otitis media, which is essentially a clear possibly Amber colored fluid underneath the eardrum, typically seen in older children and adults from Eustachian tube dysfunction or blockage of these station tube. Commonly after a cold, after an allergic rhinitis episode, potentially after airplane flights as a Barrow trauma, Cicala. Simply fluid associated with hearing loss and a full feeling in the ear.

And then as a third type is the chronic mucoid otitis media. And this is usually from a sequella of an acute otitis media episode that is not resolved satisfactorily. Can also be seen as a manifestation of a chronic use station, two blockage in adults or children. And that's a thick, tenacious fluid buildup underneath the eardrum. Typically not acutely infected. All of the types are associated with hearing loss, any fluid underneath the eardrum gives a conductive hearing loss anywhere from a mild to moderate degree. And then the other symptoms of it are going to vary depending on the infectious nature. The acute otitis media classically gives you pain and fever, especially in the young children.

Host: Thank you for that excellent explanation, Dr. Novak. What's the difference between otitis media in adults and children. And you mentioned some of the causes and the presentation of it. Expand a little bit more on what a healthcare provider might notice as far as clinical presentation. And why is there a difference between adults and children?

Dr. Novak: A lot of the acute otitis media or otitis media in general happens in young children. And by that I'm talking about less than three years old. So in the infants and toddlers, and they cannot express to you, Oh, I have an earache there's crabbiness, fussy, fever often associated with upper respiratory infections, which also have fever and melees and other symptoms that can cloud the picture. So a lot of it is the lack of ability, the lack of language to express that they have a problem. And then you have to go looking children also as any provider will know, it is hard to see an eardrum and a child. It's hard to make an accurate diagnosis of otitis media in a squirming 18 month old with a narrow ear canal full of wax. So it can be difficult to make that diagnosis. Now, if you get a clear look and see the classic bulging red eardrum, that makes it fairly easy. The adults and the older children have often protection from the bacterial components, so they don't get infected as often by any means. So you don't necessarily get the pain and fever.

You often just get the feeling of fullness, the muffled feeling, that distance sound that goes along with the hearing loss. They also have a used station tube adults and older children, that's probably four times the diameter of a young child. So much less likely to get the Eustachian tube dysfunction that gets you into trouble, but they can also tell you my ear hurts. I can't hear, I have tinnitus. There's something else going on. And then generally the adult and older child is easier to visualize the drum where even then it can be difficult to know for sure if you have fluid, simple tuning fork test that we all learned in medical school, the Weber and the Renee tests can differentiate between true hearing loss with otitis media and the sudden sensory neural hearing loss that is a post-viral sequella that needs to be treated fairly quickly and differently. But the difference is basically the acute otitis media, common in young children with the pain and fever and the fussy crabby nature. And the ability to say, I can't hear, my ear hurts.

Host: Well, that's certainly an important distinction. So Dr. Novak, how does it affect the hearing in children and adults and possibly speech development speak about what happens if otitis media is not treated and some of the complications that can result?

Dr. Novak: That's probably the biggest reason that you need to treat otitis media is the hearing loss. And here, especially I'm talking about children in a speech and language development age of say less than six years old, and even more importantly, less than three. Like I mentioned, every otitis media is associated with hearing loss. Hearing loss in an adult generally is a nuisance, unless you already have an underlying sensory neuro loss in one or both ears. And then it can create a real problem for day to day communication. But in a young child, who's trying to develop speech and language persistent effusion for months on end can definitely be associated with delays in speech, sometimes language, and sometimes later academics. So treatment of the hearing loss, often to me as an otolaryngologist, is the most important component. I like to think in terms of hearing, as opposed to just presence or absence of infection, because you can have a noninfected ear that's otherwise asymptomatic except for the hearing loss. And these can persist for months and even years in children. Sometimes they're picked up with screening, hearing tests. Sometimes we pick them up when there is a speech delay that we're investigating, but that's the bigger component to me.

Cause those can cause significant problems that may persist and require additional therapy. So my approach to otitis media basically is based on the fact that most otitis media, no matter what you do is going to resolve. That's more likely in older children and adults, but true in young children also. So almost essentially, no matter what you do, the fluids probably going to revise, resolve over a three to six week period, the fluid that persists probably two to three months, then I start to get concerned. And then after three months, this one you start to say, okay, I really need to keep an eye on this. And if it doesn't go away in the next few weeks, we may have to do something. Adults in the office, you can make a hole in the drum, take out fluid. I typically leave a tube that's going to stay in place for a couple of months, let it come out on its own. But most of the time, no matter what you do, they're going to get better. Children, it's a little different cause trying to get a hole on the drum and fluid out and a tube in in the office is difficult, if not impossible, but the hearing loss needs to be identified. And people need to think of hearing in addition to just presence or absence of infection. And that's the biggest difference the adults can tell you again, and the children camp.

Host: So as far as medical management, you're only looking at antibiotics if there's a bacterial infection in there. Yes. Is there some controversy surrounding some of the medical management for otitis media?

Dr. Novak: Yeah, there's a lot of controversy. Otitis media has probably accounted for the majority of our antibiotic overuse in the United States. The presence of fluid that is in an otherwise asymptomatic uncomplicated situation does not need to be treated. So, like I said, most of it's going to resolve if you'll just be patient and it's not going to resolve typically at 10 days. So seeing somebody back in 10 days really doesn't necessarily do you much good. I would see people back in about three weeks. Cause then if we haven't had resolutions, I'll start to think, okay, maybe this one is going to be a little different, but in the absence of pain and fever, I don't treat otitis media. Now, if I've got a fluid that's been present for several months, maybe a brief course of antibiotics to make sure that this one isn't going to resolve with antibiotics is okay. But most of the time, there's no reason to treat in the absence of obvious signs of infection. The bacteria that caused this typically strep H flu Moraxella catarrhalis are common bacteria. They're often antibiotics that are effective, but there's been so much overuse. We're seeing community resistance at a pretty good rate. So not treating can be very beneficial. There's actually, you need to treat at least eight to 10 children to get resolution of one case that wouldn't have resolved otherwise, and that need to treat a number that's fairly high.

And that's why I say if it has been a persistent infection, that persistent fluid, I may go ahead and treat, but otherwise I don't. Then when you get to the three month point, then you start to think, okay, do I need to consider referral to otolaryngology? Would a tube be indicated? My approach to otitis media, especially in children, is trying to use, what's gone on in the past to predict what's going to go on in the future. And I try to think, what is this ear going to do over the next six months to a year? And that gives me them the idea of whether I need to consider treatment. Do I need to consider tubes? Do I need referral? Because if my answer is this child's going to have persistent fluid or repeated infection for the next six months to a year. I need to start thinking of other long-term treatment methods. There's a fair amount of controversy over use of corticosteroids. I'm not a big believer in corticosteroids, unless I think that I can treat this one persistent episode. That's been there for eight to 12 weeks. And if I can get rid of this fluid, this person, adult, or child is going to do well, then a brief course of several days, three to four days of a corticosteroid can be useful. But otherwise those are also I think, overused, you know, otitis media.

Host: And as we wrap up Dr. Novak, when would you like other providers to refer to otolaryngology? Just summarize it all for us.

Dr. Novak: For adults and children. It's when the hearing loss is a problem. So the adults who are having trouble functioning, sometimes seeing them early and even offering a miryngotomy and fluid removal in the office can be very helpful. But for children, when they have had three or four episodes of acute otitis media, over six, eight months of time or fluid that's persisted for three months, is time to be sent to us to consider long-term treatment. They began, it's using the age of the child, the family history, the genetics, the pattern that they've had over the last few months, to try to predict what's going to happen over the next few months. And that also helps with referral.

Host: Thank you so much, Dr. Novak. It is great information and such an interesting topic. Thank you again for joining us. And that wraps up this episode of Expert Insights with the Carle Foundation Hospital for a listing of Carle providers, and to view Carle sponsored educational activities, please visit our website at carleconnect.com for more information, and to get connected with one of our providers. We hope the information gained will be applicable to your work and life. And if you found this podcast informative, please share on your social media and be sure to check out all the other interesting podcasts in our library. I'm Melanie Cole.