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PODCAST Ear Infections with Dr. Bradley W. Kesser

01/03/24 Bradley W. Kesser, MD, University of Virginia School of Medicine;

Season 5 | Episode 6


Joe McIntyre (Host): Welcome to another episode of the Merck Manuals Medical Myths Podcast. On this show, we set the record straight on today's most talked about medical topics and questions. Today, we're putting down the Q-tips and ear candles and listening to what an expert has to say regarding ear infections. We'll dive into the world of ear health and explore different types of infections and treatment options.

I'm your host, Joe McIntyre, and I'm joined today by Doctor Bradley Kesser, MD, with the University of Virginia School of Medicine. Dr. Kessler specializes in congenital ear disease, hearing loss, dizziness and balance disorders, chronic ear disease, and infections. Today, we're going to explore ear infections and some of the myths and misconceptions surrounding them. Dr. Kesser, thanks for joining us.

Dr. Bradley Kesser: Hi, Joe. Thanks so much for having me.

Host: Well, it's great to have you here. So, let's start with a pretty easy one probably for you. Can you tell us a little bit about what exactly ear infections are?

Dr. Kesser: I think to understand what ear infections are, we have to understand a little bit about the anatomy of the ear. So, we talk about the ear in three different parts. There's the outer part, which is the oracle, the part that we kind of see on the side of the head, which also encompasses the ear canal and the outer part of the eardrum, which we call the outer ear. The middle ear is an airspace on the other side of the eardrum that contains the little ear bones, the hammer, the anvil, and the stirrup. As those ear bones vibrate, they send the sound energy to the inner ear, which is the cochlea, and the cochlea is the snail. It looks like a spiral. It contains these very, very highly specialized cells called hair cells that convert the mechanical energy of sound into an electrical signal. That signal then travels down the hearing nerve. You can think of the hearing nerve as just a wire that carries the signal from point A, the cochlea, to point B, the brain. And then the brain processes that information into meaningful words and sounds. Now when we talk about ear infections, any of those parts of the ear can become infected, and each of those infections has its own nomenclature, its own name. Each of those different types of infections also has its own presenting symptoms, has its own diagnosis, and obviously has its own treatment recommendations. If you'd like, we can start from the outer ear and work our way inward. Does that sound reasonable?

Host: Sounds perfect to me.

Dr. Kesser: OK, perfect. So, the outer ear can become infected. We call that “otitis externa.” The common name for that is “swimmer's ear.” The most common cause of otitis externa is a combination of water exposure and Q-tip use. Yes, Q-tips are terrible for ears, and everybody wants to clean and buff their ears, but Q-tips are terrible and what Q-tips do is they create tiny little micro-abrasions or micro-cuts in the delicate skin of the ear canal. Those little micro-abrasions or micro-cuts are portals of entry for bacteria. When we swim in the summer - and we see lots of ear infections in the summer when kids go to the pool - then the combination of the water exposure and the Q-tip use will give an otitis externa or a swimmer's ear.

The symptoms of swimmer’s ear include pain. Pain is the number one symptom of an ear infection. You can also see swelling and redness around the opening of the ear, and if the ear becomes so infected or so swollen that the ear canal closes shut, then hearing loss is a symptom of otitis externa. The treatment of otitis externa is a very careful cleaning of the ear in the office. So, when we see these kids in the office, I get them under the microscope and I use a little bit of a vacuum to try to remove all the debris - the dead skin, any water that's trapped in the ear canal. Then I put them on topical antibiotic therapy. When we think about ear infections or we think about any infection, we think about antibiotics for ear infection actions, in fact, oral antibiotics. You know, an antibiotic that you would need a prescription for you take by mouth, that's not the preferred treatment for otitis externa. The preferred treatment for otitis externa is topical antibiotic therapy. And there are a number of different topical antibiotic ear drops on the market. Now you do need a prescription for topical antibiotics, so you might present to the emergency room, you might present to the pediatrician, your primary care doctor, or even an ear, nose and throat doctor - that's me. And we'll give you a prescription for a topical antibiotic drop.

Host: You mentioned a lot of children get this, but that doesn't mean children are the only people who get swimmer’s ear, I'm sure?

Dr. Kesser: That's exactly right and there's a different condition that we call “chronic otitis externa.” Chronic otitis externa is an inflammatory condition of the ear canal that's characterized by itchy, scaly, flaky, draining ears. It's typically not painful, but it can be extremely itchy, so we treat chronic otitis externa, again, with very careful cleaning and debridement and removal of any debris under the microscope in the office. We keep water out of the ear canal, we keep Q-tips out of the ear canal, and we often will treat them with a topical steroid preparation, either over-the-counter hydrocortisone cream or there are prescription strength, more potent topical steroids that will calm the inflammation that we see in chronic otitis externa. Another common cause of ear inflammation, we often see this in adults and in Q-tip users because, in order to get to the itching, you’ve got to use a Q-tip and the Q-tip only perpetuates the process. You have put the Q-Tips down and, as I tell patients, I will get the itching under control. If you can get the Q-Tips out of the ears and maybe use them for your belly button or something, someplace else.

Host: Dr. Kessler, can you tell us about the other two parts of the ear and how they may get infected?

Dr. Kesser: Yes. As we work our way in, we come to the eardrum and the airspace on the other side of the eardrum, we call the middle ear. An infection in the middle ear we call “otitis media.” Whereas an infection in the outer ear is otitis externa, an infection in the middle ear is otitis media. Otitis media is very common in children. The presenting symptoms are often pain, fever or hearing loss, pulling or tugging at the ear and fussiness, the toddler or the infant won't sleep. They're pulling or tugging at the ears, and this is essentially an infection or puss behind the eardrum. And it's very painful as the eardrum stretches because of the puss in the middle ear, that's painful and can cause fever. In contrast to the swimmer's ear or the otitis externa where we used topical antibiotics, for curing otitis media, we do need systemic antibiotics to cure the infection. I want to be clear, though, that the antibiotics will clear the infection but it won't necessarily clear the fluid.

After the child gets on an antibiotic, the pain goes away, the fever goes away, the fussiness goes away. But if the fluid doesn't go away, the child is left with hearing loss and a full ear. If you've ever been underwater and tried to hear somebody talk to you from outside of the water at the pool edge, you can't hear them very well. Children with persistent fluid behind the eardrum, we often recommend sending for a hearing test or to send to an ear, nose and throat doctor for an evaluation. So that otitis media can become chronic. Chronic otitis media with effusion just means a fluid collection in the middle ear space, even though the child doesn't have fever, doesn't have fussiness, doesn't have pain, they can't hear as well as they could because of that fluid in the middle ear. Sometimes if that fluid persists, we'll recommend putting in grommets or ventilation tubes or tympanostomy tubes or pressure equalization tubes. There are a number of different terms for tubes that we place in children's ears.

Host: Now, how about that the third part of the year? How may that get infected?

Dr. Kesser: The third part of the ear is very durable and very resistant to infection, thankfully. Interestingly, the cochlea, the organ of hearing inside the inner ear, is surrounded by the densest bone in all of the body. So, it is very well protected by extraordinarily dense bone. Nevertheless, the fluid inside the cochlea can become infected and the symptoms would be typically significant. Hearing loss accompanied by dizziness, vertigo, or the sensation that the world is spinning around, and often fever as well. Sometimes patients will have some drainage from the ear, but an inner ear infection is heralded by severe hearing loss and usually by dizziness, vertigo and imbalance. And thankfully, fortunately, inner ear infections are quite rare.

Host: Now, can all ear infections cause permanent hearing loss potentially?

Dr. Kesser: Typically, otitis externa, outer ear infections, will only cause temporary hearing loss as the ear canal is swollen shut but once the ear infection is treated, the ear canal skin reverts to its normal configuration or it reverts to its normal thickness and the sound can now get into the air canal and the hearing is restored. With middle ear infection and fluid in the middle ear, typically hearing loss is also temporary. If we can get the body to absorb that fluid, then when the fluid is gone, the eardrum vibrates properly. The ear bones vibrate properly and the hearing is restored, so that hearing loss is typically temporary. Now for inner ear infections, if it's a bacterial infection, unfortunately patients will lose their hearing and that is permanent.

Host: Now, how can you tell the difference between ear pain that may not be an infection and an ear infection? Is there a way, especially as an adult, to tell? But I'm sure children are a little bit difficult since they can't communicate it as well.

Dr. Kesser: That's a great question, Joe, because I see a lot of patients who present to me with ear pain and they come to me with the history. “I've been on multiple antibiotic ear drops. I've been on multiple antibiotics by mouth, and nothing seems to get rid of the pain.” I want to stress to the audience that not all ear pain is an ear infection, especially in adults. The most common diagnosis that I see in adults that present to me with that clinical scenario of ear pain, but no real hearing loss, no dizziness or balance disorder, is stress on the temporomandibular joint. The temporal mandibular joint, or the TMJ, sits directly in front of the ear canal. The front wall, or the front bone, of the ear canal is the same bone as the back wall of the jaw joint. I tell patients, put your finger in your ear and open and close your jaw. You can feel your jaw joint moving in the ear canal. If you get stress or strain on the jaw joint, it will feel like ear pain in the absence of a true ear infection. The treatment for TMJ strain would be heat and a soft diet, so rest the jaw and a little bit of ibuprofen or Advil or Motrin. It’s a very common cause of ear pain in adults.

Host: Now, so many of the infections you've talked about children are prone to more so than adults. Why is that the case?

Dr. Kesser: Yes, children are very prone to middle ear infections. Not as much as outer ear, but definitely, they're prone to middle ear infections. To understand why, I have to teach you a little bit about the physiology of the middle ear. As I mentioned, the middle ear is an airspace. It has air in it. So, you might ask the question, “Well, how does air get in the middle of our head in the middle of our skull?” There is a little tube called the eustachian tube that brings air from the back of the nose into the middle ear. Every time we swallow, yawn, pop our ears, that's the eustachian tube opening to deliver air into the middle ear. So, if you swallow right now, as you're doing with your water, you will hear your ears pop, and that's a totally normal physiologic function of the eustachian tube. Now, in children, the eustachian tube is short. It's wide and it's straight, so it doesn't do as good of a job getting air into the middle ear, or I should say, it doesn't do as good of a job protecting the middle ear from all the snot and all the mucus in the nose. Mucus can travel up the eustachian tube and into the middle ear and cause an ear infection in children. As we get older, the eustachian tube matures - and what I mean by that is that the eustachian tube elongates, it becomes longer, it becomes narrower and it takes a bend, and in doing so it does a much better job of protecting the middle ear from all the mucus and all the secretions and snot in the nose. It also does a much better job of delivering air into the middle ear to prevent fluid from building up in the first place. Now, there are adults who have eustachian tube dysfunction, where the eustachian tube still doesn't do a very good job of bringing air into the middle ear, and there are certainly adults that need ear tubes or more extensive surgery to help their eustachian tubes.

Host: Now for a parent or parents who have a child who may be particularly fussy, how can they know that their child is dealing with an ear infection? Is there any way to know other than taking them to their pediatrician? Or is there something else they should be looking for?

Dr. Kesser: The fussy child who can't verbalize or can't tell you what's wrong can be a challenge. Is it an upset tummy? Is it an ear infection? Are they cutting teeth and have mouth pain and gum pain? I think the only way really to diagnose it for sure is by taking the child to a pediatrician and having the pediatrician look in and diagnose an ear infection, and usually in that scenario, an otitis media, a middle ear infection, to get that child on some antibiotics. Now sometimes the ear infection will be so bad that it will rupture the eardrum and if the eardrum ruptures, the ear now starts draining puss, which actually is not horrible because of ruptured eardrum, even though right up into the rupture it's extraordinarily painful, once the eardrum lets loose, the pain goes away and the fever goes down, because in essence, you've drained the infection or the infection has self-drained. And now the child does need to be on antibiotics. But thankfully, the child is not in as much pain and it doesn't have fever as a result of a ruptured eardrum. I will also reassure you, in the audience, that 95% of ruptured eardrums from infection will heal on their own.

Host: Dr. Kessler, how effective is the wait-and-see approach when it comes to ear infections? Is that safe? Is that effective? How long should parents wait before seeing a doctor for their child?

Dr. Kesser: Many years ago, we thought as a specialty, we were putting in too many tubes and that was probably accurate. What we are finding is that you don't necessarily - I mean you need to treat the child with an acute ear infection with antibiotics. The antibiotics will sterilize the fluid. The question is how long do you need to wait in a child's ear with fluid who doesn't hear as well before you recommend ear tubes? I would say a starting point of three months. If the fluid has not cleared in three months, I would recommend referral to an ear, nose and throat doctor and to an audiologist for an audiogram, a hearing test, to see how much hearing loss the child has as a result of the fluid. Now, the audiologist or the ear, nose and throat doctor may not recommend putting in those ventilation tubes. They may recommend continuing a wait and see approach. Most children's ears will clear the fluid with time, but you don't want to wait too long because the child does have a hearing loss as a result of that fluid and we can restore their hearing with insertion of the ventilation tubes. So, as a first blush, I would recommend three months referral to an ear, nose and throat doctor and an audiologist for a hearing test. Based on the hearing test and the ear, nose and throat doctor's exam, either waiting or potentially recommending moving forward with ear tubes. But during that three month period, I want to stress that the child does not need to be on antibiotics. Antibiotics alone will not clear the fluid. The ear, the body has to clear that fluid, and if that fluid hasn't cleared after three months, I would recommend referral to an ear, nose and throat doctor.

Host: Let's talk a little bit about some of the myths that I'm sure you've heard over the course of your career. First starting off with airplanes and cabin pressure, is it possible to get an ear infection from the cabin pressure when traveling on airplanes? I know so many people feel or experience discomfort or even pain on airplanes. Is that an ear infection or is there a way to get an ear infection that way?

Dr. Kesser: That is a real problem for sure in patients with eustachian tube dysfunction. We talked about the eustachian tube and its role.  If your eustachian tube is not doing as good a job of getting air into the middle ear, then if you change the pressure on the outside by going up or down in a plane, by going snorkeling or scuba diving, you've got to change the pressure in the middle ear space and it's the eustachian tube that does that. If you travel in an airplane, usually the ascent going up in the plane is not a problem because you're going from higher pressure at sea level to lower pressure at a higher altitude, 30,000 feet. Of course, cabins are pressurized, but people get into problems when the plane starts its descent and people worry about long plane trips over to Europe or to Asia. Well, interestingly, the longer plane rides have a much slower, more graduated descent. It's the short plane rides from city to city within the United States that can be very challenging. The plane goes up relatively quickly and the plane comes down very quickly, so you're going from a high altitude at maybe 20,000 feet down to sea level, and that change in barometric or change in altitudinal pressure can put a lot of pressure on the eardrum. The things that I recommend for patients who have trouble on airplanes - and that's not necessarily an ear infection, that's just pain on the descent of the plane - the things that I recommend for patients who have trouble with airplane or any change in in altitude or atmospheric pressure would be first to chew gum and try to pop your ears, drinking a beverage and small swallows, multiple swallows will help. There is an over the counter product called ear planes that you can put in the ears that is a kind of a membrane that more slowly adjusts the change in altitudinal pressure as the plane comes down. And finally, I recommend topical Afrin. It's an over the counter nasal decongestant, a couple of puffs, about 10 or 15 minutes before the plane takes off and then as the captain comes on with 20 or 30 minutes left in the in the trip, another couple of puffs will help decongest the nose, open the eustachian tube and improve the function of the eustachian tube so you can pop your ears and equilibrate more easily.

Host: And relief for so many travelers, I'm sure.

Dr. Kesser: I hope so.

Host: Now, you mentioned how Q-tips or ear swabs are unsafe for the ear, I think that's pretty clear. But a lot of people have questions about how they should clean their ears. Generally, what do you recommend?

Dr. Kesser: I'm glad you mentioned Q-tips because you're right, Q-tips are dangerous and terrible for ears. In fact, if you look at the box of Q-tips, there is a warning label not to be put in the ear canal. So, then it begs the question, as you have asked, how do we clean our ears? Amazingly, the ear is a self-cleaning system and cleans itself through the migration or the movement of skin. To give you the example and how we discovered this was that researchers put ink spots on the surface of the ear drum. So, if you put an ink spot on the surface of the ear drum, over about three to four weeks that ink spot will actually migrate and move completely out of the ear canal. So, through the migration of skin inside the ear canal, the ear is a self-cleaning system.

Now when we put Q-tips in the ears, we are pushing the wax back down into the deeper part of the ear canal. In fact, the term Q-tip was taken from a civil war implement used to pack gunpowder into cannons. So, you get the analogy. You get the idea of what a Q-tip is doing to people who wear hearing aids, have trouble with wax also, and some people have narrow ear canals, and some people make a wax that's just like molasses, just very tenacious and sticky. You're right, Joe. Some people just need to come and see me once a year or maybe twice a year just for a cleaning under the microscope to keep their ears clean. But routine, I often just recommend a dab on the end of the pinky finger of mineral oil. Once or twice a week, the mineral oil softens the wax. It softens the skin of the ear canal and allows the ear canal to clean itself.

Host: Very helpful. What about ear candling? I'm sure you've heard of this. Is this at all effective or even safe?

Dr. Kesser: I am glad you asked about ear candling. It is neither effective nor safe. Everyone says, “Well, look at all the wax I got out of my ear.” That's the candle wax. It's not your ear wax. I have seen burns to the ear as a result of ear candling. Please, please, please do not use ear candles. They are neither safe nor effective.

Host: What about some other common myths that you may have found yourself hearing or dispelling with patients over the course of your career? I'm sure there have been plenty.

Dr. Kesser: There are myths, but I really would like to emphasize one point as we're kind of closing it out, and that is the importance of hearing conservation and hearing protection. You know, with air pods and we used to talk about Walkman, I guess I'm showing my age, but there are a lot of high-volume exposures that we have on a day-to-day basis. We live in a noisy world, and we know that noise exposure, chronic noise exposure, causes hearing loss. If I had to say one other take-home point to you and the audience, it's if you anticipate using a power tool, going to a rock concert, operating heavy machinery, whatever it is - if you're going to be around loud noise, please, please, please put your hearing protection in. Whether it's just a foamy that goes in the ear canal or even, my cousin put in a piece of toilet paper before he went to a rock concert because he forgot his earplugs. But hearing conservation is extremely important. We live in a noisy environment. If you operate heavy machinery, if you operate a power tool, lawn mower, leaf blower, whatever, please put your hearing protection in; it will save your ears, and you will be very happy as you get older and you continue to have good hearing.

Host: Finally, Dr. Kesser, if our listeners are looking for more information about ear infections or just general ear health, where would you send them?

Dr. Kesser: For additional information on ear infections, both outer middle and inner ear infections, I think the Merck Manual is an excellent resource. There are some great online resources through the House Ear Institute where I did my fellowship training. They have great resources. The Merck website is excellent, the Merck Manual actually provides excellent information both for doctors as well as for patients, parents, and children on ear infections.

Host: Of course. And as we close out, I'll let Dr. Kessler leave our listeners with the final word.

Dr. Kesser: As a final word, truly, knowledge is power. I'm very much about educating my patients about ear infections as well as hearing conservation. I mentioned hearing protection earlier, so be educated. Educate yourselves about the anatomy of the ear, about ear infections, and through education, you can make very good choices for yourself and for your children about how to treat your infections and how to protect your ears from the noisy environment in which we live.

Host: Dr. Kessler, thank you so much for joining us on this podcast. It's been a great conversation, busting some of the myths surrounding ear infection. Thank you very much for that.