Sunday, July 29, 2012

Summer's Here and So is Swimmer's Ear

To all those that are practically part fish out there: Yeah, you know who you are. The ones that can't stay away from water. The smell of chlorine gets your blood pumping and you all but grow fins. The water calls to you, beckons sweet nothings. And there you are, jumping in, yelling "Cannonball!" But a few days later, you come into my office complaining of ear pain.

Well, stop it. Stop that water addiction. Your poor ears are ten seconds away from sitting you down for an intervention. But we all know your intense Romeo & Juliet relationship with water, so your ears will just have to suffer. Right? Well, not completely.
So, let's talk about Swimmer's ear: what it is, how to identify it, how to prevent it, and how to treat it.

Often even in medical settings, swimmer's ear, or in expensive medical terms, otitis externa is often mistaken for otitis media, which is an infection behind the tympanic membrane (ear drum) and it is mistakenly treated with oral antibiotics that don't do jack for it. Yep, antibiotics taken by mouth don't do diddly squat to treat it.

Distinguishing Swimmer's Ear from Otitis Media
This is where understanding the difference between the two main types of ear infections comes in handy.

Otitis externa is an infection that usually presents with a swelling of the external auditory canal which is fancy and again expensive way of stating outside ear canal. Also, it will typically have white, icky gooey gross stuff drain out of it, in a condition called otorrhea, medical jargon for runny ear.
Another characteristic is that the external auditory canal will often times swell shut, thereby causing a temporary hearing loss.

Fevers may be present but rarely go above 101 degrees Farenheit (38.3 degrees Celsius).

Other characteristics: Most common in the summer. Recent swimming. Pain is achieved by pulling on the ear.

Otitis media is an infection with fluid and pus behind the ear drum. The condition occurs most commonly in winter months and is associated with a recent upper respiratory infection. Has a runny nose then think more otitis media. Children with it will often act  more restless at night.

As far as drainage, the pus typically doesn't drain out the ear unless there is a perforation of the tympanic membrane. This occurs when the pressure behind the eardrum becomes so great that the membrane blows open like a pair of briefs after a burrito binge-fest, thus letting the pus go pouring out screaming "free at last!"

But under normal circumstances, there is no drainage from the ear, unlike in otitis externa which runs a marathon.

Fevers are present the majority of the time and are often times greater than 101 degrees F (or greater than 38.3 degrees C)

In addition to fevers, sufferers of otitis media most commonly have a dense loss of hearing that feels similar to trying to hear while under water.

Hearing loss can be up to 30 decibels is more commonly seen in otitis media than in Swimmer's ear... because normally, otitis media doesn't drain, which is why one of the main treatments for chronic otitis media is to place tubes in the ear drums. (Note: otitis externa can cause hearing loss if the canal is occluded due to increased swelling.)

Speaking of drainage from the ear, the type of otorrhea can actually help you in diagnosing what type of ear infection or injury you have.  Yeah, I know what you are thinking: "Ewe, I don't want to know more about diarrhea from the ear!" But come on, you know you're curious. It's like the trainwreck that you just can't help staring at. It has that so gross but so addicting thing about it. Pretty soon, you're going to start looking in people's ears, searching for waxy treasure and loving every minute of it.

So here it goes: The low down and dirty of ear drainage.

Otitis Externa
  • Acute Bacterial  --- Scant white mucus (yummy) but can be thick and juicy 
  • Chronic Bacterial --- Bloody drainage
  • Fungal --- Fluffy and white like a kitten. But can be black, or bluish-green. Ahh, it's colorful.
Otitis Media with Perforated TM
  • Acute --- Yellow to white pus with Pain
  • Chronic --- More Pus but without Pain
Head Trauma
  • Cerebral Spinal Fluid Leak --- Clear, watery 
  • Bony Trauma --- Bloody mucus
Had to throw the trauma stuff in there, because heck this is a wilderness/disaster medicine blog. Got to keep it real. ;)

So before I get too technical, I might as well show you the anatomy of the ear. I'm only doing this for you. I, personally, really didn't like anatomy. I smelt like formaldehyde after each class. Parfume a' la cadaver bodies. Not good for the social life, so I'm a little bitter. But for you, I'll make an anatomy exception.

There. That's my extent of giving you anatomy. Feel the love. Okay now, moving on.

  • Swimming
  • High humidity
  • Higher outside temperatures (a.k.a summer)
  • Sweating
  • Water contaminated with bacteria (okay, all water is "contaminated" with bacteria unless it comes to you in a sealed bottle stamped "Sterile.")
  • Sticking stuff in your ears like Q-tips, keys, toys, unlucky rabbit's feet, etc.
Otitis externa presents like you've been kicked in the ear. The American Academy of Family Physicians states that the most common symptom is ear discomfort. But come on. How many of you mer-people will actually jump out of the water long enough to go to the doctor's office for "ear discomfort."

Yeah, that's right. I see you in my office when you're screaming and crying, wailing and gnashing of teeth, because it hurts like a freaking sea horse kicked you in the ear... correction an itcy seahorse. Did I forget to mention the intense itching? Or pruritis, if you want to be technical. Itching = $5 word. Pruritis = $5,000 word. Doctors like to use the $5,000 word: it pays for our yachts, or in my case, my beaten up RV.

So, in a nutshell: Ear discomfort (otalgia, another $5,000 word), which worsens with touching the ear or chewing, and ear drainage (otorrhea. Again, Cha-ching!). A bad case of swimmers ear can be so intense with pain though that the a patient may require analgesics. Patients may also complain of ear "fullness" and/or hearing loss due to the swelling of ear canal until it occludes the opening.

Stay out of the water. Okay, that's not going to work. That's about as useless as saying to a room full of drug addicts: don't take this crack that I'm leaving here on the table in front of you, because it's bad for you.

Dry Your Ears
Next option, is to dry your ears after water immersion. Using a blowdryer to gently dry your ears is actually quite affective in preventing Swimmer's ear. The excess moisture in your ear, removes the natural protection of your ear's waxy secretions and thus increases the pH in the canal. This provides the optimal environment for growing bacteria and thus leads to infection. The most common bacteria that infect the outer ear canal are Pseudomonas aeruginosa and Staphylococcus aureus.

Acidify the Canal
Yep, you heard me right. The natural environment of the external auditory canal is relatively acidic around a pH of 4.5 compared to the body's internal pH which is 7.4. This acidic environment protects the canal under normal circumstances from infection with bacteria.  (For more information: Read the article "Change of External Canal pH in Acute Otitis Externa published by the Annals of Otology, Rhinology and Laryngology

  • Mix one part alcohol (rubbing alcohol, not beer) with one part white vinegar.
The vinegar is acetic acid and provides the acidic part of the solution, while the alcohol helps to disinfect and dry out the ear canal. Apply 3 drops of this mixture to each ear after swimming to reduce the occurrence of infection.In fact, this little home remedy is similar to the expensive pharmaceutical treatments requiring prescriptions.

Put Nothing in Your Ears
My boss, Dr. Tacket is quoted to say, "Put nothing but your elbow in your ear."
 So literally, it means put nothing in there. No Q-tips, no keys, no bobby pins, no fingers, no toys, no bugs, no nada. Nothing. Zippo. One, you can damage the external auditory canal, making it much more susceptible to infection. Two, you push the ear wax down towards the tympanic membrane where it can get lodged and cause cerumen impaction, which results in a reduction of hearing.  And three, I seriously don't want to dig out that junk out of your ears. It exhausts me. Granted, digging cockroaches and beetles out of people's ears exhausts me more, because I have to fight my gagging reflex the whole time and end up paranoid for weeks about a bug climbing into my own ear. Not fun, I tell you. Not fun.

Keep Ears Dry
Then don't allow water in your ears. Where good fitting ear plugs while bathing or in the water. A cheap way of preventing water getting in your ears while showering is to put a cotton ball in your ear with vaseline on it (on the side of it facing outward). This acts as a water barrier. Then immediately remove the cotton balls or ear plugs from your ears once you are out of the water.

I know, I know. I just said don't put anything in your ears. Well, ears plugs and temporary cottonballs dipped in Vaseline don't count.

This is the interesting part. As with all things, the treatment varies according to severity of condition. But there are some straightforward ground rules:
  • Oral antibiotics don't work for swimmer's ear at all, period. They only work if otitis media is involved due to perforation. But that's otitis media.
  • The antibiotics that are useful are in ear drops or even eye drops.
  • The antibiotics must come in direct contact with the bacteria on the surface of the ear canal for them to work.
  • If the ear canal is swelled shut, you have to force a wick into it, which is a painful process, and then drop the ear drops onto the wick.
  • You need certain instruments available that you can clean the infection debris out of the ear with.
  • Six, never, never, never under any circumstances flush the ear with water or get water into the ear. Makes the situation worse like throwing gasoline onto an oil fire.
  • Seven, oral antibiotics don't treat otitis externa.
So let's discuss the treatment options and what you can do at home to help treat your loved one's otitis externa.

The main treatment of otitis externa is topical. If the external auditory canal is not occluded, place antibiotic drops in the ear canal itself.

Some of the topical solutions out there, according to the American Academy of Family Physicians include the following (The brand name will be in paretheticals):

Pharmaceutical Acetic solutions (or you can use the homemade alcohol/vinegar solution)
  • 2% acetic acid solution (VoSol)                                                       $49
  • 2% acetic acid with hydrocortisone (VoSol HC otitic)                    $59
  • 2% acetic acid with aluminum acetate (Otic Domoboro)                $18
Neomycin Otic Solutions & Suspensions
  • Neomycin with polymyxin B-ydrocortisone (Cotisporin)               $42
Quinolone products
  • Ofloxacin 0.3% solution (Floxin Otic)                                             $34
  • Ciprofloxacin 0.3% with hydrocortisone suspension (Cipro HC Otitic)     $59
Opthalmic Quinolones (eye drops used for swimmer's ear)
  • Ofloxacin 0.3% (Ocuflox)                                                              $29
  • Ciprofloxacin 0.3% (Ciloxan)                                                        $30
  • Gentamicin 0.3%
  • Tobramycin 0.3%
Give 3 antibiotic drops to each infected ear 4 times a day (except quinolones that are only given twice a day) for 5 to 7 days. Warm the bottle of ear drops in your palms before putting the drops in the patient's ear. It minimizes the occurrence of dizziness. (Cold drops of any liquid in the ear will cause vertigo.)

Push the tragus (that small flappy thing that everyone asks why is that thing there in front of your ear canal) in a few times after administering the drops in order to further distribute the antibiotics within the ear canal.

The symptoms should start to cease after 3 days. If the symptoms don't stop than the external auditory canal is most likely swollen shut and the antibiotics aren't reaching the infected skin.

Insert wick using an otoscope (or you can use a headlight strapped to your forehead and a magnifying glass) into the infected ear canal. It will hurt the patient terribly, so be prepared to be beaten. Give the patient pain killer before proceeding.

Ear wicks are made by several different companies, namely Otocell and Americell brands. After inserting the wick, then apply the ear drops to it.

If a wick is required than the drops should be applied every 3 to 4 hours while patient is awake. After a few days (2 to 5 days), pull the wick out and reexamine the ear canal. Redo this process every 2 to 5 days until the swelling of the canal is resolved and the wick is no longer needed.

If there is an ear drum perforation, the only drops that you can use are ofloxacin (Floxin Otic) drops.

For more information, please refer to:
J. David Osguthorpe, MD and David R. Nielsen, MD. (2006). "Otitis Externa: Review and Clinical Update," American Family Physician, 74, pp. 1510-1516.

Robert Sander, MD. (2001). "Otitis Externa: A Practical Guide to Treatment and Prevention," American Family Physician, 65, pp. 927-936.

Anyway, thanks for reading. TTFN

Dr. Princeton, D.O.

Edit Note:
In terms of barotrauma of the ear, or trauma due to changes in pressure:

The pain associated starts during a descent of a plane or while scuba diving. Blood may or may not appear behind the tympanic membrane. If there is blood, then this is called either a tympanic membrane hemorrhage or a serous/hemorrhagic middle ear fluid expression. About 10 percent of adults can get barotrauma after a regular flight, making this a very common occurance.

Friday, July 27, 2012

Trailer Tracks and Sun Strokes: Managing Heat Illness

Okay, it's official: I am a trailer park doctor. Yep, you heard me right. I'm a trailer park doctor. (I just had to put  this picture because I'd like to think someday I could look like that.)
I moved to Michigan this June and have been searching diligently for a house since. A billion bids on 12 homes later, I am still living in an RV. Don't ask. Real estate fiascos are just too painful to talk about. But anyway, let's see how I fair on the trailer park doctor check:

  • Living in an RV. Check.
  • Changing sewage pipes every freaking five seconds, while bonding with your neighbor about how things back up so easily. Check.  
  • Have become the official RV park doctor for the "hey doc what's this big hairy thing on my elbow? I think it moved there yesterday. Is it cancerous?" Check.
  • Driving a car with a beatup rear light due to being too stubborn to buy a new one or get it fixed. Check.
  • Sporting a paste of meat tenderizer on your hand where a bee stung you. Check.
  • Meat tenderizer worked within a minute, but I was too lazy to take it off for five minutes. Double check.
Don't get me wrong: I don't really mind being able to identify with every Jeff Foxworthy Redneck joke-- in fact, I'd like to think I could look like that bombshell picture and I adore RV campers, they're great people--but I have to admit being a trailer park doctor isn't that glamorous. Yet, I am grateful and happy that I am a family practitioner starting out somewhere.

In fact, it sometimes can be hardwork. I have seen too many cases of heat illness this summer among campers that heat illnesses have become my new soap box.

There has been an unprecedented heat wave moving through the northern states, enough that the southern states are laughing at us. Aren't we northerners the pathetic step-children now? It's as though the underworld has opened its gates too let some demon pass a foul air-bisquit upon our once cool countryside. The south is cool. Why can't we be cool too? With this diabolical heat wave we northerners weren't prepared for, comes a lot of heat exhaustion, heat stroke, and dehydration.

 Here I was one glorious Friday afternoon...okay, not so glorious it was a whopping 109 degrees outside, even the flies were fanning themselves.... Contemplating whether or not I should risk the lactose intolerance and glucose rush for a bite of ice cream, and the camp groundsman comes running up to me, saying, "Doctor. Doctor, there's a little boy that's acting funny?"

There are something's that you just don't want to hear when you're about to pound a heaping pile of rainbowbrite icecream down your throat.  I practically choked. "Funny?"

"He looks like he's going to pass out." That was even worse.

Now it is a true fact that children usually will play until they are about dead. In fact, children don't show signs of hyperthermia or hypothermia until they are severely ill. They literally will play themselves to death. So here was a boy about 12 years old acting like a drunk man after a fraternity kegger. Yep, not a pretty sight on several levels. I knew this was going to be bad.

"Put ice packs in his armpits."

Let's pause here. I know what you are thinking... Ice in his armpits? Yeah, and on his neck and in his groin. Heck, I even had him hug a bag of ice like a teddy bear.

The key to treating hyperthermic illnesses is to immediately do everything you can to bring down the body's core temperature. These treatments are also used post-cardiac arrest to decrease the work load upon the damaged heart muscle.

When a person's body is subject to high temperatures, a series of physiological responses take place starting with vasodilation. Basically, your blood vessels get huge like portbelly sausages, allowing for blood to shunted to your skin in order to cool you down. Your body uses evaporation, which is the most efficient means of cooling down (if the humidity is low).

Here in Michigan, the humidity stays around 50 to 70% and that day was around 109 degrees.
So how do we identify heat illness? Let's break it down into categories of heat illnesses and how to identify and treat each one.

Heat Cramps
One of the earliest heat illnesses is called heat cramps. These occur when a person is hydrated well with plain water, is exercising in the heat, but the body starts to lose essential minerals and salts. These are those people that have just been running around in the heat, drinking lots of water but start having muscle cramps in their legs (especially the calves) or in their sides.

The treatment for mild cases is to drink water with electrolytes in it, such as drinking a quart of water with 1/4 to 1/2 teaspoon of salt in it. Yummy. Or you could add water to a sports drink with a pinch of salt. Severe cases need IV fluid of one-liter boluses of normal saline (0.9% NaCl).

Heat Exhaustion
The precursor to Heat Stroke, which we will talk about later, is known as heat exhaustion. This is the more commonly seen presentation of heat illnesses. This is where the little kids start getting a little whoozy. They start acting "funny," but they will still keep playing.

This condition occurs when the heat stress on the body leads to marked sodium depletion and low intravascular volume. What does that mean for us? Basically, they overheat, get dehydrated, and sweat out all their electrolytes. So when end up with thirsty, sweaty, cranky cooks running around.

The signs and symptoms of heat exhaustion, include the following:
  • Thirst (Duh!)
  • Fatigue
  • Weakness
  • Headache
  • Drowsiness
  • Lightheadedness
  • Irritability
  • Increased heart rate
  • Profuse sweating (but they may stop sweating in the more severe cases)
  • Decrease in blood pressure upon standing from sitting or from lying down
  • Increased breathing rate
  • Nausea
  • Hyperthermia is maximum 104 degrees Farenheit or 40 degrees Celcius body temperature
  • NO--and I repeat--NO changes in their mental status
Treatment includes giving them as much cold water and electrolytes to drink as possible. The goal should be to get them to drink at least 1 to 2 liters of fluid over 2 to 4 hours.  Except, and this is a big except: the drinks you give them cannot exceed 6% carbohydrate content.  This means no sugary fruit juices and no soda pop. Sorry to all those coke addicts out there. No coke for you!

Remove the patient from direct sunlight and remove all their restrictive clothing, moving them preferrably to an air conditioned environment. (Air conditioners remove moisture/humidity from the air, thus increasing their body's ability to evaporate sweat and cool them down faster.) Try to keep them from shivering by using ambient temperature... shivering increases the body's heat and needs to be avoided.

Under normal circumstances, the best way to rapidly cool a person down is to get them sopping wet and put them into a cool dry room with a fan blowing the AC on them. If you're in a high humidity environment with no AC, then this option doesn't work. Humidity adversely affects the body's ability to use evaporation as a means of cooling down. So if, you're in places like Michigan or an island with a gorgeous beach (which I am envying right now), you're best treatment is to put ice in their pits and groin.

Heat Stroke
This is a medical emergency. No ifs, ands, or buts about it: they need to go to the hospital. This the 911 call that must happen regardless of being in a sweaty campground trailer with a dozen or so people watching you.

To give you an idea of how much of an emergency this is: it is classically defined as a central nervous system (brain) disturbance caused by severe hyperthermia. This is where the child starts acting "really funny" and starts to pass out on you. There core body temperature increases above 104 degrees F (40 degrees C)

The main difference between heat exhaustion and heat stroke is the appearance of altered mental status changes. A heat stroke victim will walk funny (ataxia), talk funny (slurred speech), and pass out which isn't funny. CNS disturbances literally are a hallmark that the patient has progressed from heat exhaustion into heat stroke.

The boy at the campground had slurred speech and passed out twice. You can imagine how concerned I felt while treating him waiting for the ambulance to arrive. He could barely stand with a wobbily gait in a manner called ataxia.

Ataxia, or a lack of muscle coordination most commonly seen in walking, is one of the first neurological signs of heat stroke. The patient with ataxia will walk like a sailor on land... or a person with a severe case of ants in their pants.

Another common sign is that the patient stops sweating (anhidrosis). The lack of sweating can occur in the late stages of heat exhaustion, so it isn't as diagnostic as ataxia.

The signs and symptoms of heat stroke include the following:

  • Ataxia or abnormal gait pattern
  • Severe irritability
  • Slurred speech or inability to form sentances
  • Confusion
  • Bizarre behavior
  • Combativeness
  • Seizures
  • Loss of consciousness (syncope or "pass out")
  • Very late in the process, coma

Note: Heat stroke is where the children will slow down and pass out. They will quit playing and that is not a good sign.

The key to treatment and preventing heat stroke is to realize this illness and heat exhaustion are not two separate conditions, but that they are a progression of the same illness.

So the treatment of heat stroke, uses with the exact same treatment as you would for heat exhaustion just with more advanced and aggressive measures. So consider the following as being "in addition to" the treatment for heat exhaustion.

First off: You need to worry about airways with the heat stroke patients. They need to have their airway, breathing, and circulation evaluated (which is an entirely different post on basic Life Support and CPR) and handled accordingly.
High flow oxygen via non-rebreather mask is one of the first line treatments administered to a heat stroke patient in addition to the treatments used in heat exhaustion. And, cardiac monitoring and IV fluid infusion with normal saline (ideally 1 to 2 liters given over the first hour) are also administered.
The patients vital signs need to be monitored continuously (temperature, blood pressure, heart rate, respiratory rate, and  oxygen saturation)
In heat stroke, ice packs are used aggressively in armpits, on the groin, and on the neck, with cold compresses on the scalp and forehead. The sopping wet treatment as demonstrated in the heat exhaustion treatment is preferred here as well, with an effort to keep the patient as wet as possible in a tepid (comfortable ambient room temperature with air conditioning) environment and continuously fanned.
Since it was extremely humid in Michigan that hot day, we opted for the ice packs, a fan, an amazing air conditioner, and a busload of cold water.
The goal is achieve a core body temperature of 102 to 104 degrees F (39-40 degrees C) as fast as possible then to taper the cooling down to avoid hypothermia.
Prevention of Heat Illnesses
The best way to prevent heat illnesses is to hydrate, prevent long periods of heat exposure or to decrease heat, and to acclimatize yourselves slowly to heat.
Seriously people, if you're going to go out in the bristly sun, then you need to be a fish. You need to drink bare minimum 4 to 8 ounces of water or a sports beverage every 15 to 20 minutes that you are out there in that scorcher exerting yourself.
The goal is to drink fluids until your urine is clear. Yes, this means you have to look when you go.
Also, you need to keep in mind that you sweat out your electrolytes, so you need to eat salty foods, such as saltine crackers, pickles, canned vegetables, etc. Why? Well, the salt helps you retain water and you need to replace the salt that you are sweating out, lest you get heat cramps.
And you can always use that 1/4 tsp to 1/2 tsp of salt to one liter of fluid. The World Health Organization recommends for rehydration adding 1/2 tsp of salt and 6 tsps of sugar to one liter of pure water.
Decrease heat:
Wear light-colored, loose-fitting and breathable clothing. In less humid locations, frequently douse exposed skin with water or a cool misting spray. In humid regions, frequently go into air conditioned environments and fan yourself. Avoid direct sunlight whenever possible.
You need to allow your body time to get used to a hotter temperature. This process will activate a physiological system called the renin-angiotensin-aldosterone axis which helps your body increase sodium conservation, expand blood volume which helps the cardiovascular system to adapt, and maximizes sweat production. Adults usually take 7 to 10 days to acclimatize to a hotter temperature. Gradually increase the time you spend in the great hot outdoors over the 10 days.
Children and elderly take longer to acclimatize. They can take up to 14 days. (10 to 14 days) Also, people whom are coming from colder climates immediately into hotter ones, such as those vacationing from say Phoenix, Arizona (was a peachy 70 degrees that day with no humidity) to Southwest Michigan (humid 109 degrees) will have a harder time acclimatizing and should gradually increase their exposure over the 14 days.
On the other side of things, it usually takes 1 to 2 weeks to de-acclimatize from going to hot temperature to colder temperature.

Health Condtions
Certain health conditions act as risk factors for increased chances of getting heat illness:
Heart disease. Number one in my book
Lung disease
Skin diseases (such as sclerodermal conditions)
Endocrine disorders (diabetes, hyperthyroidism, obesity, etc)
Neurological diseases (alzheimers, Parkinsons, etc)
Medications (such as heart meds, allergy meds, antidepressants, aspirin, antipsychotics, and recreational drugs)
If you have anymore questions concerning heat illness, please refer to the Wilderness Medical Society whose link is listed in the side bar.
Thank you for reading. TTFN.
Dr. Princeton