Your Child’s Ears and Nose – PediaCast 478
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- Our Pediatrics in Plain Language Panel returns to the studio as we consider your child’s ears and nose. We explore swimmer’s ear, middle ear infections, ear wax, nosebleeds and little objects—like beads and peas and legos—that get stuck in the ear and up the nose. We hope you can join us!
- Ears and Nose
- Middle Ear Infections
- Swimmer’s Ear
- Ear Wax
- Foreign Bodies
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello, everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We are in Columbus, Ohio.
It's Episode 478 for November 12th, 2020. We're calling this one "Your Child's Ears and Nose". I want to welcome all of you to the program.
It is November and here in the Midwest, November means cloudy skies, dropping temperatures, dropping leaves. Although in October, the leaves are on the trees. They're kind of pretty. Now, they're just crunchy on the ground and getting wet and deteriorating.
And you combine that with some gray skies and some lower temperatures, and the presidential election, and the COVID pandemic. And it can be a little bit depressing to be honest.
And I have to have, there was a ray of sun and warm weather this past weekend. And my daughter and I were able to get out. We avoided crowds, but we did go to nature area that is near where we are here in Columbus called Glen Helen. It's outside of Yellow Springs, Ohio.
And we had a wonderful hike. It was like a four-mile hike and my daughter has really been into bird watching with the pandemic.
I think we've all picked up like new hobbies. And her new hobby that really began this summer was birding and bird watching. And she's got a life list now of the birds that she's looking for.
And so we had a wonderful time and she saw some new birds to add to her list. And I mentioned this because in this dark times, it's really important to find something you love to do and try to get outside when there is warm weather. Again, avoid crowds but go on hiking and birding, just a couple examples. I'm sure that, hopefully, your family has been up to some fun things as well.
The other thing with this pandemic, you get all these sponsored ads, right, through social media. And so you find some new things that way which is, of course, what these companies want to do. It's marketing, but you can find some cool things. And so, I wanted to share one of those with you.
And I want to preface this by saying, this is not a paid advertisement or endorsement. It's just one of those things that we checked out and have really loved it. It's called Sitka Salmon Shares. And basically this is a fisherman's collective.
So, you've got a fishing families in Alaska and they catch fish. They flash freeze it and then it goes from the boat. There's a short storage period as they're boxing things up, but it does get to your doorstep really fairly quick.
This is pretty fresh fish and you're supporting a fishing family. You even find out who your fishing family is, where particular fish, which boat that it came from. And, of course, you're getting fresh seafood which, we all need to eat more seafood.
And them depending on the season, you may get salmon, tuna, halibut, sable fish which by the way, here in the Midwest, we don't get sable fish, also known as black cod, very often. It's a delicacy that's primarily on the West Coast because what is caught generally gets purchased up in that area, So not much of it makes its way to the Midwest. So that's kind of cool.
Pacific cod, you get crab, and shrimp. And so far, we've really enjoyed it and it's a great way just to get fresh seafood to your doorstep. And it does come frozen.
I know I sound like this is a paid advertisement. It's not. I just found Sitka Salmon Shares and we've really enjoyed it. I'll put a link to it in the show notes if you would like to look for yourself. But we all have these little things during the pandemic, right, that are new in our lives. And for us, Sitka Salmon Share has been one of them.
So, the other glimmer of hope in this dark time is that our Pediatrics in Plain Language Panel is going to join us again this week. It's always good to welcome friends into the studio. Even though the studio is really a virtual studio.
But you will recall that when Dr. Mary Ann Abrams and Dr. Alex Rakowsky, when they join me, we try really hard to cut out the medical jargon. We want to use plain language in the podcast, which I try to do most weeks, but we really make an extra effort to use plain language during these particular episodes when they come in and join.
And plain language is important as we consider health literacy. So, I want to understand really what is going on with your child's health and how a particular illness or injury affects the body, when to worry, who to see?
Is this something you take care of at home? Do you need to see your regular doctor? Do you need a specialist?
Where do you see them? Is it an office visit? Or do you need to go to an urgent care or an emergency department? Why is a particular medication or other treatment plan prescribed?
When should you follow up? What complications or side effects should you anticipate? And how do you respond to any additional problems that may arise?
These are all important questions when you're dealing with any illness or injury. And to understand all of these and really participate in your child's care, you have to learn and understand some things about the human body including the ins and outs of illnesses and injuries that frequently affect kids.
However, it's difficult to learn and understand these things when we, as medical providers, fail to use plain language. Medical jargon is a barrier to learning and understanding, right? Of course, sometimes medical jargon is unavoidable. There may not be a plain language or version. But then, we need to take the extra time to explain exactly what the words that we're using mean as we go along.
And we should pause as we go and make sure patients, parents, families really do understand what we are talking about. And, of course, this takes effort on two fronts. As providers, we have to go slow and explain as we guide families and anticipate their questions and challenges. But there's also responsibility on the part of patients, parents and families to take an active role on healthcare.
So, if you don't understand something, be sure to stop your provider right then and there, ask for a better explanation to get all of your questions answered. And that way, we're all in the same page with the knowledge and understanding needed to improve the health and wellness of children which, of course, is a very important thing.
This week, we're going to explore your child's ears and nose, much like we did a few weeks ago when the topic was your child's eyes. So, we're going to cover ear infections, middle-ear infections, swimmer's ear, also cerumen which is medical jargon for earwax. See what I did there?
And we'll talk about the reason for earwax, when it's a problem and strategies for removing it should that need arise. We'll also discuss nosebleeds, which the big word there is epistaxis, but nosebleed is the plain language word. We're going to talk about why they occur and how to prevent them along with the best and most effective method for stopping a nosebleed.
We'll also talk about foreign bodies in the ear and nose, which is medical jargon for little things like beads, and peas, and Legos that kids have a habit of putting up their nose or in their ear. Without realizing that it might be more difficult getting it out than it was putting it in.
So, these are the many conversations coming your way soon. Before we get to our panel, I would like to remind you, you can find our PediaCast in all sorts of places, really wherever podcasts are found. We are in the Apple and Google podcast apps, iHeartRadio, Spotify, SoundCloud, Amazon Music and most other podcast apps for iOS and Android.
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So, let's take a quick break. We'll get our Plain Language Panel connected to the studio. And then we will be back to talk about your child's ears and nose. It's coming up right after this.
Dr. Mike Patrick: Our Pediatrics In Plain Language Panel is in the house once again. You'll recall that Dr. Mary Ann Abrams is an assistant professor of Pediatrics at the Ohio State University, College of Medicine, and a pediatrician with Primary Care Pediatrics at Nationwide Children's Hospital.
Dr. Alex Rakowsky is also an assistant professor of Pediatrics at Ohio State and a pediatrician with Olentangy Primary Care at Nationwide Children's.
Let's give a warm welcome back to our friends. Thank you so much for visiting us again today.
Dr. Alex Rakowsky: Thanks, as always, Mike, for having us. And happy Thanksgiving to everybody who's going to listen.
Dr. Mary Ann Abrams: Thanks, Mike, for hosting.
Dr. Mike Patrick: And I really appreciate both of you being here today again. We always start these episodes with a reminder of plain language and why that's important. And Mary Ann, you want to give us a reminder, why do we care about plain language?
Dr. Mary Ann Abrams: I think, hopefully, now more than ever, we understand how important clear communication and plain language are.
It's just so important that we give information in a way that's understandable to everybody that is clear and not confusing. And that we're very careful about using complicated terms or what we call jargon, which means either combination of technical words or words that have a special meaning in healthcare and medicine.
I think last time I mentioned that article I had come across that talk about different kinds of jargons and technical terms. And I just think it's really interesting. I gave you a couple examples last time. I thought I'd add a couple more today.
One, I might have talked about them last time. It's the technical non-plain language terms. So, don't ding me, Mike, because I'm announcing ahead of time that this is not a plain language term, is a medical vernacular. And these are words that might be familiar to a lot of people but they're not universally known or understood.
And these are some of the common words that maybe picked up if you watch a lot of medical shows on TV. You hear words like sepsis or steroids or lymph nodes or cultures or you might hear a lot of these words now because of all the talk about different parts of the whole COVID pandemics.
So, we just have to keep in mind that even though some of these words are they're the right word and they're commonly understood by a fair number of people, they're not commonly understood by everybody.
And the other category is called medicalized English. These are words that we know that they have different meaning in the context of medicine. And good examples of that are a positive test or negative test. So, people tend to think of positive as a good thing and negative as a bad thing, but depending on what that test is, positive can be not very good and negative can be good news.
So, if you have a negative strep test, that's good because it makes you don't have strep throat. If you have a positive biopsy or cell test of your lymph nodes, swollen glands, that may be a really bad result because it could indicate that something very serious is going on.
Those are just the couple of examples that I thought were interesting. And then words that we might let come out of our mouths, again not purposely, when we're examining a patient or talking with them. We might say something like, "Well, I don't appreciate any murmur." What the heck does that mean, right?
We're talking about, you just listened to my chest. What do you mean about appreciating a murmur?
Some people don't know what a murmur is, which is a sound made in the heart when the blood swishes through it. And the word appreciate kind of means I listened really carefully, I listened hard but I'm just not hearing a murmur. And that's technically good news too.
So, bottom line is we need to try to communicate clearly. But we also want everyone to ask if they're not certain or if they're confused. We need to use living room language.
Dr. Mike Patrick: Yes, really great points all around. A few resources that we have for folks that we mentioned with all of these episodes, one is there's a book that we're kind of loosely following as we do this Plain Language Series of episodes. It's called What To Do When Your Child Get Sick. It's from the Institute for Healthcare Advancement. They're non-profit. And I'll have a link in the show notes where you can find that book.
Actually, if you use the discount code POD719, you get a 40% discount. It's only 12.95 book to begin with. So that makes it $7.77 if you buy it through them. And you can also get it through Amazon, and Barnes & Nobles. But it's a really good book to have at home for families. It's written in plain language and really what to do when your child get sick. So, great information.
And then I also want to mention, we do have a survey for folks who listen to these episodes. And I'll put a link to that in the show notes for this episode, 478, as well. We'd love your feedback on our Pediatrics in Plain Language Panel episodes.
And then, you can find all of them in one convenient place over on SoundCloud. We have a playlist that includes all of our past Plain Language episodes which includes, last time we did your child's eyes just like we're doing ears and nose today. We've talked about fever and illness, newborn baby care, keeping kids safe. We've talked reading and family literacy, fitness facts and ideas.
One of them is Winter Time Blues. And we're heading into, of course, it's even a darker winter this year compared to when we originally talk about the Winter Time Blues. But that may be a good one to listen to as we move forward over the next couple of months and lots more. So, I'll put a link to that playlist over in the show notes for this episode 478 over at pediacast.org.
And then, before we get started, one other thing I wanted to mention, I know we have a lot of pediatric providers in the crowd and those would like some more advanced information as we consider ears and throats, I did a PediaCast CME episode with Dr. Charles Elmaraghy. He's chief of Otolaryngology, which right there I got a...
Dr. Mike Patrick: Otolaryngology is not plain language. He's an ear, nose, and throat doctor at Nationwide Children's Hospital. And I did an episode with him called "Tubes, Tongues, Tonsils and Toys: An ENT Update" That was PediaCast CME Episode 43. And I'll put a link to that in the show notes, too.
So, let's get started. And Dr. Abrams, the place we wanted to begin was with ear infections. What type of ear infections can occur because not all ear infections are the same, right?
Dr. Mary Ann Abrams: That's right. One of the main ways to think about an ear infection is to think about what part of the ear is infected. And let's just back up and talk about what does it mean to have an infection.
So, you can have ear pain and ear ache. When you have an ear infection, you will have pain or soreness and other symptoms that we'll talk about. But having an infection means bacteria, or sometimes a virus, have sort of set up housekeeping in the ear, more than the normal number of bacteria that live there normally to help keep our bodies healthy.
We have healthy bacteria all around us. But if one kind of bacteria starts to grow out of proportion or a bacteria or a virus, that can tend to make you sick. Like I say, it's sort of sets up housekeeping and starts to reproduce and grow in part of the ear, that's what we call it an infection and that leads to more problems.
But there's two main areas of the ear that can get infected. One is outer part of the ear. Sometimes we call that external ear and then middle ear. And outer part of the ear is basically everything from part of the ear that you can see and try to wiggle around. And then the little ear canal, the little tunnel that goes in from that area up to where the eardrum is are what we call the tympanic membrane. So that area is external ear.
And then, there's the eardrum. And behind that are the hammer, the anvil and the stirrup that people might have learned about awhile back in science class. And those are called the ossicles, so those little bones that help conduct sound from that ear canal, through the eardrum and on to the nerves that lead to the brain that helps it actually heal.
So, there can be a buildup of fluid or irritation or something else that can cause bacteria to kind of ticket out of proportion. Or unusual bacteria can start to grow there and that's what lead to an infection.
And the fancy word for that is otitis. So when you hear the word otitis, otitis means inflamed and irritated and often infected. And oti means ear. So an otitis and then either externa, meaning the outer external part of the ear. Or otitis media, which means that middle part of the ear.
Dr. Mike Patrick: So, otitis media, that's a word I think families hear from time to time. So I love how you broke that down. Otitis, inflammation of the ear. Media, it's the middle part.
And you mentioned bacterial buildup in that space. Alex, take us through what causes middle ear infection. How do those bacteria get there?
Dr. Alex Rakowsky: I love how Mary Ann kind of broke it down. But just to kind of continue the visual. So again, you have your canal and then the canal ends in the eardrum. And middle ear infection doesn't involve anything before the eardrum.
So the middle part of the ear has bones. And those bones transmit sounds to what we call the inner ear, which then gets converted to your brain hearing it. And there is natural fluid in that middle ear.
So imagine like a tunnel or hallway yawning to your eardrum, that's your external ear. And you have your first room, that's your middle ear. And then, there's bones in that first room that has some lubrication or fluid in there. And then, you have your inner room which we won't talk about.
So, if you have a backup of fluid to your middle ear, again, it has to stay lubricated. So, there's a connection between your middle ear and your nose, et cetera. And you have something called ear toileting or ear drainage, where your ear gets just washed out multiple times day to keep that area clean.
So, if you have an ear infection, like a middle ear infection, you now have fluid that's kind of buildup in that middle ear because these are blockage where the tube got blocked off because of a cold that embowels your nose. We have something that kind of punctured through that eardrum.
The punctured-through eardrum is really rare. So the majority of times you get ear infection, you have to have a cold. It backs off fluid more than it should be. A lot of fluid sits there and then bacteria that live naturally in your nose work their way up. They kind of like living in fluid, so now it live in your middle ear and that gives you what we call bacterial otitis. Again, ear, media, middle. So a bacterial otitis media infection or acute otitis media.
So it really is you need a fluid buildup to begin with, in most cases, to get a middle ear infection.
Dr. Mike Patrick: There's a historical significance to middle ear infections in that with this podcast because one of the questions you get asked a lot in primary care pediatrics, "Why does my kid keep getting ear infection? Is it because they're getting water in their ear? Or is it because there's cold in their ear?"
And I always, like you did, Alex, kind of really try to explain the anatomy. There's this thing called the Eustachian tube that connects that middle ear space to the back of the throat or the ear, or I'm sorry, or the nose, so the middle space to the nose or back of throat. And then, mouth bacteria, nose bacteria can go up that tube to a place where it's not supposed to be.
And then, you get a cold and you get mucus being produced and that can clog that tube up, so the bacteria now get trapped in that space. And your body sends white blood cells in and causes the infection.
And I love really painting that picture for people. But you don't have time when you're in a really busy practice to kind of go through all of that. And that's why I thought of making a podcast and explaining things to parents, hopefully, in terms they can understand using plain language. And that's really how PediaCast got started.
So, I always love mentioning that when we talk about ear infection because it's really historical for this program in this audience.
Moving on from how middle ear infections occur, how then are they treated? And this has kind of evolved over time a little bit, right?
Dr. Alex Rakowsky: Yeah, so it really is, we'll talk about prevention next. But the way they treated is if you are a higher risk patient, in other words you have some problem with the Eustachian tube, the tube that connects the middle ear to the back of your nose. Or you're a younger child, the chance of that bacteria clearing naturally by itself is pretty low.
In those situations, you give an antibiotic which then gets into that middle ear space, kills off the bacteria and you're hoping that ear-to-tube, by the time your cold's over or what have you, is open again, you kill the bacteria and that fluid drains. So, it's a combination of your body draining and also the antibiotic working.
If you're a lower risk child, in other words, you have a functional or a tube that's actually working well between your middle ear and your nose and an older kid, unless it's like a really rip roaring infection, you can actually wait. And some call it watchful waiting, where if you see an ear, the child's not overly sick, they don't have a high fever, you can actually give it 48 hours.
And what we'll do in our clinic is give him a prescription and say the child is doing better in 48 hours just naturally. Then, it just can potentially drain out of there, you don't need the antibiotic.
I think when we trained back in 15, 20, 30 years ago, those are almost automatic antibiotic for everybody. But I think there's more push now to let the body have some time to drain on its own, to see if those are going to work for you or not.
Dr. Mike Patrick: Yeah, absolutely. And the other thing when we trained, it was ten days for everybody. That's how long you treated an ear infection. And now, we know that for kids who are over the age of two, who don't have a severe ear infection, so just a mild to moderate. And by severe we mean a lot of pain, high fever, vomiting, that sort of thing.
If it's not a severe ear infection, it maybe you could get away with just doing it for seven days. And if you're over the age of five, even a five-day course maybe adequate. So again, just trying to be stewards of antibiotics, using them. And again, what you said, Mary Ann, what was that, medical English?
It's not really jargon but we want to be stewards of antibiotics. That means use them appropriately so that we don't get as many resistant organisms.
Dr. Mary Ann Abrams: Medicalized English.
Dr. Mike Patrick: Medicalized English, that's it. I love that. I learned something today. So what about prevention then, Alex? You've mentioned that you're going to head in that direction?
Dr. Alex Rakowsky: Yes. So essentially, if you think about the fact that it's really a fluid buildup that kind of has set the stage. So, if you can keep the stage from getting set, then you actually have prevented a large number of the ear infections.
So, if you can cut back on the number of really bad nasal infection or infections that give you a lot of congestion that helps out. So starts off with basic hygiene, wash your hands. If you're sick, stay at home. Currently everybody has a mask on, so keep the mask on.
If you're somewhere and there's somebody sick, like your family member that sick with a bad head cold, try not to go to that family member just to avoid the head cold. Get a flu shot because flu is actually one of the worst congestion producers. So the chance of getting an ear infection is small, but after the flu is actually very high.
So, number one is just your typical things to prevent getting sick. Don't touch your face, wash your hands, get well rested, et cetera.
There are also some kids who have problems of the Eustachian tube. There has been some work looking at OMM which is the osteopathic medicine to kind of do some manipulations to keep that tube more open.
There are some work looking at a gum called xylitol gum which is a type of sugar, which seems to kind of help keep the bacteria counts down. They're not really proven on larger studies, but there have been some information about that.
And I guess we can talk a little bit about ear tubes, if you want here, because ear tubes for kids that are going to have multiple infections usually because they have something wrong with that tube, the Eustachian tube. Be it because of a family issue that you're going to outgrow eventually or that tube isn't well produced because of something in the way your face has been sort of developed. Like kids, for example, with Down syndrome have Eustachian tubes that act a little bit differently.
Then what those tubes do, instead of having the fluid go back into the nose, the fluid comes out to your canal. So now, whereas, you're clearing that room of any fluid to kind of prevent ear infections from developing.
Dr. Mike Patrick: So, the ear tube is a little tiny piece of plastic with the hole in the middle of it, so like a little tunnel. And it goes through the ear drum so that anything that's in that middle ear space, that room is able to drain through it into the ear canal. So, if you have pus filled up from an infection, that can drain.
But also, if you've had bacteria that went from the nose up to Eustachian tube into that middle ear space and then if mucus is clogging up the Eustachian tube, it doesn't become trapped in that room. Because now, it can use that ear tube as an exit path and becomes skin bacteria in the ear canal. And they don't build up then in that space and the body doesn't feel like it has to send in white blood cells to take care of things.
In that sense, it can prevent future ear infections. But just like anything else... Oh, go ahead, Alex.
Dr. Alex Rakowsky: I think it's important also to mention that the ear tube is put in by our ENT experts. And the category or the criteria to actually put in the ear tubes has changed over the years as well. So they are little less likely to put them in, but they are lot better about getting a family history.
So, it's important to know my brother, my cousin, my uncle, my grandpa all had problems with the ears. There's a higher chance that their child is going to get an ear tube because there may be something in the family that takes a longer time for that Eustachian tube to develop normally or get large enough to drain. And you're basically buying time for couple years of that no artificial ear tube.
Dr. Mike Patrick: It's a really good point. In fact, that's the direction I was heading, is that it's a surgical procedure. There are potential complications with it, not only the surgery itself which is a pretty short easy surgery. A lot of those kids don't even have to have a breathing put down because they can do it so fast.
However, you can have complications with tubes that are in there a long time. And then you can get a hole that doesn't close once the ear tube comes out. You can get scarring in there.
My son, in fact, had ear tubes when he was little. And then, as a teenager, where his ear tube was, he had some scar tissue. Did a somersault underwater and blow out his ear drum and have to have reconstructive surgery.
Again, that doesn't happen with every kid. It's a low risk but those kind of complications can happen. And so, you really want to make sure that you're looking at the benefit versus the risk of a procedure. But when you're having a ton of ear infections and kids are having fevers recurrently and pain, and it can interfere with their hearing, which can interfere with language development, then you got to look at that risk and say, "Well, an ear tube could really put a stop to this process. So it's worth that risk of issues down the road."
And this is where I think you really need a good primary care doctor, a good ENT, ear, nose, and throat doctor to kind of walk your family through the risks and the benefits of any decision that you make in medicine because there's always two competing interests, right?
Dr. Alex Rakowsky: Yeah.
Dr. Mary Ann Abrams: I was just going to add a couple other things about preventing ear infections. One of those is smoking around children can really lead to more irritation and set them up for multiple ear infections, which could then cascade or lead to what those Mike and Alex have been describing.
And also, some of the teething practices like always, we call it bottle propping, not just laying a baby down and leaving a bottle with them. So that whatever is in that bottle kind of runs backward at the back of their throat and up the Eustachian tube, or up through their nose. And then, that also can create and predispose to an infection.
So, you want to feed the babies upright. When they're finished, they're finished. Not just leave a bottle with them. Position that well, too. Those are just some other important things to do, especially when little ones are under the age of two or even one to help keep them healthy.
Dr. Alex Rakowsky: I'm sorry. If I could just add, thank you for bringing up smoking, Mary Ann. There's been a couple of studies looking at what we call recurrent ear infection in kids who do not have a family history of them. And by far the number one risk factor is smoking.
Number two is daycare but you can't sometimes avoid daycare. By far, the most controllable thing is smoking in the house. And it increases your risk substantially. I mean, it's like seven-fold harm but if it's a lot.
Dr. Mike Patrick: Yeah, absolutely. Great points, and allergies too. So, if you have allergic rhinitis which is medical jargon for seasonal allergies, hay fever. Pollen creates lots of mucus, that can also to ear infection if you don't have those under control. So, keep the seasonal allergies medicine going to also prevent ear infections.
Let's move from the middle ear to the external part of the ear, the ear canal. So, now we're on the outside side of the eardrum. Mary Ann, what causes those infections?
Dr. Mary Ann Abrams: These otitis external or external ear, outer ear infections, they're usually caused by something that irritates the skin. There's a very thin sort of fine skin that lines the inside of that ear canal or that tube, that leads from the outside to the ear drum.
And the way the ear canal curves, there is sort of a little low spot that lends itself to pulling and liquid accumulating. A lot of times you hear otitis external referred to as swimmer's ear. And that's a really common association or cause or related to these kind of infections because lots of swimming and exposure to being underwater can irritate, the chemicals in the water can irritate that thin skin.
The water can stay in there in and pool, and especially if it's in that little low spot that can, again, set up a perfect little place for these bacteria, that either normally live there or get in from the outside to start to grow.
And when they grow, that leads to irritation of the skin, that lining and the other symptoms that are associated with that. I'm going to talk about that in just a second. But the other things that are little less common but also associated can be just irritated ear.
Unfortunately, sometimes, people stick things in their ear. And if they're fortunate enough not to actually go too far and poke their eardrum, they can still irritate that lining of that ear canal. And really it's very, very sensitive.
It can be very painful just from irritating it, let alone irritating it making a little tiny cut and then letting bacteria start to grow in that nice warm plate. And then, those bacteria cause swelling and irritation and redness. And pus starts to accumulate.
And depending on how bad it is, you can have different kinds of symptoms. So often, if it's mild, maybe you have some irritations, some itchiness, "Oh, my gosh. My ears bothering me."
And then, a more concerning one, not concerning but worse one or middle moderate one, a little bit more pain, a little bit more itching. You can have that pus can accumulate to the point that you can start maybe see if you're looking in there. And sometimes, the outside ear starts to get sore or tender, especially if you touch it or wiggle it.
And then, there can be a lot more severe where you can't even see in that ear canal because it's so full of puss. The ear itself, it can be red and swollen and very tender and very painful.
So those are sort of the way, the spectrum, the variety of ways that those swimmer ear and external otitis can show up.
Dr. Mike Patrick: And you mentioned that poking and sort of mechanical injury from things that go in the ear. And that's why we recommend, don't use Q-tips, don't put your fingernail and scratch your ear. My grandma used to tell me, don't put anything in your ear that is smaller than your elbow. So elbows are fine to put in your ear. Anything smaller than that, you want to keep away.
Once you have an external ear infection or like you call swimmer's ear, although, again, you don't have to be swimming to get one, how are those treated then?
Dr. Mary Ann Abrams: If it's really mild, sometimes you can stay out of the water. Take a little something for the pain, and kind of let it go. But usually, if it's bothering people from more than couple of days, it's enough to be pretty uncomfortable.
The pain is bad. The itching is driving you crazy. And you may start to see some drainage either crusting on the ear and the pillow. Or it's starting to come out. Or the ear itself might be tender, in which case you usually do need to go and see the doctor, and the nurse practitioner, your primary care provider who can take a look.
We can see all the way through. We want to make sure that the eardrum itself doesn't have any holes in it and that middle ear that Alex just described is okay. And we can often tell right away because when we go look, we can obviously look at the outside of the ear but when we go to look in the ear, we hold the part of the ear. And usually, if they got a rip roaring otitis externa, they're going to let us know really quickly to stop doing that.
So it's a pretty straightforward diagnosis to make. And occasionally, if there's so much drainage or there some other part of the story or the background to this that we're not a 100% sure, again, sometimes we ask our ear, nose and throat colleagues to take a look as well. Because they have all kinds of special magnification and instruments that can get a really good look in that ear canal.
Dr. Mike Patrick: So, antibiotic drops are going to be because now when we...
Dr. Mary Ann Abrams: Oh, forgot to even talk about that.
Dr. Mike Patrick: No, that's all right. Antibiotic drops are going to help this sort of infection because now, we're just putting drops into the ear which are going to pool on the outside side of the eardrum. And so that can help with these kind of infections. But drops are not going to help the middle ear infections as long as you have an intact eardrum, right?
Dr. Mary Ann Abrams: Right. And I got so busy talking about the range of illness that I forgot to talk about the drops that we use to treat most of these. And they are definitely intended to treat the external part of the ear, not be taken by mouth and not to treat middle ear and otitis media infection.
One of the most important things is to make sure the drops get in the ear and can reach the part that's irritated and inflamed and infected. If there's a ton of drainage, that's when we really want to try to get that out before we use these drops. But if it's mild to moderate, we can prescribe an antibiotic drop.
There's different kinds. Some have antibiotics. Some have just a little bit of a steroid that can help soothe that red irritated lining of the ear, and some other things. But to make sure those are pooled in the affected ear and have that ear facing up. And either lay down or plug that canal a good cotton ball or something for 5 to 15 minutes, so it has time to penetrate and to work.
And then, usually, if you use that several times a day for at least a week, maybe a little bit longer and not do anything to re-irritate it or make it worse. If you're a swimmer means staying out of the pool until you're totally better. Don't stick anything smaller than your elbow and use those drops.
Dr. Mike Patrick: Absolutely. And the caveat to the drops if you have an ear tube that is in place correctly and not blocked, then you could use drops to get into the middle ear space, then you don't want to use a steroid in those drops. So there's some nuances to this that you definitely want to be talking to a medical provider who is trained in all of these different things to think about, as you're figuring out what to do for your particular child who has ear pain.
And then, in terms of preventing this swimmer's ear otitis externa, and especially, you mentioned swimmers, like competitive swimmers, I mean, you can't get away from water being around your ear. What are some ways that they can prevent this process from happening?
Dr. Mary Ann Abrams: I think I totally understand a competitive swimmer or just someone who enjoys swimming for exercise or recreation, you don't want people to not be able to do that. So, being aware of that upfront and then wearing really good high quality earplugs is a good start.
When I was little, I remember seeing kids get out of the pool and shake their heads to one side and the other. And literally you're actually calling on gravity to kind of help you get that extra water that could pool in there, pardon that pun, out.
Some people talk about even a thing like a blow hairdryer on very low setting and not right next to your head, but 12, 18 inches away to just help dry that area. Because you really want to let that interlining of the ear canal be at its normal state, not too wet, not too dry, not too hot or too cold. So trying to keep it even, and then again, not irritating it with instruments or Q-tips or fingernails or anything else.
Dr. Mike Patrick: So we can't get away from talking about ears without mentioning earwax. So, Alex, what is earwax and why is it there?
Dr. Alex Rakowsky: Earwax or cerumen is the term that you're going to hear is just there naturally to protect our...
Dr. Mike Patrick: I'm just going to give you a little magic there because you still use the word and then explain exactly what it means. Cerumen is earwax.
Dr. Alex Rakowsky: Yeah. I actually have a story about earwax because the word sincere. So when the Romans were buying marble tables or marble statues, the cheap ones would have wax put in, so it look like there weren't any defects. So, the tables or the statues are made out of marble that had no wax. They're "sin", no, sincere. So, that's how we got the word sincere. They are wax-free table. So, just a little word game of today.
Dr. Alex Rakowsky: So here we go, okay. Earwax is just naturally there to kind of keep stuff from getting into your eardrum. It's just produced naturally by the canal. And the canal's job is to sort of amplify or sort of increase the sound that goes through your eardrum and also to give you a little bit of a tunnel, so eardrum doesn't get hurt.
And it's very easy to hurt your eardrum because it's a very sensitive area because it has to move. So the wax is there to help. There's a natural reason for the wax.
Dr. Mike Patrick: Great. When is earwax a problem?
Dr. Alex Rakowsky: People think if there's any earwax and that's an issue. And it's not really the case. Everybody should have probably a little bit of wax in there. I know some parents are obsessed and I think some docs are obsessed to get all the wax out of there. But having a little bit of wax in there and you have no problems hearing, you have no leakage coming out, then you should be fine. It really is more of a hearing issue or an irritation. If you don't have that then, you really don't have to worry about it.
Dr. Mike Patrick: And in cases where you do need to get wax out, it's probably better to, because again, we're saying don't put anything in there that's smaller than your elbow. If you do need to get wax out, you probably have to see a medical provider and let them give you some advice on the best way to do that.
Because it also depends, sometimes you can get an impaction of wax and especially if you've been using your Q-tip or been putting your finger in there and you push it all against the eardrum. And that becomes thicker and more compressed. And then it can become uncomfortable.
So, you're really better off having a medical provider to let you know what's the best way to get that wax out because there are some different methods.
Dr. Alex Rakowsky: I think there are four options. The first is actually have the medical provider go and take it out. Commonly, we can take it out. So then we give earwax drops. A common brand is something called Debrox, which is a combination of essentially peroxide and oil that kind of loosens that wax up when it comes out.
The third option is actually make your own ear wax removal drops. And essentially, it's like two to three drops of warm water, two or three drops of just regular peroxide and put that combination in to make sure it's warm water. So you don't give your kid a disease caught from using too cold water. And then you do that twice a day until that wax comes popping out.
And the fourth, if you know somebody who has elbow thinner than your ear canal, then they can go in there get it out for you. Sorry.
Dr. Mike Patrick: And I've heard of vinegar and rubbing alcohol as well.
Dr. Alex Rakowsky: We have a larger family, so we've tried it all. We have a couple of swimmers. And I think if you're preventing fluid in the ear, then there is some data to support using ice or vinegar or rubbing alcohol. But you have to make sure you dilute it out pretty well.
And for wax, it's probably not as good because it's more for the water. For the wax, it's probably better to have like a peroxide mix because it kind of bubbles and loosens up that wax. As long as you tell parents it's going to give some bubbling in there, so they don't freak out, or the kids will freak out by having a bubbling sound in their canal.
Dr. Mike Patrick: And you really don't want to get hydrogen peroxide or vinegar...
Dr. Alex Rakowsky: In the eye.
Dr. Mike Patrick: In the eye. Yeah, exactly. And that's going to be if this, especially if you're a swimmer and this is something that you're having problems with earwax over and over again, then your provider can explain, "Hey, try this at home." But if this is not something that you usually have an issue with and you're having trouble hearing or you're having ear discomfort and you're not sure if it's your wax or not, you're probably better off seeing someone. Let them take a look and see exactly what's going on and figure out what's the best approach to dealing with it would be.
All right, let's move on from ears to nose and the big thing I wanted to talk about there and there's a lot of things we could talk about, but nosebleeds, especially this time of the year, kind of become a bit common. Mary Ann, what causes nosebleed?
Dr. Mary Ann Abrams: First, I just want to acknowledge that nosebleeds can be very scary. They aren't scary most always, they're rarely really scary. But they can seem really scary because blood invariably looks like a lot even when it's just a little bit. And when it's coming out of your child's nose and your child is upset and it looks like a lot of blood, it can be scary.
So, I want to offer a really reassurance, to start with. The most common causes I think of nosebleeds are dry air, like we have in the winter when there's not much humidity. And if you have a humidifier in your house, that's great but even that, it's not going to be as moist and not kind of a normal amount of humidity or liquid in the air. And that just dries out.
Again, it's very thin skin that lines the nose. And underneath that very thin skin are the blood vessels that take oxygen to the nostrils and on the nose and all the different parts of the nose. And those blood vessels are very very close to the surface because that skin is so thin.
So anything that irritates that is going to almost feel like if you scrape your knee. It's like scraping the middle part, that septum, that divider in the middle of your nose. That's the part that usually bleeds.
So, really dry air, just like your hands can get dry in the winter and chafe and almost sometimes bleed, that in itself can do it.
Another very common cause is trauma. And those common cause of trauma is nose picking. Just assume everybody, every kids at least picks their nose. It's just sort of the way it is and that's a very common thing.
And then third, when people get a cold, they're rubbing their nose. They're blowing their nose, they're sniffing, they're rubbing, and that is also very irritating. So they may be blowing their nose, and then the next thing now, they see blood on the tissue and then it starts to bleed.
So, the common denominator there, the common thing, is irritation to that very thin lining of the nose and those blood vessels being too close to a surface.
Dr. Mike Patrick: And often, we'll see clusters of nosebleed. And it really kind of make sense because when anything that bleeds, you're going to get a clot, so kind of like a scab on your skin. And anything that disrupts that clot or that scab while the healing process is taking place is going to make it start bleeding again.
Dr. Mike Patrick: So often, we will see kids who have a nosebleed. And then the next day, they have another one. The next day, they have another one. And until you go a few days without a nosebleed, you're still a little prone to having that bleed again. So, that's one of the things we always have to reassure folks.
There are some bleeding disorders that can cause recurrent nosebleeds, but those are not common. And certainly if you have a kid who's having a recurrent nosebleeds, you want to see your doctor, then they can decide if that's something that you need to be worked up for.
And then, another thing that a lot of parents are always worried about is could it be high blood pressure? You hear that a lot. But really, we don't see nosebleeds as a symptom of high blood pressure.
So now, this is the most important thing I think. Tell us, Mary Ann, how parents can best stop a nosebleed. What's the best way to make that bleeding stop?
Dr. Mary Ann Abrams: Key message here... By the way, work up is kind of jargony term. Workup means we're going to...
Dr. Mary Ann Abrams: Means we're going to figure that out. We're going to do some test. We're going to ask you more questions. We're going to examine you. So if we're going to workup your frequent nosebleeds, it just means we're going to get to the bottom of it.
So that's again, it just comes off our tongue and we don't even realize we're saying it. But it could come up, "What do you mean? I'm already worked up about all this."
Anyway, key message here. I think one of the most important things is a watch. Because anything, to stop bleeding, the bottom line is to put pressure on it, right? Whether it's a cut here, on your arm or leg. And to put pressure on a bleeding nose means that you take your finger and you press your nostril firmly, not too hard, against the middle of the nose, the septum.
And I recommend just the side that's bleeding, so that people don't feel like they're totally can't breathe out of their nose because little kids can get worried and cry. And if there's anything you can do make this kind of a calm thing. Or if a child is doing it, they can do it themselves. But it's really firm pressure outside of the nostril, pushing it against the nasal septum, the nose septum.
And then, the really important piece why do I say about the watch. Minimum, at least five minutes. And I even say set a timer because five minutes when you're doing this feels like forever. But if you don't do it for at least five minutes, some people say, "I think if you shoot for ten, maybe you'll get five to seven minutes."
You need that time for that bleeding to stop, and for that blood clot to start to form and to kind of be secure enough in there. So that when you take the finger away, it doesn't pull it up back up and have it start bleeding again.
So, firm pressure at the bottom part of the nose, the side, not way up high, not where close to the eyes, but right there on the soft part of the nostril, five minutes at least by the clock.
And obvious is that lean forward, lean backward, whatever. The bottom line is if the child could kind of lean forward, what does that is to avoid having any blood that's already in the nose run down the back of the throat. And that's not a terrible thing but it can be alarming or frightening and worrying. If they lean forward just a little bit at the waist, that might keep that from happening and just help keep everybody calm.
Dr. Mike Patrick: And since you can't keep put pressure exactly where the blood is coming from, if you do like gravity, at least pull it down to where you're applying pressure. Then the clot is going to back up and help it to stop.
Whereas, if you put your head back, then there is way that the blood can still flow and so you may not get the clot quite as quickly.
But if you've got a two-year old who is hard enough to get the pressure, you may not be able to really say what position their head is in very effectively. Yeah, Alex?
Dr. Alex Rakowsky: And thanks for five minutes, Mary Ann, because I think that's the key, as parents forget about the five minutes. And don't check every minute if it's still bleeding. It's five minutes, don't look, count or saying silly songs for five minutes, because if you look, you don't let the scab form.
Dr. Mike Patrick: Absolutely. And even if you stop...
Dr. Mary Ann Abrams: You have to start over again, right? That's when you start the pressure and keep it on.
Dr. Mike Patrick: And we generally recommend, when I see kids in the emergency department, they want to know "When do we come back?" And do it for five minutes. Check if it's still bleeding another five minutes, another five minutes. You get a 15 minutes and you're not getting done under control, start heading in to see their urgent care or an emergency department.
I would say 99% of the time, by the time you get there, it has stopped which is good. But yeah, you just got to keep at it over and over, but don't wait too long.
Okay, the other thing with noses and with ears are foreign bodies. And I mentioned the intro to the show that that's kind of medical jargon, foreign body. It's really little things like peas, and beads, and Legos that kids put in their nose or their ear. Because they think for some reason, it's going to be just as easy to get it out as it was to put it in, which is often not the case. Tell us about these objects that kids put in their ears and in their nose, Alex.
Dr. Mary Ann Abrams: We have seen it all. I think there's a combined 70 years of experience here, so you name it, we have seen it up on nose or in ear. We have our own kids stick things up the nose or the ear.
I don't know why they do it. But I think every child goes through this phase experimenting on their body. Rule of thumb is number one, try not to be a hero. If you can't easily pull it out, then just let us take it out.
And I see probably the majority of disasters is from people trying to be very aggressive to pull something out of the ear. I've had people try to suck in their infant's or their toddler's nose to get something out of there cause more damage. I had somebody who blew water off to upper nostril to sort of get that foreign body or that piece whatever it was, it was a Lego in this case, and ended up like blowing a hole into the brain because they were pushing so hard.
I've seen ruptured eardrums. This is one you go to urgent care, ER, and just let us try. If it's really deep or if it's something that sort of like mushy and has been there a couple of days and it's starting to rot, I'd say ER instead of urgent care, speaking as urgent care person her. Occasional, urgent care shifts. If it's a bit rotting and it looks like we can't get it out of there, we're probably going to send it to the ear, nose, and throat specialist in the ER.
There are few things that you just automatically think, "Okay, I'm not going to even try." And this is one of those categories where unless you see it, unless you can get it out of there quickly, unless your Uncle Joe has elbow thinner than your ear canal, then don't even bother. Just come on in.
Dr. Mike Patrick: And ears are a little less emergent than something stuck in the nose. And when I work in the emergency department, sometimes our ear, nose, and throat doctors, it's not really an emergency if something's in the ear. Because when you think about it, kids have ear tubes, there's a plastic tube in your ear. And they oftentimes come out and they're in the ear canal, kind of hanging out in the wax.
As long as they're not in intense pain, that's something that can wait because it's a little easier for the ENT to remove things in their office where they have a microscope and special equipment, that they actually don't have available to them in the emergency department. So ,that doesn't necessarily have to be like an immediate referral.
Nose is we get a little more worried about because it's the small enough object, it's something that they could potentially... Remember the nose and the back of the throat are connected. And so if it's something small that a kid, especially in their sleep, it might go up and then down into their windpipe, and then could choke on it.
If it's a larger object, that's less likely to happen. But then if you wait too long in the nose, you can get an infection associated with a foreign object that's in the nose. So you want to take care that a little bit quicker.
But I love that advice of just go in, let someone take a look at it and decide what you need to do or where you go from there. Yeah, Mary Ann?
Dr. Mary Ann Abrams: Just a couple of things to tag on to both of those really good recommendations. One, if you think or you can see and you know that something is up your kiddo's nose that's, like as you said, it's urgent and you don't want it to become an emergency. So, I would go in, because depending on what it is, if it's soft often the longer it's there, it will start to absorb the liquid and the mucus that's in the nose and it swells.
So that makes it harder to get out, something that might have been kind of easy to tease out with the right instrument suddenly is soft and mushy. And sometimes, it can get embedded and it makes the lining of the nose swell. So then it's harder to get it out or to get it all out.
And then, if you don't know but it does happen, and suddenly, two or three days later although you don't know it's later at this point, your little toddler has a really bad smell coming out of their face. That is also a good sign that something could be up their nose, because the longer it's there, the more likely it is to get bacteria around it. And the body tries to fight it off and create pus. And all those things can result on that smell or that odor, which is a good clue to us when we see those kids, so we know what needs to be done.
Dr. Mike Patrick: Absolutely. Some of the more interesting things I've seen in noses and ears, once I had a kid put a bunch of Nerds, the candy, Nerds in their ear. So they're really little and they're out there down deep. And I was a young doctor at this point and I said, "Why don't we irrigate it and see if we can get them out with a little irrigation in the ear."
And so we did that. And, of course, the Nerds melted and made a very multicolored liquid that came back out, but we got them out. That was kind of fun. And I've seen Barbie shoe in the nose. My own daughter put corn in her nose when she was little, so they happens. It definitely happens.
Dr. Alex Rakowsky: I trained when Pop Rocks were still common. I'm not sure if people... And this kid shoved the bunch of Pop Rocks and they would just blow up. And as the moisture kind of hit them and he was as freaking out in the ER. We actually have to sedate him just to get stuff out of there because you really can't pour psyllium in there and get out of there because he will completely freak out. That was a difficult one.
Dr. Mike Patrick: Especially in the nose.
Dr. Mary Ann Abrams: And another thing that can make kids... Or I think it would make me freak out is if a bug, a live bug, a bug gets in there and doesn't meet demise. And they'll tell you, "There's something crawling around my ear." And depending on what it is, it can be very scary and painful. So there are occasionally insects that may not be life threatening that are very, very frightening and uncomfortable.
Dr. Mike Patrick: That's not one to wait on. If you have a live bug in your ear, go see someone and let them get that taken care of right away. Absolutely.
Well, Dr. Mary Ann Abrams and Dr. Alex Rakowsky, we just, again, love it when you guys drop by and visit. Mary Ann, tell us again about Primary Care Pediatrics at Nationwide Children's Hospital.
Dr. Mary Ann Abrams: I guess the main thing I want to tell you that Primary Care Pediatrics at Nationwide is we are all over the city. There's a location near you. We are working very, very hard to make sure it's a safe place to bring your children and yourselves, even with COVID going on.
We have so many things in place so that people can still come to the doctor and be checked and get their regular well child checks even at this time. And we do offer telehealth, the telephone type visits. So that's available.
We don't want kids to miss out on their well visits, their vaccinations, the screenings that get to take place as part of that well child care. And, obviously, if you're concerned about your child being sick or having an otitis externa or a middle ear infection or nosebleed, call us and we can help you decide whether you need to come in. We may be able to do deal with it over the phone or on televisit, but we're here to help you and your family.
Dr. Mike Patrick: Absolutely. And I'll put a link to Primary Care Pediatrics at Nationwide Children's in the show notes for this episode 478 over at pediacast.org.
Also, our Primary Care Referral line here, if you're a family in Central Ohio and you need to find a primary care provider, 614-722-KIDS. That's 614-722-K-I-D-S and that service will get you linked up with the provider in your area that's affiliated with Nationwide Children's Hospital. And I'll put that phone number in the show notes for everyone as well.
So, once again, Dr. Mary Ann Abrams and Dr. Alex Rakowsky, both with primary care pediatrics at Nationwide Children's Hospital. Thanks so much for joining us today.
Dr. Alex Rakowsky: Thank you.
Dr. Mary Ann Abrams: Thanks, Mike. Great to see you.
Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that.
Also, thanks to our guests this week, Dr. Mary Ann Abrams and Dr. Alex Rakowsky, both with Primary Care Pediatrics at Nationwide Children's Hospital.
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