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Diagnosis: Ear Infections

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Eric Ogden

The phone rang at 3:02 a.m. "Dr. Michel? Hi, it's Julie Zilm*. I am so sorry to call you at this hour, but we're at our wits' end. Tyler's been crying nonstop for an hour, and we don't know what to do! We first thought it was a nightmare, but he's awake now and has been crying since 2 a.m."

Was this call a nightmare? I pinched myself. No such luck. I sat up in bed, also definitely awake. Tyler, 2 years old, had gone to sleep as usual that night, Julie told me. When she tucked him in after his bath, she noticed he was a little warm but didn't think much of it. He'd been sniffling slightly the past few days but seemed fine otherwise. Before calling me, Julie had pressed on his stomach to test for belly pain, felt around his ears to see if they ached, and inspected his mouth to check whether a new molar was coming in. Negative on all counts. Since it didn't sound as though Tyler was acutely ill, I advised Julie to relieve his pain with 1 1/2 teaspoons of Children's Tylenol, the proper dosage for a 25-pound child, and to give me a call in the morning.

The next day, Julie brought Tyler into our offices. They both had gone back to sleep once the pain medication took effect, but Tyler woke up in the morning with a fever approaching 102°.

"Sorry about last night, Dr. Michel."

"Oh, that's all right. Part of the job," I assured her, waving a tongue depressor before Tyler like an airplane. "Tyler, say 'Aaah.' Good, now turn your head for me. Aha -- there's our culprit."

I turned off the otoscope and let Tyler's hair flop back over a bright red ear. "No wonder he was unhappy last night. He has a whopping ear infection."

"I knew it was something serious!" Julie said. "So I guess he'll have to take antibiotics, right?"

"Maybe not. Concerned about an increase in antibiotic resistance, the American Academy of Pediatrics now recommends a watch-and-wait approach, since most ear infections clear up without antibiotics. This way children aren't exposed to antibiotics unnecessarily."

"What if it doesn't get better?"

"If his symptoms don't subside within a couple of days, we may have to treat him."

"What about the pain?"

"Give him acetaminophen or ibuprofen every four to six hours, as needed, to head off the pain. If he's still hurting after two days, call me."

"That's it?"

"That's it," I said as I held out a jar of sugar-free suckers and let her pick out the usual non-staining white one for Tyler.

My little patient's fever dropped from 102? to 99? that day. But two days later, although it seemed Tyler was continuing to improve, Julie found some blood on his pillow and fluid dripping out of his ear. She brought him back to see me.

This time I didn't even need the otoscope to give a diagnosis.

"Tyler has a perforated eardrum," I said.

Julie's face turned white, and Tyler responded to her fear by starting to whimper.

"It's not as bad as you think," I assured her. "An ear infection can behave just like a pimple. Sometimes the fluid from the infection builds up within the eardrum and the pressure can make it rupture. By the way, this can happen whether the ear infection is treated with antibiotics or not. The good news is that once this fluid build-up pops, the pain disappears and the eardrum heals over just like new."

"Um, so no antibiotics?"

"If the fluid doesn't stop draining within a few days or if his fever returns, we may have to give him an antibiotic. We won't know for a couple of days."

Two weeks later, Tyler came back in for his regularly scheduled checkup. He was all better, Julie told me, except for one thing. "I have to repeat things a few times before he understands what I'm saying to him," she said, her voice again betraying some slight anxiety.

"Well, ear infections, treated or not, can decrease hearing for a month or two because of lingering fluid behind the eardrums," I told her. "But it's extraordinarily rare for a routine ear infection like Tyler's to cause permanent hearing loss. If fluid persists for three months or if you notice a delay in language development, then we'll check his hearing."

But as we watched Tyler opening and closing every drawer in the office, I added, "He's also at the age when he may start to ignore what you say on purpose."

"Hey, Tyler, want a lollipop?" I asked. That got his attention immediately.

*Names have been changed to protect privacy.

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Copyright © 2004. Reprinted with permission from the September 2004 issue of Child magazine.

All content here, including advice from doctors and other health professionals, should be considered as opinion only. Always seek the direct advice of your own doctor in connection with any questions or issues you may have regarding your own health or the health of others.