Vol.6 Issue 1
Otitis media

We asked two clinicians with diverse approaches to patient care to discuss the management of a patient with asthma. The participating clinicians were:
David W. Miller, MD, FAAP, LAc, DiplOM – Dr. Miller is in private practice in Chicago and is a part-time faculty member of the Pacific College of Oriental Medicine.  He teaches the core curriculum course in Integrative/TCM Pediatrics at PCOM.

Arlene Sperhac, PhD, RN, FAAN – Dr. Sperhac is professor, Department of Women and Children’s Health, Rush University College of Nursing, Chicago, Illinois.

CASE STUDY

Jimmy Jones is a three year old male with a history of recurrent otitis media. Since his first ear infection at 11 months of age he has been on eight rounds of antibiotics. He presents to the clinic with a temperature of 101.2° F, irritability and ear pulling.  Visualization of the tympanic membrane (TM) reveals a bulging, erythematous membrane with obscured bony landmarks. 

Jimmy’s mother has a friend who has never taken her children to conventional health care providers and has not had them vaccinated against childhood illnesses. When they are ill, she takes them to a practitioner who uses homeopathic and naturopathic approaches to care. In view of her friend’s success and reports in the popular press that some ear infections may resolve without antibiotics, Mrs. Jones is reluctant to consent to another round of antibiotics. She asks for your advice.

Moderator: Dr. Miller, how would you manage this patient?

Dr. Miller: As medical doctors, it is our responsibility to be honest with ourselves and our patients about the limits of our treatment tools. Our mainstream doctors’ bags are a bit lacking when it comes to treatment options for otitis media (OM), in that our options are generally limited to antibiotics and surgery, as Jimmy’s case illustrates. While the superficial etiology of acute otitis media is generally understood (eustachian tube dysfunction with fluid accumulation, inflammation and superinfection), the role played by the underlying psycho-physiologic state of the host (the child) in creating an environment ripe for the development of either acute otitis media (AOM) or otitis media with effusion (OME) is not. 

Fortunately, most cases of OM (up to 80%) will resolve on their own with or without our intervention, and most people will outgrow their proclivity to OM as their anatomy matures i.e., the oropharynx will “drop,” while eustachian tubes will increase in diameter, become stiffer, and will angle downward from approximately 10° to 45°. Since studies have shown that a high percentage of infections will resolve without antibiotic treatment, the evidence basis for our antibiotic prescribing habits has been called into question.  In many cases, antibiotics are prescribed to palliate parental anxiety, rather than to treat the child’s condition. Thus, while we at times we can actively decrease OM-related morbidity, sometimes we seem to merely occupy the family until the child outgrows the problem.

Antibiotic therapy is not without morbidity and negative consequence. The selection of antibiotic-resistant bacteria is a growing problem. Additionally, since antibiotics distribute to other tissues, disruption of the natural bacterial flora of the child may also occur. Currently, research is being conducted to determine the effects of systemic antibiotic therapy on intestinal flora and the development of gut dysbiosis. 

At times antibiotic therapy and myringotomy tube placement is clearly the best solution to help children avoid middle ear damage, spread of infection to intracranial structures, and hearing loss. However, it would be preferable to prevent and resolve these infections prior to the need for these therapies. Both the holistic pediatric approach and the Traditional Chinese Medicine (TCM) approach seek to pinpoint the underlying problematic state which is leading to the propensity for the infections and tube dysfunction and to correct it.

In the current case, something is clearly not working for Jimmy. I would strongly support Mrs. Jones in her reluctance to go forward with another round of antibiotics without further history and physical examination. What I know about Jimmy is extremely limited and a more thorough history is needed to determine probable exacerbating factors in this child. Hence the treatment approach I would use for this child cannot be determined without further detail. What I can tell you is the overall approaches that might be taken.

For both a biomedical approach and a TCM approach, the first step is to determine factors in Jimmy’s environment and in “the environment of Jimmy” that may be problematic. For example, does anyone in the home smoke? Are there animals, dusts, molds, fumes or other environmental components that may be causing irritation and/or an allergic response in this child? If Jimmy were younger, we would question about feeding positioning as well, being sure that he was not taking a bottle in a supine position. We should still check if he is thumb sucking.

The TCM approach also considers seasonal components to Jimmy’s condition. As the environment changes throughout the year, modulations occur in temperature, humidity, “winds,” and other variables to which our bodies must adapt to maintain homeostasis. If for any reason Jimmy is unable to adapt to environmental demands, this will further his tendency to illness. To further emphasize the individual evaluation, we must know more about Jimmy’s constitution to apply this body of knowledge. For example, does Jimmy run hot or cold? A hot child may have more problems in summer, and a cold child in winter.

I actually saw a child today that can further illustrate these points. This was a three and a half year old African American male with a history of failure to thrive, asthma, a heart murmur and behavior problems. He was born by induced vaginal delivery at 8 months EGA, with a birth weight of 5 pounds, 1 ounce. He’s had problems with OM for as long as mom can remember, getting multiple infections each year. Interestingly, he tends to run high fevers, often without clear cause. He talks incessantly she reports; is extremely active; sweats a tremendous amount; has concentrated urine (not excessive urine); is “constantly constipated” with dry, hard stools; he’s thirsty; he gets “boils”; he does not produce much phlegm if any; he has eczema with very dry skin (mom had “greased him down” less than 2 hours before I saw him and he was very dry at exam); and his asthma is triggered by excessive play and heat. Mom says he has the most problems in the summer and in the winter when he’s indoors and the heat is on. Further, he’s frequently irritable and somewhat violent, to the point that she had him evaluated by a psychiatrist.  He generally uses only albuterol, but is currently on another round of amoxicillin.

A TCM doctor would look at this child and say heat, heat, and more heat! This is obviously a very different picture from a “cold kid” who’s tired, pale, passive, phlegmy, and cold, and who might have a soft voice, and normal skin. The diagnosis for our “hot kid” would include excess heat, likely blood deficiency (different from anemia), heat in the liver/gallbladder system, and potentially retained fetal toxins or a retained external heat pathogen. We would suspect he’d benefit from herbs that are cooling, moistening, blood tonifying, and that free-course the Qi and anchor and calm the spirit. He could receive acupuncture or pediatric Tui Na (Chinese massage) as well, especially using heat clearing techniques. The cold kid, on the other hand, would need warming, drying, “boosting” herbs that also clear phlegm and support the spleen system.This is clearly a totally different treatment approach for the same diagnosis of “otitis.”

There is a careful classification system in TCM to describe OM, and there is a differentiation made between acute and chronic OM. Factors which we would consider when treating with Chinese medicine include all mentioned previously, but also more about the underlying physiologic state. We would evaluate whether or not Jimmy is getting repeated syndromes, known as “wind-cold or wind-heat invasions with or without dampness”. These often, but not always, correlate with what we diagnose as “viral infections” in biomedicine. If this child is prone to these, and these frequently precede the OM, we must address the underlying constitutional disharmony (not “illness” in this case) that clearly underlies the predisposition.

TCM’s list of exacerbating and predisposing factors to OM also includes what is to me a fascinating, and I believe, brilliant observation. As illustrated by the “hot child,” a child that is chronically stressed and/or chronically angry will in some cases be predisposed to otitis media. In this case, the stress leads to what is known as “liver Qi stagnation with or without liver/gallbladder heat/damp-heat.”  Regardless of the unique terminology, as biomedical physiology advances, this underlying cause makes more and more sense.  Based on what the field of psychoneuroimmunology is revealing, we know that stress influences the state of the immune system. Cortisol reroutes white blood cells, for example. Stress and anger also alter sympathetic/parasympathetic balance, which disrupts any number of other base functions. 

As well, it is accepted as established fact that anger and stress lead to specific and predictable facial expressions and specific physiologic posturing. I would hypothesize that because these postures involve the face, head, and oropharynx, stress states may alter the tension in the tiny accessory muscles involved in regulating the eustachian tubes, specifically the tensor veli palatini, and tensor tympani. (I would refer the interested to an article by Joseph Schames, DMD, et al. called “Trigeminal Pharyngioplasty:  Treatment of the Forgotten Accessory Muscles of Mastication which are Associated with Orofacial Pain and Ear Symptomatology” for more background.)  Alteration in the functions of these muscles would lead to impaired eustachian tube drainage, even in the absence of other immune dysfunction.

What about “the environment of Jimmy?”  In holistic medical models, the body is seen as an environment influenced by innate factors, as well as diet and lifestyle habits. We need then to look at a number of factors: first, Jimmy’s diet should be reviewed.  Before we do this though a point must be emphasized. Many criticisms of holistic treatment techniques are based on “direct effect” thinking. For example, a practitioner will recommend a specific diet change and some will counter that “there’s no evidence that that contributes to ear infections” (e.g., the article entitled, “Fad Therapies” in Pediatrics in Review, 2005; 26: 371-376). Yet, in less linear paradigms, Jimmy’s whole physiologic state contributes to his ear infections, therefore maximizing his potential health will affect his tendency to illness. It is irrelevant whether a particular recommendation has been tied directly to OM. Common sense dictates that good nutrition must be a part of the treatment plan. 

In TCM, we note that what is termed “excess dampness” often contributes to ear infections, and that damage to the digestive system of the individual (termed “spleen taxation”) worsens this further. Hence, it is recommended that an individual avoid certain foods that promote damp. One beautiful thing about TCM is that it has already catalogued these foods. While in western theory we point to individual foods that may be of concern for reasons as yet unclear, in TCM there are broad categories of foods that are empirically lumped together as similar in ultimate effect to the individual’s physiology.  Here, dairy, sugars, highly refined grains and oils should be minimized or avoided. In addition to this, foods that are easily digested should be encouraged (such as soups and stews). Eastern nutrition also includes foods that may be specifically beneficial to given conditions. This interplay is too detailed to be expanded upon here, but Paul Pitchford’s book Healing with Whole Foods goes to some length to help in explanation.

Interestingly, there is a growing body of western health professionals finding patients who are responding negatively to dairy. This is not a factor in every child, and randomized trials that do not take into account genetic variation and that do not have a sizable study population (i.e., all the trials conducted thus far) will not reveal this finding consistently. This diet recommendation, in my opinion, should be offered to any child showing excess secretions and/or atopy. Particularly in a three year old with a varied diet, no harm will come from a two month trial off dairy. If nothing changes, the child can return to old eating habits. The caveat is that parents must truly stick to the plan (100 percent), and not relent to tantrums for ice cream every few days. Similarly, it will not hurt Jimmy to avoid refined white sugar, white bread, and “Cheeze Curls” for a bit. The hot child above was drinking a good deal of Pediasure to supplement his diet. Pediasure contains sodium caseinate and whey protein concentrate and a load of sugar. Probably not the best option for this atopic child, even though he’s not full of phlegm.

We should also look at other aspects of Jimmy’s medical history. Was he full term? Was he on a ventilator? Was he breast-fed? Do we have other reason to believe there might be abnormal structure to the oropharynx such as a minor cleft gone unnoticed? What happened at 11 months of age when he got his first infection (e.g. diet change, day care, new smokers in the house, new emotional stressors, upper respiratory or other infections, abnormal dental development, accidents which may have lead to structural trauma, did the family move from one climate to another)?

Other possibilities for treatment (not an exhaustive list) include chiropractic manipulation, craniosacral therapy, homeopathy, energy therapies, and certain types of massage. While as with current orthodox biomedical therapies, these have not been conclusively shown to be effective in all cases, I know many health professionals who  have found them to be effective. I would recommend, however, that parents seek out practitioners with specific experience in working with children.

Treatment in TCM will involve specific lifestyle, environmental and diet recommendations, with one or more of acupuncture, Tui Na massage, Chinese herbals, possibly medical Qi Gong techniques, and a number of other auxiliary techniques such as gua sha, cupping or moxabustion as appropriate.

So…treatment summary for both the Holistic western doctor and the TCM doctor: 

1.)  Careful history and physical
2.)  Environmental screening
3.)  Diet modification
4.)  Evaluation of the child’s cognitive state and psycho-social stressors
5.)  Holistic western: Treat the immediate problem and the chronic with (pick one or more): chiropractic manipulation, craniosacral therapy, homeopathy, energy therapies, western herbs and certain types of massage, IN ADDITION to dietary changes, lifestyle and environmental changes discussed
6.)  If absolutely necessary, do not abandon the possibility of another round of antibiotics.  However, the assumption should be made that this child has at least a beta-lactam resistant organism, and therapy should be targeted appropriately. One might consider tympanocentesis at this point. A thorough review of the previously used antibiotics should also be done, as he may never have received appropriate antibiotic therapy to begin with. If infections continue, myringotomy tube placement should not be discarded as a possibility as well.
7.)  When the infection is resolved, do a hearing test. Jimmy is at risk for loss.
8.)  Consider a course of probiotics. These are cheap, safe, and a growing body of evidence is suggesting their efficacy. Jimmy would fit the bill of a kid whose gut flora might be out of whack.
9.)  For TCM: Determine the details of the child’s physiologic state as classified by TCM. Use the tools mentioned above (acupuncture, etc.) to resolve (or support through) the acute infection, then work to restore balance so no further infections manifest.

Doctors to consider for this care:  Holistic pediatricians [find through the Holistic Pediatric Association (HPA) or the American Holistic Medical Association (AHMA)]; doctors of traditional Chinese medicine (licensed acupuncturists/Chinese herbalists); chiropractors with pediatric certification (International Chiropractic Pediatric Association); craniosacral practitioners with pediatric experience (The Upledger Institute); naturopaths (American Association of Naturopathic Physicians); homeopaths (North American Society of Homeopaths); and massage therapists with expertise with children (American Massage Therapy Association). 
Dr. Sperhac:  What would your plan of care for this child entail?

Dr. Sperhac:  Jimmy should be made comfortable, given plenty of fluids and treatment for his otalgia (ear pain). Taking into consideration Mrs. Jones’ preferences for and experience with caring for Jimmy, treatment of pain should be addressed.  Acetaminophen or ibuprofen, the mainstay of pain management for AOM can be used, alone or along with home remedies such as external application of heat or cold, topical agents such as benzocaine (Auralgan, Americaine Otic), or naturopathic (Otikon otic solution) or homeopathic agents.

Since Jimmy is over 2 years of age, the American Academy of Pediatrics Clinical Practice Guideline for the diagnosis and management of acute otitis media (2004) recommends observation and not immediately beginning antibacterial agents. This is an appropriate option since Jimmy's mother calls the office or brings him in when she has a concern. Observation is an appropriate option only when follow-up can be ensured and antibacterial agents started if symptoms persist or worsen. If an antibacterial agent is needed, amoxicillin is recommended because it is generally effective when used in sufficient doses, is safe, inexpensive, and has an acceptable taste and narrow microbiologic spectrum. The dosage should be 80 to 90 mg per kg per day. If Jimmy is allergic to amoxicillin and the allergic reaction is not a type I hypersensitivity reaction, cefdinir, cefpodoxime, or cefuroxime can be used. During the early period of management with antibacterial agents, Jimmy may worsen slightly; however, he should stabilize within the first 24 hours of therapy and should begin to improve during the second 24 hour period. If he has not improved by 48 to 72 hours, there is another disease present or the chosen therapy was not adequate. To date, there are no studies that conclusively show a beneficial effect of alternative therapies used for AOM.

There should be discussion with Mrs. Jones about risk factors for AOM. These include smoking in the home even though Jimmy may not be present when people are smoking, and group child care since reducing the incidence of respiratory tract infections by altering day care center attendance may help. She should also be told that Jimmy is growing and his eustachian tubes are narrower and longer (not as short and wide) as when he was younger. With growth, children generally become less predisposed to AOM.

Mrs. Jones is right to be concerned about starting Jimmy on another course of antibiotics since judicious use of antibiotics is recommended. The use of antibacterial agents in the management of AOM has been routine in the United States; in some countries in Europe it is common practice to treat the symptoms of AOM initially and only institute antibacterial therapy if clinical improvement does not occur (AAP & AAFP, Subcommittee on Management of AOM, 2004). Concerns about the rising rates of antibacterial resistance and the growing costs of antibacterial prescriptions have focused the attention to more conservative methods of treatment.

References

American Academy of Pediatric & American Academy of Family Physicians, Subcommittee on Management of Acute Otitis Media (2004) diagnosis and Management of Acute Otitis Media. Pediatrics 2004:113:1451-146