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.
I think that this is one of the most high yield topics that we can talk about as pediatricians and as otolaryngologist together. Um as you know this is so common and we we all struggle through this and it's very humbling even as an E. N. 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. And I'm also a company founder for a small medical device company that revolves around the development of tracheostomy alarm systems. Um to detect one the tracheostomy tubes out of the neck. So we'll talk about Otitis media and its history. The definitions of otitis media um and 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 A. P. And then we'll talk all about your tubes and when they're indicated and what kind of things can go wrong. And then also some new trends and kind of the future of management of otitis media. The tightest 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 uh so you know ancient Egyptians were Lansing ear drums and draining puss. There's some evidence of that Um and there's always been focused on, you know what causes otitis media is an allergy, is a bacterial base um is a 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 um since the 1950s and it still is one of the most common things that we do. Um We're always looking for ways not to put in tubes yet. It still is really, the most common surgery that we do is E. N. T. S. And so as I mentioned, allergy has been looked at as a potential contributing factor to otitis 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 1980s and 90s. And we really based a lot of our a lot of our treatment guidelines on this research that was done back then. Um and then watchful waiting has become a more of a focus ever since the 90s really and 2000s um Otitis media is very common as as we all know. Um 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 the M. T. Um to see if they need your tubes after after seeing you after 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 are the common times for your infections, not so much the eight year old, 10 year old, 18 year old. Um and so that can 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 um slightly. I feel becoming more common with the vaccine. Um Of course we do have the Hib vaccine but um still it's a predominant organism. Um Some say this is a less H flu is less painful and has milder symptoms, whereas strep Pneumo is very pilot 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 the tightest media age is still really a common risk factors. So we talked about your infections in Children younger than two or year and a half. That's the most common age. Otitis Media After Age six is less common. Um 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 and double blinded clinical trials. Family history is extremely powerful association. I always ask patients, you know, have our families have, have you or your 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 here. It's a really strong association. Um and uh it's something that we always look for daycare. Also. In fact we're seeing less Otitis media these days because fewer Children are 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 breastfeeding is a fairly strong association, tobacco smoke and actually marijuana smoke is a fairly strong, um, uh, pollutant which can cause mucosal swelling and therefore you station to dysfunction and then therefore you otitis media pacifier use uh, somewhat of a risk factor and 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 bill? 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, that 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 problem issue. Station tube, this 1.5 cm area of real estate is the root cause of so much problem that goes on with a year. 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 master bed compartment for that matter, Um that space can fill up with fluid and as soon as 20 minutes. Um and the reason for that is that you get negative pressure when the station tubes don't open and close that well. The negative pressure is from rapid gas absorption, um 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 or faces to swell. Shut The ears fill up with fluid, usually a thin fluid. And then over time the water gets reabsorbed from that fluid and so you start with a serious effusion and then it goes to a McCoy diffusion Or glue here 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 the 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 frankly we have difficulty with this at 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 you or I, so you know, starts as a cold and the next thing that years start to hurt, it's really painful, the middle ear, it's filled with puss and that's under pressure and it's it's bowing out that your drum laterally and that is really painful. Your drum has a ton of uh nerve innovations and it's it's really painful to have, you generally get fever because it's such an inflammatory reaction. Um and then you have this bulging to panic membrane and then there's a cloudy appearance to it. Think of the urge to make a hazy window that you can kind of see through um and you know, you tend to see plus um so plus behind the eardrum pain must be there. Uh you know, it's a rip roaring infection um 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 to have have that, although you're tugging can be common and this is an important thing to talk about your italian, most Children touch their ear, they experiment with their ear touching it, it doesn't necessarily mean they're in pain. Oftentimes they're noticing that they can't hear as 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 can still tug on their ear and this fluid causes a 20 decibel hearing loss and that you're done will appear dull and pacified. And 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 eardrum. Um And sometimes yes they can have poor balance so bulging to panic members in simple single most important sign. And then look for translucency and we'll go through some pictures. But and also pneumatic A. Tosca. P. Is a good way to see if you can move that year time. I'm always that reliable though, so we actually focus more on just the appearance of it. Uh Panna grams are also helpful. So you know type beats and pentagram is indicative of a. Um or O. M. E. Um. Type A. S. Or short. Type 18 panna graham sometimes is indicative of serious fluid. Um And then type regular. Type A. And type C. Is negative middle ear pressure with the urge on this sucked inwards and then um Let's look at some diagnostic dilemmas. Just plain old. Oh diarrhea draining here. Um Sometimes you know we're often asked if this can be a titus external A. Or is this otitis media with tim panic membrane rupture. And sometimes the treatment is the same for both. But um 99% of the time if you see a draining here, 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 ear and it's not titus external to. And the difference is otitis external. When you look, 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 trigger is pulled up in and sometimes that's tender but you should see a swollen your canal. Whereas acute otitis media with tim, panic, Miriam rupture, there won't be any swelling, There'll be um oh diarrhea and fluid cake around the sides of the wall but that your canal itself won't be swollen. Um And so artery is almost an indicative indicative of titus media with rupture. Please give oral antibiotics and drop, 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 flocks and is covered by almost all insurance. It's very affordable rather than cortes foreign or super decks or super agency. Um Okay. And then went to refer for for oh diarrhea. Uh 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 close to home at that point. And then if drainage has lasted longer than two weeks we become concerned about cholesterol toma hiding somewhere. Um And then other diagnostic salama's abnormal your findings. Um This is a patch of temporal sclerosis, it's calcium plaque and it's usually from previous ear infections. Sometimes this looks like cholesterol toma and it can be difficult to discern but this is usually just a thin plaque embedded within the region. Whereas 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 and occupy the entire drum. Um and it's just a sign that someone has gone through prior your infections and we see it quite a bit. I'm sure you do too. Okay, so white patches are usually timpano sclerosis. Um look out for a sunken in ear drum or really retracted your drum. And if you look inside of here 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 reflex reflexes that seem in odd places. You see these defined what looks like obstacles or hearing bones. Um This is a sign of your joint retraction, which is likely occurring over months to years and um if it goes long enough it will it will erode the obstacles and then the patient will get what's called a maximum conductive hearing loss which is about a 60 decibel hearing loss. Um And that's essentially when there are no longer using their hearing bones to here. Now they're just using the vibrations of their entire skull um to then transmit to the cochlea which still works. Um And so 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 a bit older kids, Children after the age of six and then uh cholesterol toma. I mean this is something that we are always on the lookout for cholesterol. Toma is basically a skin cyst um that goes awry and grows inside the middle ear space and causes destruction And um the most common finding is um crusting that you'll see sometimes crust on the eardrum 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 rule out a cluster toma. And this requires surgery, There's no medication for it and it can cause deafness over time and it certainly can be fatal over time. Can cause meningitis and and uh and intracranial problems. Um The lingering effects of otitis media. You know this is good data to not commit to memory but just it helps understand why we put in tubes and how middle ear fluid 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 flu gets reabsorbed or goes down the station tube. And we have Good literature on how how how long this takes. So with infusions, you know, let's say you see an infusion um 40% of the time it's still gonna be there in one month. Only 20% of the time. Well that infusion 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. Um and so 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 flew to make sure it does go away. Otherwise it will result in um not permanent hearing loss but they're not going to be hearing well during this time. And that's going to have effects on their well being as far as the school performance. Um 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. Um 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 slosh 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 uh amber fusion that's usually indicative of thick viscous effusion. Like um you quoted infusion basically mucus in the middle of their uh and this is a real infusion. You can see that your jumps under pressure and bowed outwards. This is a serious infusion because you can see air bubbles. Um You know Children can actually hear quite well sometimes with serious infusions. Uh This is um you got 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. Um And uh these are views with an endoscope so may look a little different than what you're used to. Um But yeah, this is glued here. You know if we were to do 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 an ear infection or the fluid developed because of a cold and the you're 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's a that's obviously it 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 is 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 are indications in our literature for ear tubes in our treatment guidelines. So we classify that as recurrent acute otitis media and 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 mucoepidermoid lint or coid, but any kind of fluid that's there for longer than three months is otitis media with effusion. Um And then you have a draining ear chronic separated 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 and 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 because hearing loss is just so isolating I think that it sets up a cascade 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 resources and then complications. But really I think speech delay an impact on social development. School performance are equally important. Obviously, you know, there can be deadly complications from otitis media, but usually it goes okay and usually they recover 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 the patients early life. So the impacts, you know, um Average child experiences three months of decreased hearing. Um And these are important formative months for the child. And so this can affect their speech discrimination and background noise when they have an infection or when they have fluid. We've looked at cognitive development. So auditory processing skills and attention and speech and language and educational outcomes such as reading comprehension. Um And it seems that earlier Otitis media has a greater impact on education and attention outcomes um until the ability to stay focused. Um And then central auditory processing is another issue that we borrow a lot of, we make a lot of um we infer 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 respond. And so um some of these patients are kind of get labeled as spacey or just kind of not really really slow, they hear fine, but they have difficulties with processing. And so this is picked up by an auditory brainstem response. And maybe our test can't 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 kind of issues and 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 and and ear infections, but there's other effects on just auditory memory and um an auditory processing skills and um that we thought we feel linger. Um And then 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 um this has been a kind of an interest and certainly of mine also just the psychosocial impact of not hearing well. Um And I see so many Children school age Children who get a lot of your infections or who have fluid and they tend to act out. They tend to um 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. Um And so you know if you find a child that has behavioral issues and has a history of Otitis media um I would check their hearing because it's an important box to check because sometimes not hearing what will cause the child to 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 can be very frustrating. Um So let's talk about quickly about complications of otitis media. Um Master data. This 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 mast oid. And um you can think of the ear, the middle ear space kind of like a house. Um It's a room, it's a 11 room house and Only has one opening 1 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 attic. It's about the same size as the as the house itself and the attic is the mass toyed. And actually we even have a name for this communication between the two sites and that's the Adidas at Antrim. We also call it the attic and that's the pathway to them asteroids. So a middle ear infection can spread to the mass away through the attic. And um there's puss in both and it's basically the same process in both. And once it spreads to the mass away, the puss is looking for a way out or the body is looking for a way to drain it and it drains out behind the ear. And that you can get a subpar hostile 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 auricular lymph node and you almost always need to c plus behind the eardrum. So it's it's really an ear infection gone arrived with puss in the master right now can spread to the brain and can cause an abscess. So um in order for everybody to be mastered itis there has to be passed behind the eardrum. It's really hard to have it without that. So um we diagnosis with a cat scan generally and um and the treatment is generally an ear tube and mastectomy. So an incision behind this area and drilling out the massive void cavity. Uh CT scans are really helpful. Um 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 master otitis 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 the mass died. But there's no bony destruction. Whereas mastered itis. You have bony destruction. It's such a aggressive infection that the regular bone of the asteroid is eroded and then um sometimes we will see an abscess. And so that's how we distinguish the two. Um you're dumb perforation. We can get after many year infections or after a really bad ear infection under pain or under pressure. And we have good data on how commonly these clothes. Um 90% will close within four weeks. And so if you have the tightest media that ruptures and drains out that 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 uh perforation closes. And of course the E. M. T. S. Are always happy to do that. Um But it's certainly something that you can do as well and you can double check that it's closed by doing a timpano graham. Okay let's talk about just treatment guidelines in general. Um and this is more relevant for the you know treatment guidelines as far as antibiotics. Um and so that 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 they're key statements where that um you should diagnose securitize media and Children who present with really moderate to severe bulging of the year jump. So a bulge in your jump has to be present. That's a statement one a statement and um you may um so they do mild, moderate and severe bulging. Um, I just think if there's bulging at all, um, that's in your infection because fluid generally doesn't bulge the eardrum. So, um, but yeah, if you see bulging, that that's really the most indicative thing of an ear infection and medical catastrophe can help. Um, their, their statement once he says you should not diagnose acute otitis media and Children who do not have middle ear effusion. So they must have a middle ear effusion to for otitis media to even be present. Yeah. And then they also mentioned, the observation may be appropriate when the child is a federal, if there's no your pain. And again, I think that you're tugging doesn't count if the child's touching their ear doesn't necessarily mean they're in pain. They may just be experimenting with, you know, they're not hearing as 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. And then also have close follow up. This is possible, you can't observe and then here's another summary of their antibiotic choice. So amoxicillin remains first line um but Augmentin many gravitate towards that. I do like Augmentin for acute otitis media, especially in older Children. Um and then alternatives are sefton here and then um um paroxysm and and uh and subtract zone obviously for one or three days I am dose and you know we see many patients who have gone through this this algorithm and then they were making their way to the anti doctor for this prolonged infection. And so um you know really consider augmenting 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 Augmentin in general. Um There's controversy over the first line therapy, so due to the diminished presence of strep pneumo um and the increase in the incidence of h flu and marcela. And so Augmentin has been more considered because of that. And then of course the subtract zone for three doses for three days if an insulin resistance is suspected and the duration of therapy, I'm just kind of summarizing the treatment guidelines from 2013, um 10 days for age younger than two years old, or any age with severe symptoms, seven days for age 2 to 5 and 5 to 7 days for age six and above if it's if it's mild um And then just general controversies in 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. Um and that and only the first one really I think needs antibiotics. And then is this a viral infection, bacteria 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 drum really just but you know, parents are they're really anxious and everyone, everyone is suffering and you want to treat. Um but you're unsure if it's indicated. And 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 this 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. Um And sometimes the patient will have you know, a resurgence of pain due to your 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 these are all just interesting caveats of what we see on every day. And so um Watchful waiting has been endorsed since 2004 uh and they really emphasize the accuracy of the diagnosis more recently. So watchful waiting for Children 6-23 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. Um So, you know, I 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, and all these international treatment guidelines that I've looked at watchful waiting, they're much more inclined to recommend observation um which is interesting. So what's the waiting is the initial management? Um Nearly for all uh your infections in Korea. Um and then the Japanese ontological society really endorsed watch awaiting more from mild symptoms for all infections for the 1st 72 hours. So even if there is pasta behind the eardrum, 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 um for all and then of course the United States. Um So in non severe otitis media, the clinician should either prescribe antibiotics or offer a close follow up without antibiotics um if they don't seem to be in pain, so pain is really an important descent uh important point in the distinguishing the difference. And then of course no prophylactic antibiotics for recurrent otitis media is indicated. Um And then additional considerations, you know, um if you have a draining here 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 separate decks, which tend to be expensive and then you have to pay out of pocket for it um depending on the insurance and um so if there is a draining here, 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 and I feel there was synergy um being able to equalize pressure, so pinching your nose and blowing or 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, Afrin, 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 to happen naturally. The best ways. Um cleft palate. You know, these patients are really prone to your infections and types media so be aware that they often need ear tubes. Um obesity has been looked at as a risk factor. You know, these are just kind of more recent studies that have looked at this kind of thing. And um we do find that there is a slight uh mm predominance with obesity and musician tube dysfunction also. Um one of one of the nerves important for taste travels through the middle ear actually. Um and so if you have a lot of episodes of inflammation, that nerve doesn't work as well and so they don't taste things as well. And so they like to have a higher fat diet with more salt and found that that to be true. And especially adults actually. Um let's talk quickly about your tubes. I realized we're kind of approaching the ends are close to the end. Um 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 food longer than three months, those are the kind of the anchoring indications for ear tubes. Um And then sometimes we recommend thyroidectomy and um you know, how could remove the adenoids help the years? There's a lot of good literature on this actually. So annoyed. Ectomy is indicated for the child who needs your tubes if they're older than four or if this is their second set of tubes or third set or four set, we recommend an appendectomy. The adenoids. The animal tissue is a part of lymphoid tissue. It's similar to console 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. Uh X rays are helpful but not not shown to be as effective as a nasal endoscopy that we can do. And if you shave this tissue down it can um it can open up the station tube or faces. And when we do not need ectomy, we actually are seeing the the openings of the station tubes on either side, and we often see this tissue blocking the two blocking the openings. And so removing it has been shown to be very effective and that's why we do add up to me with tubes sometimes. So clinical paroles um just to kind of wrap up for acute otitis media. I really think that they must have a pure linen fusion pain and usually fever if they're not in pain. If they're not in discomfort they may be touching the year from time to time and parents may be worried about that. But if there if they 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 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 define but a acute otitis media, they're really they're going to have a cold generally and a painful ear infection not acting themselves pretty fussy whereas for fluid it might be a little bit fussy but no fever certainly not in tremendous pain. Um And for a draining here use that to your advantage, give drops in addition to oral antibiotics. Um If the drainage persist for longer than two weeks I recommend a referral to E. N. T. And um if any child has a you or I they are likely to have a middle ear effusion and 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. Um We have good data to show that that food will usually persist and then they'll go through periods of not hearing well and 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 you can have a profound effect. Tubes are helpful but they can also cause harm. As an anti doctor I'm always looking for a way not to put in your tubes. Um 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 ear drum. 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 care patients. Where you become a your patient for life, you have a thin your drum that ruptures easily, then you have a long term perforation and you have to get that repaired and then it may not work, and then you have drainage off and on and it just sets in motion this whole cascade. So tubes are helpful, but we're really looking for ways not to put them in if necessary. Um and so watchful waiting when the diagnosis is uncertain is really recommended. So, if you're unsure about deputized media, I really recommend observing for a period of time um unless the patient is really in pain and has fever, and so when you refer uh if the tightest media's, I recommend referring to anti if there's the tightest medium setting, the speech delay if the food has lasted 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's a 20 decibel hearing loss or greater or any difficult, your patient for that matter, concluding thoughts um is a diagnosis is in the eye of the beholder. Uh Apologies for this, I think my colleagues um uh computers going, but um the media's challenging and encourages the practice in the art of medicine. The decision, which were for early, can have a lasting impact. Um So please don't hesitate to refer astro 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 an ear that's been draining off and on for years as a sign of a cluster toma and then they need to be evaluated and um 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 as well. Uh 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 8-6. And this is kind of a one stop shop way to refer, patients can call, so can physicians, doctors, offices, anyone and um a patient can schedule a family, can schedule a appointment uh And then you can also process the referral through this number and then the facts 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 or on both sides of the bay. We kind of have a one day campaign or or vision. Um And so this is in walnut Creek Brentwood and of course Oakland Mission Bay and also in marin. And we'll be expanding also I think on the peninsula and Redwood shores. So um thank you so much for listening.