Ask the Allergist: Little Ears, Big Infections
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In this podcast, Allergy and Asthma Network Mothers of Asthmatics founder and president Nancy Sander talks with prominent allergist Dr. Talal Nsouli, clinical professor at Georgetown University Hospital and director of the Watergate and Burke Allergy and Asthma Centers. Their subject? Otitis media, inflammation of the middle ear and its connection with allergies.
Dr. Talal Nsouli: What is otitis media? Otitis media is an accumulation of fluid. The middle ear is a cavity that has a lining. This lining produces mucus. This cavity is connected with the back of the nose and the upper part of the throat, the nasopharyngeal area, with a tiny tube called the Eustachian tube.
So patients, when they get congested-- and this lining of the nose and the lining of the Eustachian tube is totally similar to the lining that we see in the nasal cavity. So we have nasal congestion, when we have inflammation of the nose, this inflammation migrates to the Eustachian tube, causes significant blockage, which is a very, very thin tube-- this tube gets blocked. Once this tube gets blocked, the fluid that it creates in the middle ear does not clear anymore, and starts to accumulate.
This would lead to a decreased compliance of the drum. It means the drum does not move anymore. And one can experience conductive hearing loss, which is what we see in kids coming to the clinic. One of the first chief complaints is that they aren't hearing. So there is no pain involved.
Now what happens later when this fluid continues to accumulate in the middle ear, the fluid that contains some microorganism within days can start to get infected, replication of bacteria, and you can have acute otitis media at the time it's an inflammatory infection, inflammatory process that will cause redness of the drum, will cause an infection that required intervention with antibiotics at that time.
But most of the time we do not need to get to this stage if, first of all, we can prevent it, and if we can flush the fluid before the infection is occurring, especially in patients that do have nasal allergies and nasal congestion. So this is something very important to keep in mind.
Nancy Sanders: So otitis media does not have to be an ear infection.
Dr. Talal Nsouli: That is right. Otitis media is a broad spectrum term that's used, and this covers underneath otitis media with effusion, which means only fluid in the middle ear. And then you can have acute otitis media. That means that the fluid got infected. So it's important to differentiate it.
So initially, we do have not infected fluid sitting in the ear. Once it sits for several days or several weeks, slowly, slowly, infection can take place, and then you have microorganisms replicating, and the child with suffer severe pain, fever, and have to use some antibiotic.
And what you are doing with that, you are only patching the problem. We are patching the end result. Then three, six, eight weeks later, or eight months later, the patient will start to reacclimate within the ear, the fluid will become infected, and we have to use another antibiotic and another antibiotic.
And what you are doing by prescribing antibiotics for otitis media-- we are only patching the problem and not finding the root of the problem. We're not finding the underlying allergen, the offending allergen that could be causing the nasal congestion, hence the congestion that goes to the Eustachian tube, blocking the Eustachian tube, not allowing the fluid to clear, resulting in recurrent middle ear disease. Hence the importance of looking at the underlying allergen.
So often the pediatrician does not think about the possibility of food allergy or environmental allergy. We know that in this small population, below five years of age, the majority of children that do have nasal congestion could be due to food hypersensitivity. And ordering the appropriate testing, and an allergy skin testing, a prick skin testing, or an in vitro testing such as ImmunoCAP test, or any of the above, could be very helpful in identifying the offending allergen that will decrease this congestion, and this would result in a significant improvement.
Now the question is, when do we consider having the patient surgical procedure on the ear? The consensus so far-- if, despite the treatment, the underlying allergy treatment or the underlying conservative treatment, does not clear the fluid, and the fluid persists more than six months in both ears, then most likely the spatial benefit from a tympanostomy ventilating tubes to be placed in the drum in order to avoid irreversible hearing loss, irreversible hearing damage.
So I think this is something important. But again, I think the allergy evaluation should be started first. One should consider an allergy evaluation, to send the patient to the allergist-immunologist to be evaluated for food allergies, to be evaluated for environmental allergies, and as I mentioned, a simple testing by the allergy prick skin testing could be done, or it could be done by the in vitro testing IGE. That could be very helpful in order to give us some guidelines.
Of course, these tests should be ordered and conducted by the expert allergist immunologist in order to be able to give the appropriate results, and the significance of this testing to the parents, in terms of avoiding the food or changing some foods.
Keep in mind that numerous studies show that tobacco smoke also can really predispose. Why? Because tobacco smoke produces chronic inflammation into different respiratory tracks, including the nasal cavity-- the Eustachian tube blocks them. So if we have smokers around the house, this is something that has to be considered, as well.
Nancy Sanders: Is it normal for infants to have a runny nose or congestion? I'm talking eight weeks old. Is this normal for them to have this congestion for a long time?
Dr. Talal Nsouli: I think for a short period of time, the answer could be possibly yes. Long-term, the answer is no. We are dealing with an underlying food allergy. And this is one of the typical. So again, I think, for the primary care physician, for the pediatrician, and for the parents, as well-- not to underestimate anyone. But we are observant. We are observing what is happening with this individual that is the patient.
So when do we have a high index of suspicion? If we have the patient with a current middle-ear disease and also chronic nasal congestion, highly likely we're dealing with allergies. And then the allergies have to be addressed and have to be treated, and we have to avoid exposure to the offending allergen, whether it is an environmental allergen or an ingestant, a food allergen.
Nancy Sanders: So the first symptom a mom might notice or a dad might notice is that the baby's nose is always congested, or the baby is always congested, before they notice that the baby is not hearing correctly. Would that be true?
Dr. Talal Nsouli: That is correct. So this could be an indicator at that time, and one can certainly be observant of that.
Nancy Sanders: So with the allergist, what you're getting is a real strategy, a real analysis. It's kind of like being detective and getting to the root cause of why these symptoms are happening in the first place.
So I want to give families a way of knowing when to see the doctor and what to expect the doctor to say.
Dr. Talal Nsouli: A very good question. The answer to this question-- because the consensus is as follows. If we are having three or more than three ear infectious per year, this means the discharge should be evaluated for possible underlying allergies and be treated appropriately to find out what could be the culprit, what could be the underlying allergen, in order to be able to get the appropriate treatment.
If the child, despite all this treatment, continues to have middle ear effusion, otitis media effusion, that will not respond to the treatment, and will linger up to six months, then the patient may benefit from the surgical procedure called tympanostomy tubes-- ventilating tubes that are placed in the drum. Let's keep it simple in order to ventilate the middle ear and to clear the mucus out. These are the consensus that we have right now.
Nancy Sanders: So babies can be tested for allergies, is that right?
Dr. Talal Nsouli: Babies can be tested for allergies, absolutely right. And mainly we see food allergy in kids that are below families of age, and even above families above the maximum. The maximum instance of food allergy does occur in children that are less than five years of age.
Nancy Sanders: OK. I'm going to ask you one more question. So if I get a referral to the allergist, what can I expect will happen? Is it one visit? Is it multiple visits? How does it work?
Dr. Talal Nsouli: Excellent point to discuss in here. Normally the allergist will sit down with patents and will take a careful history to know exactly the intensity of the symptoms, what's the chief complaint, what are the different issues that are bringing them to visit the allergist. Then after that, the allergist will do an allergy physical exam, will look in the nose, will look in the ears of the child, and then will perform a tympanometry, which is a machine that will detect, in an objective manner, any fluid behind the tympanic membrane.
And then after that, if the symptoms are strong enough to possibly suggest allergy, we'll move to the allergy skin test. And the allergy skin testing could be done as the allergist skin testing through the prick skin testing, or the in vitro allergy testing that has been improved tremendously within the last many years. And this will give us a good idea about whether or not the child is allergic, number two, what the child is allergic to, and number three, how severe are his or her allergies, to tailor an appropriate treatment.
So we have a complete strategy going on that has to be considered, and we have to respect the strategy in order to provide best medical care.
Nancy Sanders: Have a question you'd like an allergist to answer on this podcast? Send it to AskAnAllergist@aanma.org. That's AskAnAllergist@aanma.org.
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