Building a Whole Person Approach for Earaches and Ear Infections (Acute Otitis Media)

An Introduction to Four Levels of Care:

Why talk about a different, or expanded way of doing medicine?

Mainly because the standard medical approach has become too one-sided. It’s main focus is to continually do more things, faster.

This one-sidedness comes from a belief that if we can manage and master an ever greater number of aspects of health, then we will all be healthier. It relates to a somewhat paradoxical definition of health as the absence of disease—which in daily practice means that if everyone has normal values for blood pressure, glucose, temperature, etc. then as a whole population we will feel better and live longer. There is of course logic in that view, mostly because outer, measurable markers are many of the tools we use for both diagnosis and management of an illness. But no single viewpoint is limitlessly appropriate, because if you push one viewpoint to its extreme it eventually brings imbalance (and often unintended consequences).

A present day consequence of this view is the continual development of more and more assessments and more and more interventions. We keep learning new ways to step in and change illness symptoms. New technologies accelerate that trend. A second consequence is that because there are so many things to be looking for we need to fit them all in, and so we are also constantly looking for greater efficiency. Put those two dynamics together and it means that we now have a medical system which spends a tremendous amount of money on testing and interventions, but tries to do it in less and less time. The care provided is complex, but scattered. And it becomes difficult, if not impossible, to fit in everything that is needed. We don’t have enough money or resources to meet all those expectations.

There is, however, a different kind of “complexity”—one that is not (yet) taught in standard medical education. It has deep roots in more traditional healing practices and recognizes that richness comes not just by adding more interventions, but by being able to think and act in multiple ways. That keeps us from getting too imbalanced. For example, more comprehensive healing asks that we not only address the symptom of the moment, but also explore “how did we get here?” That’s an second level of care, to watch for patterns and progression. That might seem obvious, but in a world of 8- to 12-minute medical visits, that perspective frequently gets skipped. We don’t have enough time to think about time.

An important third level of care asks us to look not only at current symptoms, or their progression, but also to consider: which symptoms are part of an illness process and which symptoms may actually be part of the healing activity? Why should we take time to think about this? Well, if blocking all symptoms helps you feel better in the short term (next minutes or hours), but actually prolongs the overall illness (in terms of days, weeks, or months) then we ought to know that. Otherwise we can end of chasing our own proverbial “tail,” wondering why something keeps coming back over and over even when we are doing lots of treatment. For some situations it’s absolutely necessary, in terms of both safety and for manageability, to step in and take control of an illness process. But much of the time we should also leave space to explore more options.

That’s because considering a third level of care also prompts us to think about the body’s own ability to regulate and heal itself. As knowledge and treatments have grown so much over the last century—spurred by advances like the discovery of aspirin or penicillin—we’ve maybe lost confidence in our body’s own ability to heal. We found powerful medicines and so we put them to use, a lot. That needs to be balanced by recognizing the things we can also do to support our own healing process. This third level gets exciting because it can go in a lot of directions, from things like simple homecare treatments and natural medicines, to individualized therapies, lifestyle recommendations, even meditation and mindfulness. Then we’re not just suppressing symptoms, we’re working to make real change.

Our view is not complete, however, without a fourth level of care. This aspect has never really left the art of medicine, but it admittedly does not fit so neatly into a mechanistic view of illness. It doesn’t thrive with protocols; it can’t be captured by a blood test. It’s a level which says: “I acknowledge the individual person who stands before me.” This part is completely unique. This level knows that, as human beings, we are continually changing and growing and learning. This level acknowledges that while illnesses and infections are stressful and inconvenient, they are also the way that our immune system develops. Similarly, this fourth levels points out that: physical strength comes from challenging work for the muscles and bones; that better balance and coordination come through movement; and greater synaptic connections grow in the brain with experience. We refine, we adapt by going through things. We are on a journey and we don’t want to lose sight of the fact that illness (and healing) are invariably part of it. Sometimes we learn a lot by standing right at the heart of our own healing process.

These four lenses may sound unusual. At the beginning, learning to work with them can even feel challenging. But they open perspectives for healing that are so needed in the world today.

To make these ideas more approachable, let’s practice this kind of fourfold journey. We can begin with a very common illness in younger children: acute otitis media (AOM)—more commonly described as earaches or ear infections.

The First Level of Care—Background Facts and Standard Recommendations

Many aspects of ear infections are well known and well-quantified. That serves as the starting point for our journey.

To build the first level of care, we need to gather information, especially about measurable, quantifiable aspects—numbers and statistics are very helpful here. We want to know facts like the rates of infections and frequency of usual treatments. Let’s begin.

Recent review articles share that “acute otitis media affects most (80%) children by 5 years of age and is the most common reason children are prescribed antibiotics.”[1] Acute otitis media is a common illness, “affecting 5 million children” in the U.S. each year, with standard treatment centered around the use of fever reducing medications (anti-pyretics) and antibiotics: “resulting in over 10 million antibiotic prescriptions in the United States (US) each year.”[2]

Common symptoms of an ear infection include fever, ear pain (or tugging on the ears), decreased hearing, discharge coming from an ear, and a balance disorder.[3] Diagnosis is based on seeing fluid behind the ear drum, as well as bulging and/or redness of the ear drum[4] (which medically is described as the “tympanic membrane”). Looking to see if it is possible to move the eardrum with air pressure (pneumatic otoscopy) provides one of the most accurate indicators of the presence of fluid and mucus. It’s important to know if discharge or drainage from the ear is due to a rupture of the ear drum, because of the high pressure that comes with a build-up of fluid and mucus in the middle ear, or if it is something like “swimmer’s ear,” where irritation or inflammation are only in the outer ear canal.

Once a diagnosis of acute otitis is made, treatment often turns to antibiotic treatment. Overuse of antibiotics is known to contribute to antibiotic resistance, as well as disruption of intestinal bacteria and increased diarrhea symptoms. Yet, “an IBM MarketScan database reported that 85% of patients diagnosed with AOM in the US and 80% of patients in Europe receive immediate antibiotics” and that“Electronic health record data indicate that more than 95% of children are likely prescribed an immediate antibiotic.”[5] That is a lot of intervention, that’s a lot of antibiotics! Are all of those necessary?

Such high rates of antibiotic prescription don’t really match the science. They are likely given so much because when we are faced with an uncomfortable or risky situation, everyone naturally wants to do something, to act. But there are additional good ways to support a child. Multiple other tools are available, though in order for us to understand them, we first have to talk about progression.

For the second level of care we begin by asking: How does child get to this point? Do ear infections just happen spontaneously on their own, or do they follow a pattern? And are there other helpers, beyond fever reducers and antibiotics?

Second Level of Care—Watching for Patterns to see Progression

The second level requires more than a single snapshot. It requires some time. It asks us to be observant and look at a child multiple times. But it brings essential insights. As we will see, the pattern and symptoms of ear infections really benefit from this extended view.

It’s true that fluid and/or mucus seen behind the ear drum may represent an infection, either a viral or bacterial one. A bacterial infection in the middle ear, left long enough, can then result in serious illness. There can be serious complications like hearing loss, mastoiditis (infection that spreads into the boney part of the skull behind the ear), or meningitis (infection that has spread into the fluid space around the brain, a space which is bordered by tough protective membranes, the meninges). Those are rare but dreaded outcomes, that may come as late steps in a bacterial infection and can be life-threatening. So, we know where we don’t want to go to that point.

To better avoid those complications, let’s go backward. What comes early on, especially at the beginning?

Antibiotics are given for ear infections in order to kill and reduce bacteria that may be growing in fluid which has collected in the middle ear (see diagram A). Differentiating between fluid which is related to a viral or to a bacterial infection is not so easy. Bacterial infections do carry more risk of progression or complication, but many ear infections will resolve on their own. There is consensus that a period of observation prior to initiating antibiotics can be appropriate for children whose symptoms are more likely to resolve on their own.[6],[7]  That group includes children who are two year of age or older and have healthy immune systems, who have no chronic ear conditions or ear drainage, who are experiencing only mild pain, who have had pain for less than 48 hours, and whose fever is less than 102.2°F/39°C. This means that, for many children, there is space to safely observe and watch the progression. Waiting also has an impact on intervention: “In studies, use of observation or delayed prescribing reduced antibiotic use by 65–88% and resulted in no difference in symptom duration, severe complications, or parent satisfaction.”[8],[9],[10],[11],[12] That’s interesting! To have basically the same outcomes, but with much lower antibiotic use and no increase in severe complication means that

·       Many of the children studied could get better on their own

·       Antibiotics are not always necessary

An additional aspect, which we know more generally, is that

·       A significant number of ear infections are caused by viral infections--and antibiotics have no effects on viruses

It is also true that there can be a combination of both a viral process and a bacterial infection, but they are usually not there at the same time. With many upper respiratory infections (ear infections, sinus infections, bronchitis, pneumonia) an illness process starts with a viral infection and then sometimes progresses to a localized bacterial infection, especially where there is a congestion of fluid and mucus. Very often the viral infection happens first.

This transition is useful to think about and to consider the steps from a viral infection to the gathering of congested or blocked fluid in which bacteria grow. Because by the time a child is sick enough to see a doctor, it may seem like there are really only two decisions to be made: first, whether there are signs of an ear infection, like congested fluid with an inflamed or bulging ear drum; and then, whether or not it should be treated with antibiotics. As was shown in the studies mentioned above, those two decisions often become one—i.e. if you see signs of infection, then you give antibiotics.

Perhaps because there are thousands of different variations of the rhino-, adeno-, influenza-, parainfluenza-, corona- and respiratory syncytial-viruses that come with most colds, little medical attention is given to those early stages. Treatment for otitis media typically does not begin until a later stage, where it’s important to determine if an antibiotic is needed. We know we can step in with multiple different kinds of antibiotics if we need to. That availability of antibiotics has perhaps made us a little blind to the whole process leading up to that point.

What works quite effectively, against both viruses and bacteria, is our own immune system. That’s why so many ear infections clear without antibiotics. Of course, children’s immune systems are still developing, but they learn and gain capacity through practice. When we say that a viral infection “goes away by itself over a few days” that’s not really accurate. It’s the immune system that works to clear out that infection. And some of the symptoms we experience during an infection are actually part of the way the body works to clear something out. Now that’s starting to enter into the third level of care—we’ll get to that. But before we go there, let’s complete a deeper look into progression and pattern.

To really explain those we need to look at the anatomy of the ear, the nose and the skull.

The ear is divided into three portions: an external canal (the part which opens to the outside on one end and extends in until you meet the ear drum); the middle ear, a hollow space where three tiny bones convey sound vibrations inward from the ear drum; and the inner ear, where the delicate sense organs for hearing (cochlea) and balance (vestibular apparatus) are located. The external canal and middle ear space are separated by the ear drum, which is a thin but strong membrane that moves sensitively in response to sound we hear from outside. The bottom of the middle ear space extends in and down via the eustachian tube, which eventually connects to the back of our nose. The openings for the eustachian tube—there is one for each ear, each side—are located near our adenoids. The eustachian tubes regularly open, which allows air pressure in the middle ear space to equalize with outside air pressure. That’s exactly what happens when your ears “pop” with yawning or chewing, especially when gaining or losing altitude in an airplane or while driving over a mountain pass.

For adults, the eustachian tube is larger, more developed and slopes downward as it goes from the middle ear to the back of the nose. That’s why it’s much less common to get an ear infection as a teenager or adult. In young children, that tube is smaller and often more flat. Children are also, by nature, full of tissue that swells up with infection or inflammation (like the tonsils and adenoids). This means that when they get a cold, tissues in the back of the nose tend to swell and can pinch-off the opening of the eustachian tube. When that happens, air cannot move back and forth between the middle ear and the back of the nose. That pinching-off also means that any fluid or mucus which gathers in the middle ear space cannot drain so easily. This is actually a key point in the process—that function changes, and what should be a hollow, air-filled space loses its connection to outside air. A congestion process begins. Once there is significant congestion of fluid and mucus, the body starts an inflammatory process to remove that congestion and clear things out.

When we know about this progression, then we can support the immune system in good ways. If we intervene earlier in the process, then the need for antibiotic treatment (a relatively late step) can often be avoided.

Summarizing the steps, it looks like this:

1.     Young child (lots of lymphatic tissue, more flat eustachian tube) >>>>

2.     Viral infection, with symptoms of nasal congestion >>>>

3.     Swelling of tissues in the back of the nose >>>>

4.     Eustachian tube becomes blocked >>>>

5.     Congestion of fluid and mucus in the middle ear >>>>

6.     Increased pressure in the middle ear >>>>

7.     Pain (from pressure), fever, difficulty hearing, +/- bacterial infection >>>>

Advanced stages:

8.     Complications like rupture of the ear drum (perforation) when pressure inside the ear becomes too high, or >>>>

9.     (rare) spread into bones and tissues surrounding the ear (mastoiditis, meningitis)

The need for antibiotic intervention in order to avoid more serious complications comes only many steps into the process. While we may not recognize it so easily, the immune system begins its activities for meeting and balancing a viral process already with steps 2 and 3.

One central tool for reducing antibiotics is to understand this progression and see that there are actually multiple steps along the process where we can offer support. We don’t have to wait until step 7 or 8 to begin helping.

A second, equally important insight is to recognize that for there to be real healing and resolution, the process needs to be balanced and resolved in backward order. In other words, treating with antibiotics helps reduce the number of bacteria multiplying in the middle ear space (an important intervention if a child has progressed far enough along these steps), but the underlying process of increased pressure, due to congested fluid, related to a blockage of the eustachian tube, still needs to be healed. It’s common medical knowledge that the ear drum may still look thickened for some weeks, even a month, after an ear infection. That’s true whether or not antibiotics have been used. A common complication of otitis media is that while symptoms of infection and strong inflammation may resolve, fluid may stay in the ear (which becomes a chronic “effusion” or fluid collection). That persistent fluid can cause reduced hearing, be with associated speech problems or even speech delay in some children.

Pulling back to a larger view, we see that the second level of care—time and progression—uncovers a whole pathway. Earaches and ear infections follow a typical course that unfolds over days. There are times when a child could get a cold, experiences sudden ear pain and pressure, then perforation of an ear drum, all in less than 24-hours. That’s not a common situation, and in that case it is difficult to have a child properly evaluated and treated in time to avoid rupture. What’s much more common is that a child gets a cold with symptoms of runny nose and nasal congestion, and then several days or even a week later, complaints of ear pain begin. There are also situations where one earache seems to come after another, even when antibiotics are given. That’s typically as sign that the process never really fully healed and that the middle ear stayed blocked and “soggy” instead of returning to an air-filled space.

Acute Otitis Media, with inflammation and/or infection of the middle ear space, is at its root an illness of congestion. The process begins with swelling that results in fluid filling what should normally be an air-filled space. Looking this dynamic will help us open up a whole range of additional supports, which will be explored as part of the third level of care.

 Part 2, is coming soon…

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