Common and often painful, otitis media can lead to hearing loss, with consequences for development and learning. Pediatric otolaryngologist David Conrad, MD, FAAP, presents a guide to help primary care providers distinguish causes, understand risks of recurrence or complications, and determine the best treatment for individuals, including when to consider ear tubes.
e. I think that this is one of the most high you'll topics that we can talk about as pediatricians and as otolaryngologist, uh, together, A Z. You know, this is so common and way all struggle through this, and it's a very humbling even as an e m t doctor. Um, otitis media just continues to be a difficult, um, thing to treat. Yet it's just so common. And so I think it's important that we talked about it. I have several financial disclosures. I have several patents among the board of directors for the Children's First Medical group, or C F M G. On that. I'm also a company founder for a small medical device company that revolves around the development of tracheostomy alarm systems. Um, to detect when the tracheostomy tubes out of the neck So we'll talk about the tightest media and its history. Uh, the definitions of otitis media. Andi, What are the consequences of having recurring ear infections and going through life not hearing well at certain periods, uh, also review the past and present treatment guidelines from the AP on. Then we'll talk all about your tubes on when they're indicated and what kind of things can go wrong on then. Also some new trends and kind of the future of management of the Titus media. What types Media goes back, Um, you know, really millennia. And so does cholesterol toma and draining ears. Um, it's been a really a surgical problem before. Antibiotics and eso, you know, ancient Egyptians were Lansing ear drums and draining puss. There's some evidence of that Ondas always been focused on. You know what causes otitis media? Is it allergy is a bacterial base, isa reflux. And then the aren't The YouTube came along, and that's really saved a lot of hearing a lot of cholesterol toma actually since the 19 fifties, and it still is one of the most common things that we dio. We're always looking for ways not to put in tubes. Yet it still is really the most common surgery that we we do is NTS. And so, as I mentioned, Allergy has been looked at as a potential contributing factor to a Titus media, although it's really not thought to be such a a major cause. And then there's famous studies that came out of Pittsburgh in the 19 eighties and nineties and we really based a lot of our a lot of our treatment guidelines on this research that was done back then. Aan den Watchful Waiting has become a more of a focus ever since the nineties, Really, in two thousands, Um, otitis media is very common, as as we all know, it's one of the most common reasons the child visits the pediatrician and actually one of the most common reasons that a child comes into a N D to see if they need your tubes after after seeing you after seeing seeing the pediatrician, um, and so most of the time it's occurring before age two. It's really rare to have your infections after age six, I would say Really rare. It can be some common, but, um, you know, as you get older, your station to function improves, and therefore your infections become a common. So if you have an 18 year old with, you know, a ton of your infections, um, that doesn't really drive. That doesn't really make sense. And so it really helps to kind of put these patients in age groups and what's most common in those age groups and those Children who are younger than two or three. Those air the common times for ear infections. Not so much the eight year old, 10 year old 18 year old bond. So that could be helpful. Strep pneumo is still the most common cause of agent. There's been some changes with the pneumococcal vaccine, and that's changed things slightly. H flu is actually very common, slightly e feel becoming more common with the vaccine. Um, of course, we do have the hit vaccine, but, um, still, it's a predominant organism. Um, some say this is a less eight. Flu is less painful and has milder symptoms, whereas strep pneumo is very Piola genic and causes a lot of pressure and pain. Um, but still very common group A strap is also common, Um, and then all the way down at the end of the list E. Coli. We see otitis media in some infants, and most of the time it's the culture results. Culture results are E. Coli. Um, let's talk about risk factors of otitis media Age is still really a common risk factor, So we talked about, um, your infections and Children younger than two or year and a half. That's the most common age. What types Media after age six is less common. Allergic rhinitis analogy. Uh, there's really a week association there, and so therefore, nasal steroids haven't been shown to be very helpful in, um, double blinded clinical trials. Family history is extremely powerful association. I always ask patients, you know, have our families have have you? Are you know Mom or Dad had tubes? Anyone in the family needed your tubes in the past, had a lot of your infections ever had a draining year. It's a really strong association on duh it SSM thing that we always look for daycare also. In fact, we're seeing less otitis media these days because fewer Children are, you know, around other Children in daycare or in school. And so that's such a strong association that we've seen a big drop off in the amount of otitis media, which is great. Lack of breast feeding is a fairly strong association. Tobacco smoke and actually marijuana smoke is ah, fairly strong, uh, pollutant, which can cause mucosal swelling and therefore you station to dysfunction and then therefore you otitis media, a pacifier use somewhat of a risk factor on then race and ethnicity. You know, classically Native Americans have really poor you station to function for whatever reason, and that's always been kind of quoted in our literature. But what's the root of all here? Ville. So, um, some say money is the root of all evil. I say, I say to you, Station tubes are the root of all evil. Um, it's really the most common reason that there that's something goes wrong with the ears. We have such great literature on this. A lot of studies. It's kind of this anomaly in our, you know, in our development as humans. It's just this this problem, this you station tube, this 1.5 centimeter area of real estate is the root cause of so much problem that goes on with the ear. And why is that? Well, the middle ear relies on pressure equalization, and there's been animal studies that have been done. So if you include the station tube and cut off ventilation of that middle ear compartment and the Mastoi compartment, for that matter, um, that space could fill up with fluid. And as soon as 20 minutes, Um, and the reason for that is that you get negative pressure when you station tubes don't open and close that well. The negative pressure is from rapid gas absorption, mostly nitrogen gas. And so if the station tubes don't work as well because of a cold, which is the most common reason so swelling, you know, um, swelling in the back of the nose, causing the station tube offices to swell shut. The ears fill up with fluid, usually a thin fluid. And then, over time the water gets through absorb from that fluid, and so you start with a seriously fusion, and then it goes to a mute, coy diffusion or glue ear. And so this fluid will dampen down the vibrations of the eardrum and automatically cause about 20 decibel hearing loss. And so, you know, pressure equalization maneuvers sometimes can help. So pushing air into that area. Um, so let's switch gears now and talk about, I think, one of most important parts of this talk. And that is the ability to distinguish acute otitis media from simple middle ear fluid or an infusion. Um, it's just such a common dilemma, even for us, and and frankly, we have difficulty with this a times, Um but it's just such an important part. So acute otitis media is a really painful infection, and it's most likely preceded by a U R I so you know, starts as a cold, and the next thing that you start to hurt, it's really painful. The middle ear, it's filled with puss, and that's under pressure, and it z bowing out that your drum laterally and that is really painful. You're drunk, has a ton of no of innovations, and it's it's really painful to have you generally get fever because it's such an inflammatory reaction on Ben. You have this bulging to panic membrane, and then there's a cloudy appearance to it. Think of the You're doing like a hazy window that you can kind of see through. Um, and you know, you tend to see plus, um, so plus, behind the aerodrome pain must be there. Uh, you know, it's a rip roaring infection with lots of information, so that's acute Otitis media versus just fluid in the middle ear space. This is usually painless does not hurt. Generally tohave have that, although ear tugging can be common and this is an important thing to talk about your Italian. Most Children, you know, touch their ear. They experiment with your ear touching. It doesn't necessarily mean there in pain. Oftentimes they're they're noticing that they can't hear us well, when they touch that part of their ear versus, you know, pain and really tugging the ear and being uncomfortable so you can have fluid. Um, that doesn't hurt, but they could still tug on their ear. On this fluid causes a 20 decibel hearing loss, and that you're done will appear dole in a pacified on. So these two things are important. That bulging eardrum must be there, and it's generally painful with fever, whereas just a middle ear effusion doesn't hurt. Still has a dull appearance to it because there's food behind the ear drum on. Sometimes yes, they can have poor balance so bulging to panic members and simple, single most important sign and then look for translucency and we'll go through some pictures. But you and also pneumatic a Tosca P is a good way to see if you can move that your time. It's I'm always that reliable, though, so we actually focus more on just the appearance of it. Uh, timpano grams are also helpful. So, you know, type B Timpano graham is indicative of a O. M or O M E Um, type A s or short Taipei Timpano Graham sometimes is indicative of serious fluid on Ben type Regular Type A and Type C is negative middle ear pressure with the urge on his sucked inwards. And then let's look at some diagnostic dilemmas. Just plain old, oh, diarrhea draining year. Um, sometimes, you know, we're often asked if this could be a tighter external A Or is this a Titus media with Tim Panic membrane rupture? And sometimes the treatment is the same for both. But, um, 99% of time. If you see a draining year, it's from the timpani. It's from acute otitis media that built up pressure and then rupture the eardrum. And now that passes leaking out of the year. And it's not Titus external and the differences of Titus external when you looked. When you go to look inside the ear, the ear canal is usually swollen almost shut, and it's exceptionally painful for the patient to put a speculum in and look at that year, you can pump on the trade against or pull the pin, and sometimes that's tender, but you should see a swollen your canal. Whereas this huge otitis media with Tim Panic Miriam Rupture there won't be swelling. They'll be, um oh, diarrhea and fluid caked around the sides of the wall, but that your canal itself won't be swollen. Um, and so artery is almost indicative. Indicative of a tightest media with rupture. Please give Orl antibiotics and drops, so if there's a draining year, use that to your advantage. You can give drops topical, uh, drops. We usually use flocks in, um, it does not have to have a steroid in it. There has been shown to have any benefit, unless it is true otitis external so fox and is covered by almost all insurance. It's very affordable rather than Courtis foreign or super decks or superagency. Okay? And then went to refer for for, oh, diarrhea. If there hasn't been any improvement with antibiotics or drops for 10 days, if the child is over six years old, we start. We start to become concerned about class Daytona at that point, and then if drainage has lasted longer than two weeks, we become concerned about closed eight Omagh hiding somewhere on the other diagnostic. Salama's abnormal Your findings. Thistles. A patch of timpano sclerosis. It's a calcium plaque, and it's usually from previous ear infections. Sometimes this looks like cholesterol toma, and it could be difficult Thio discern. But this is usually just a thin plaque embedded within the region, where the class d'attoma is more of a pearly mass, and I'll show you some pictures of that. Um, plaques like this typically don't cause any reduction in hearing unless they're really massive and occupy the entire drum. Andi. It's just a sign that someone has gone through. Priore your infections and we see it quite a bit. I'm sure you do, too. So white patches air, usually to panel sclerosis. Um, look out for a some sunken in ear drum or really retracted your drum. And if you look inside the ear and it just looks weird, it's really hard to kind of, you know, even describe what you're seeing, but you don't see any landmarks. You see multiple light reflexes, reflexes that seem in odd places. You see these defined what look like obstacles or hearing bones. Um, this is a sign of your retraction which is likely occurring over months, two years. And, um, if it goes long enough, it'll it'll erode the obstacles. And then the patient will get what's called a maximal, conductive hearing loss, which is about a 60 decibel hearing loss on bats. Essentially, when they're no longer using your hearing bones to here Now they're just using the vibrations of their entire school, um, to then transmit to the cochlea, which still works on DSO. Uh, you know, if you see something like this, this is this really needs to be addressed potentially by surgery. Um, so, uh, yeah, look out for your drum retraction. That's a often, uh, that's a common finding. Usually in a little bit older kids, Children after the age of six on then class d'attoma. I mean, this is something that we're always on the look up for. Class d'attoma is basically a skin cyst. Um, that goes awry and grows inside the middle ear space and causes destruction. And, um, the most Commons finding is, um, crusting that you'll see sometimes crust on the ear drum or a white pearly mass. Oftentimes the ear is draining off and on, which is why, um, If you have a draining here for more than two weeks, you should refer to E N t. Uh, to help a lot of class Daytona. And this requires surgery. There's no medication for it, and it can cause deafness over time and certainly can be fatal over time. Can cause meningitis and and intracranial problems. Um, the lingering effects of otitis media. You know, this is good data toe not commit to memory, but just it helps understand why we put in tubes and how middle ear food clear. So if you take any child with a cold and do a cat scan, odds are that they'll have fluid in their ears. And But what happens over time is the food that three absorbed or goes down the station tube. And we have good literature on how, how, how long this takes. So with effusions, you know, let's say you see a new fusion, Um, 40% of the time, it's still gonna be there in one month on the 20% of the time. Well, that effusions still be there in two months, and 10% of those patients will have fluid still at three months. And it's those patients that have become candidates for ear tubes because we found that if fluid lingers along longer than three months, it's likely to stay there and become glue ear on DSO. Then it tends to be trapped for months on end. I'm not saying that any of these patients need antibiotics. It's just fluid, but we need to monitor that food and make sure it does go away. Otherwise, it will result in not permanent hearing loss. But they're not gonna be hearing well during this time. And that's gonna have effects on their well being as faras the school performance language development if they're young enough and just quality of life issues. Um, so it's not dangerous to have fluid in your in your ear. You know, uh, we've all gone on the airplane ride and then, you know, during descent you can't hear Well, then maybe, you know, if you flew with a cold, you feel like fluids kind of sloshing around. I can't hear well for several days. It's not at risk for becoming infected. All of a sudden, it's generally a sterile collection, Um, but it causes hearing loss, and we have to monitor it over time. So if you see air bubbles, that's usually indicative of a thin, serious confusion. If you see kind of a dull amber fusion that's usually indicative of thick, viscous effusion like, um, you coy diffusion basically mucus in the middle here. And this is apparel infusion. You can see that you're jumps under pressure and bowed outwards. This is a serious diffusion because you can see air bubbles. Um, you know, Children can actually hear quite well sometimes with serious infusions. Uh, this is, um, you quit a fusion. Really Kind of a dull look to the drum again. Think of the drama. Still kind of hazy window through which you can see on day thes air views with an endoscope, so may look a little different than what you're used to. Um, but yeah, this is glue ear. You know, if we were toe a near tube and suction this out, it would come out like thick strands of jelly. Um, it's that discus. Okay, let's just talk about general classification of otitis media. I think it helps to think of it in two ways. It's either acute otitis media, which is an acute painful infection or It's just fluid that's sticking around fluids, either after a near infection or the fluid out there because of a cold and the the ear filled with fluid and it's not really infected doesn't need antibiotics. It's just sitting there, but it is causing hearing loss and, um, and and that Z obviously needs to be monitored and addressed. So two different categories. Acute infection that's painful, that needs antibiotics versus the fluid that needs to be monitored and see if it goes away. So there's recurrent acute otitis media. So three or more episodes in six months or four or more episodes of otitis media in one year and these air indications in our literature for ear tubes in our treatment guidelines. So we classify that as recurrent acute otitis media on then otitis media with effusion or O. M. E is glue ear kind of the older term for it, and that's middle ear effusion doesn't matter if it's serious or, you know, Mucha opulent or you coid. But any kind of fluid that's there for longer than three months is otitis media with effusion on. Did you have a draining ear? Chronic separate of otitis media? Let's talk about the burden of otitis media. Um, you know, we talk about pain and complications and things like that, but I think that speech in the psychological effect of not hearing well and how you how you do in school and how others view you and it can really alter the outcome of your life if because hearing loss is just so isolating, I think that it sets up the cascade for for some in some ways, the rest of your life. Um and so obviously there's pain and suffering at stake and quality of life for everyone. Uh, parental anxiety, mistakes from work, consumption of health care resource is and then complications. But really, I think speech delay an impact on social development school performance are equally important. Obviously, you know, there could be deadly complications from otitis media, but usually it goes okay and, you know, usually they would cover well. But if you string together enough of those infections and periods of not hearing well, that's a real problem. Over the course of that patients early life. So the impact, you know, average child experiences three months of decreased hearing, Um, and these are important formative months for the child, and so this could affect their speech discrimination and background noise when they have an infection or when they have fluid. We looked a cognitive development. So auditory processing skills and attention and speech and language on the educational outcomes such as reading comprehension on git seems that earlier otitis media has a greater impact on education and intention outcomes. Um, until the ability to stay focused, um, on then, central auditory processing is another issue that we borrow a lot of we make a lot of way in for a lot from from this data, Um, this is essentially when someone is hearing okay, But what they're hearing is somewhat garbled or distorted, or it just takes a long time for them to process what they've just heard. And then, you know, respond. And so, um, some of these patients or kind of get labeled as spacey or just kind of not really, you know, really slow. They hear fine, but they have difficulties with processing, and so this is picked up by an auditory brainstem response. In a BR, tests can be picked up on a regular hearing test, but it's certainly important to refer patients who have learning issues who are school aged. I think that sometimes we can pick up on these these kind of issues on then otitis media in speech development Um, it really is true that most Children can catch up to their peers by age seven if they've had a lot of speech delay in your infections. But there's other effects on just auditory memory and an auditory processing skills. And, um, that we that we feel linger aan den. There's also basic science research that's shown that conductive hearing loss has long lasting impacts on pre synaptic and post synaptic structures of the auditory nerve synapses in the cochlea. And so this has been kind of an interest on certainly of mine. Also just the psycho social impact of not hearing well. I see so many Children school age Children with you get a lot of your infections or who have fluid, and they tend to act out. They tend thio, Um, you know sometimes have adjustment disorders or oppositional defiant disorder, but hearing loss is is very isolating. It just really is. And so these Children struggle on dso you know, if you find a child that has behavioral issues and has a history of otitis media. I would check their hearing because it's an important box check because sometimes not hearing what will cause the child act out so much that they, you know, they get labeled with a D, h, d or other issues. Meanwhile, they just haven't been hearing well and are struggling to connect. That could be very frustrating. Um, so let's talk about quickly about complications of otitis media. Um, mastered itis is kind of one of the more feared one. So this is an infection that starts in the middle ear and then spreads to the mass toid. And you can think of the ear, the middle ear space, kind of like a house. Um, it's a room, the 11 room house, and it only has one opening one door, and that door is the station is the station to um, This house also has an attic, and the attic is a pretty big addicts, about the same size as the as the house itself. And the attic is the mass toid. And actually we even have a name for this communication between the two sites, and that's the added this ad anstrom. We also called the attic, and that's the pathway to the mass toyed so a middle ear infection can spread to the master wade through the attic. And, um, there's plus in both, and it's basically the same process in both. And once it spreads the Mastoi, the puss is looking for a way out, or the body is looking for where to drain it and it drains out behind the ear and that you could get a subpar Yasiel abscess. And so this is usually Children younger than two years old who have a really bad ear infection. They should appear very ill to you and sick, um, not healthy and playing around in the exam room. And, um, sometimes it's confused with the post regular lymph node, and you almost always need to C plus behind the ear drum. So it's it's really an ear infection. Gone arrived with Puss in the Master would now, um, can spread to the brain. It can cause an abscess. So in order for everybody to be mastered, itis there has to be passed behind the ear drum. It's really hard to have it without that, so we diagnosis with the CAT scan generally, and, um, treatment is generally near tube and mastered ectomy. So an incision behind this area and drawing out the masquerade cavity uh, C T scans are really helpful. I mentioned this before. If any child is sick and you know we're doing some weird study where you're scanning them, most of those Children will have fluid in their middle ear and mass toyed. And so sometimes we get this rule out mastered itis, um, consult, and we go to look at the scan and the bone looks healthy. But there is fluid there that's just simple fluid filling that area. It's just like a middle ear effusion that spread to them asteroid. But there's no going to destruction, whereas master data, you have bony destruction. It's such a aggressive infection that the regular bone of the master it is eroded, and then sometimes we will see an abscess, And so that's how we distinguish the two. Um, you're done Perforation. We could get after many year infections or after really bad ear infection under pain, are under pressure, and we have good data on how commonly these clothes 90% will close within four weeks. And so, if you have the tightest media that ruptures and drains out the year, start oral antibiotics and drops, and then I think it's important to follow up within about, um, one month to make sure that that perforation closes. And, of course, the E M T s. We're always happy to do that, but it's certainly something that you could do as well. And you can double check that it's closed by doing it in panel. Graham. Okay, let's talk about just treatment. Guidelines in general on dis is more relevant for the, you know, treatment guidelines. As far as antibiotics on DSO, there have been updated guidelines in 2013, and the emphasis here was on pain and also making the right diagnosis. And then it also discussed the watchful waiting period and their key statements where that you should diagnose securitized media and Children who present with really moderate to severe bulging of the year jump. So a bulging year jump has to be present. That's ah, statement one a statement on. But, um, you may s o they do mild, moderate and severe bulging. I just think if there's bulging at all um, that's an ear infection because fluid generally doesn't vote bulge the ear drum. So, um but yeah, if you see bulging that that's really the most indicative thing of an ear infection and medical Tosca, we can help, um, their their statement. Once, he says, you should not diagnosis acute otitis media Children who do not have a middle ear effusion, so they must have a middle ear effusion, toe otitis media to even be present. Yeah, and then they also mention the observation may be appropriate when the child is a federal, if there's no ear pain. And again, I think that you're tugging doesn't count If the child's touching their ear doesn't necessarily mean there in pain, they may just be experimenting with, You know they're not hearing us well because there is fluid. But that fluid may not necessary, may not need antibiotics. They're just kind of tugging or pulling on their ear, but they don't seem to be in pain or discomfort. So you're touching or tugging doesn't count on, but also have close. Follow is possible. You can't observe on, then here's another summary of their antibiotic choice, so amoxicillin remains first line, but Augmentin. Many gravitate towards that. I do like Augmentin for acute otitis media, especially older Children. Onda. No alternatives are stepped in here. And then, um um, set your oxy, um, and, uh, and set track zone. Obviously, for one or three days, I am dose. And, you know, we see many patients who have gone through this this algorithm on then they're making their way to the anti doctor for this prolonged infection. And so, you know, really consider augmented in place of amoxicillin. If if you feel that the child is, um uh, well, I think this will be kind of an important discussion. Point is amoxicillin for segment in In general, um, there's controversy over the first line therapy. So due to the diminished presence of strep pneumo Andi, increasing incidents of H fluid Marcella on dso Augmentin has been more considered because of that. And then, of course, the subtract zone for three doses for three days. If penicillin resistance is suspected on duration of therapy, I'm just kind of summarizing the treatment islands from 2013, um, 10 days for age younger than two years old or any age with severe symptoms. Seven days for H 2 to 5 and 5 to 7 days for age six and above. If it's if it's mild aan den, just general controversies and treatment. And we struggled with this all the time. You know, to treat or not to treat. Is this a rip roaring, painful infection that needs antibiotics? Or is this, um, infection? That happened three weeks ago. Now there's just fluid, or is this just fluid that's never been infected? It's just chronic otitis media with effusion. Andi that and only the first one. Really, I think needs antibiotics. Andre, is this a viral infection? Bacterial? Will antibiotics even work? And, um, you know, how important is that bulge in your drum? Because we've all seen patients who seem to be in pain. But there's no bulge in your job, really, just But they you know, the parents are they're really anxious and everyone everyone is suffering and you want to treat. But you're unsure if it's indicated on then is this one of your infection? Or like, is it one long infection? Or is this like two infections back to back? And you know, we struggle with us, too. Um, it's generally one infection. And then there's fluid left behind from that infection. And so it's generally just one infection on. Sometimes the patient will have, you know, a resurgence of pain. Do you station to pressure? And that may trigger a concern that Oh, this is another infection. Now we have to treat it with another course, but it's generally one infection. Um, and so, you know, these are all just interesting caveats of what we see on, you know, every day. And so, um, watchful waiting has been endorsed since 2004 on they really emphasized the accuracy of the diagnosis. More recently, eso watchful waiting for Children 6 to 23 months if they have mild symptoms, no fever. And, um and there's a New England Journal of Medicine article that's frequently cited in these Um, it's interesting to look at the international guidelines s Oh, you know, it just it's really interesting about what you know, Korea and Asia. Parts of Asia are doing versus us. Um, in Korea, you know, they're really watchful. Waiting is actually in all these international treatment guidelines that I've looked at watchful waiting. They're much more inclined to recommend observation, which is interesting. So watchful waiting is the initial management. Um, usually for all, uh, your infections in Korea aan den Japanese ontological society really endorsed watchful waiting more from mild symptoms for all infections for the 1st 72 hours. So even if there is possibly find their job, but the patient doesn't seem to be And discomfort still do watchful waiting. Don't start antibiotics. Um, whereas Italy more inclined to do antibiotics for all. And then, of course, the United States, um, so in non severe, uh, otitis media, the clinician should either prescribe antibiotics or offer a close fall up without antibiotics. Um, if they don't seem to be in pain, So pain is really an important to suit, uh, important point in the distinguishing the difference on gun. Of course, no prophylactic antibiotics for recurrent otitis media is indicated, Um, on an additional considerations, you know, if you have a draining year, give topical antibiotics. Um, it doesn't matter if there's a steroid in there or not. So, um, flocks in is usually what we use rather than Cipro decks, which tend to be expensive. And then you have to pay out of pocket for it. Um, depend on the insurance. And, um, you know, So if there is a draining year, I do recommend oral antibiotics in addition to flocks in some would say even just flocks and only, but I find that oral antibiotics really do help. I feel there was energy, um, being able to equalize pressure. So pinching your nose and blowing our auto inflation practices or maneuvers. Those really help. Those have been shown to get rid of fluid faster. Really? No medicine has been shown to do that. So, um, anti histamines, you know, African, all that nasal steroids. They don't get rid of fluid faster. It just seems to be the tincture of time, oddly enough, and, um, equalizing pressure by forcing air into the middle ear space to get rid of that fluid and then the tincture of time being just allowing enough time for that, you or I to pass for the swelling to go down in the back of the nose. And then for just a airport, um, the air pressurization process toe happen naturally are the best ways. Um, cleft palate. You know, these patients are really prone to ear infections and protects media. So be aware that they often need ear tubes. Um, obesity has been looked at as a risk factor. You know, these were just kind of more recent studies that have looked at this kind of thing. And we do find that there is a slight, uh, predominance with obesity, and you station to dysfunction. Also, um, one of one of the nerves important for taste travels through the middle. You're actually, um And so if you have a lot of episodes of information, that nerve doesn't work as well until they don't taste things as well. And so they like to have a higher fat diet with more salt. Found that that to be true and especially adults. Actually, um, let's talk quickly about your tubes. I realized were kind of the approaching the ends air close to the end. So we put in tubes. If you've had more than three infections in six months or more than four infections in one year, or if you've had fluid longer than three months, those are the kind of the anchoring indications for ear tubes aan den. Sometimes we recommend adenoid ectomy and, um, you know, how could removing the adenoids help the ears There's a lot of good literature on this, actually so annoyed ectomy is indicated for a child who needs your tubes if you're older than four, or if this is their second set of tubes or third set or four set, we recommend annoyed ectomy. The adenoids thing admit issue is a part of lymphoid tissue. It's similar to council tissue behaves the same, but we only have one adenoid, and it's in the back of the nasal cavity really hard to see it through the through the nose. We use the scope to look at it. X rays are helpful but not not shown to be as effective as the nasal endoscopy that weaken Dio. And if you shave this tissue down taken, um, it can open up the station to offices. And when we do an adenoid ectomy, we actually are seeing the the openings of the station tubes on either side. On. We often see this tissue blocking the two, blocking the openings and so removing it has been shown to be very effective. That's why we do an appendectomy with tubes sometimes so clinical proles, Um, just to kind of wrap up for acute otitis media I really think that they must have a pure land infusion, pain and usually fever if they're not in pain. If they're not discomfort, they may be touching the year from time to time. And parents may be worried about that. But if they're if they're don't have discomfort. Um, it's not acute otitis media and and therefore, I don't think that they need antibiotics. Um, And so for fluid, though the child can't be fussy, but usually without fever. Um, you know, the child may not be hearing well, and so, you know, pain is really difficult to kind of defined. But, Kate otitis media, they're really they're gonna have a cold generally and a painful ear infection. Not acting themselves pretty fussy. Whereas for fluid, it might be a little bit fussy, even know fever. Certainly not in, like, tremendous pain. Um, And for a draining here, use that to your advantage. Give drops in addition to oral antibiotics. Um, if the drainage persists for longer than two weeks, I recommend a referral TNT. And if any child has a u. R I, they're likely to have the middle ear effusion. Andi, generally your infection. Start with you or I. So that infusion, though once you recognize it, it's important to keep tabs on it. It must clear with him three months. Otherwise, they do become a two candidate. We have good data to show that that food will usually persist, and then they'll go through periods of not hearing well, then, that sets in motion this cascade of not hearing well and, you know, having issues adjusting and socializing. And so, um, if you catch it early can have a profound effect. Tubes air helpful, but they can also cause harm. As an anti doctor, I'm always looking for a way not to put in ear tubes. They're so helpful, but they can cause harm. So if you put in more than one set of tubes, it starts to weaken the air job. And then we get worried about a perforation. And then some say that tubes can actually contribute to someone becoming what's called a chronic ear patient, where you become a your patient for life. You have a thin your drum that ruptures easily. Then you have a long term preparation and you have to get that repaired. Then it may not work, and then you have drainage off and on, and it just sets in motion this whole cascade. So tubes air helpful. But we're really looking for ways not to put them in if necessary. On DSO watchful waiting when the diagnosis is uncertain is really recommended. So if you're unsure about securitized media, I really recommend observing for a period of time. Um, unless the patient is really in pain and has fever. And so when to refer if the tightest media's I recommend referring to anti if there's a tightest medium, said in a speech delay that the food is lasting longer than 2 to 3 months if they had more than three year infections in six months or more than four in one year. Um, if they've had a draining year longer than two weeks and if there is a 20 decibel hearing loss for greater or any difficult your patient, for that matter, concluding thoughts, um is ah, diagnosis is in the eye of the beholder. Uh, apologies for this, I think my colleagues, um uh, computers going But, um, attends media is challenging and encourages the practice in the art of medicine. The decision roots were for early can have a lasting impact. Eso please don't hesitate to refer. Ask for assistance any time for any year patient. Really, Um, and be aware of the chronically draining year. So especially the older child the child has had a deer that's been draining off and on for years is the sign of a costly toma on. Then they need to be evaluated. And we're changing the way that we refer at UCSF. Um, very proud of this, and I'm actually doing some work on the administrative side on This is Well, we really want to make it as easy as possible for you to refer to UCSF. We're really trying to tear down all barriers to referring. Um, so we have a new central phone number 877 You see child, which is open Monday through Friday, 8 to 6, and this is kind of a one stop shop way to refer patients can call. So can physicians, doctors, offices, anyone and a patient can schedule a family can schedule a appointment on. Then you can also process two referral through this number, and then the fax numbers are presented there so you can check on the status of referral or, um uh, really anything. But that's the central phone number for this process Now And just remind you of our sites were on both sides of the bay. We kind of have a one day campaign or vision. Uh, on DSO This is in Walnut Creek, Brentwood and, of course, Oakland Mission Bay and also in Marin and will be expanding also, I think, on the peninsula and Redwood Shores. So thank you so much for listening.