Ear Infections.  Is The Treatment Part of The Problem?

by William G. Crook, M.D.

Middle ear problems in infants and young children occur so commonly that may parents and professionals consider them to be inevitable -- even "normal".

During my 40 years of pediatric and allergy practice, thousands of children with otitis media have sought help from me and my pediatric associates.  Problems in some of these children are difficult for us to manage and frustrating for the parents and the children.  yet, I can recall only a rare child who developed mastoiditis or other complications.

Antibiotics save lives.  No doubt about it.  yet, during recent years I've begun to feel that antibiotics may be causing unexpected, untoward effects.  And they seem especially apt to cause problems in children who take repeated or long term courses of medications.

My concern about today's "standard" management of otitis media is shared by other professionals.   And in a guest editorial in the Annals of Allergy, Raoul Wientzen, in Georgetown University infectious disease specialist said "by age three, 33% of children will have experienced repetitive bouts of otitis media with effusion (OME)... With such a high incidence of clinical disease, much has been leaned of the pathogenesis, etiology, diagnosis and therapy of OME.  Much has not!"

More recently, Kenneth Grundfast, chairman of the Department of Otolaryngology of Children's Hospital national Medical Center, Washington DC, stated that an estimated one million tympanotomy tubes are placed in the airs of American children each year and perhaps an equal number of children are given "prophylactic antibiotics" in an effort to lessen the frequency of ear problems.  Yet, in discussion such use of antibiotics, Grandfast pointed out that three are a number of drawbacks, including the development of fungal infections -- especially those caused by the common yeast, Candida albicans.

Could antibiotic-induced yeast infections in the intestinal tract contribute to the "epidemic" of ear infections in American children?

In my opinion, the answer is "yes".  This possible relationship was first suggested by C. Orian Truss who described his success in treating a young child who had experienced a series of recurrent ear infections with the antiyeast medication, Nystatin.  In discussion his observations Dr. Truss commented:

"The abruptness of the reversal of so many symptoms once Nystatin was started leaves little doubt that the yeast problem is underlying the vicious cycle.  In my opinion, this is not an isolated problem.  IT is probably very common.  Antibiotics save lives, but some individuals are left with residual problems relating to their use."

Why Antibiotic-Inducted Yeast Infections May Contribute to Ear Problems.

There appear to be several different mechanisms.  The first of these is Candida-induced immunosuppression.  In reports published in the 1970s, Kazo Iwata noted, "A selective decrease in the number of T-Cells in animals who had been infected with virulent strains of Candida albicans."  And he stated, "Upon Candida albicans infection, the toxins produced in the invaded tissues may act as an immunosuppressant to impair host defense mechanisms involving cellular immunity."

In a subsequent report of a study on wen with recurrent vaginal yeast infections, Witkin stated, "Candida albicans infections often associated with antibiotic-induced alterations in microbial flora may cause defects in cellular immunity"

When the immune system is weakened, microorganisms which inhabit many of the mucous membranes of the body may multiple, causing infections.

Other Ways Candida May be Related to Recurrent Middle Ear Problems

In a comprehensive review of antigen handling by the gut, W. Allan Walker, Professor of Pediatrics, Harvard Medical School, commented, "There's increasing experimental and clinical evidence to suggest that large antigencially active molecules can penetrate the intestinal tract in quantities that may be of immunological importance.  This observation could mean that the intestinal tract represents a potential site for the absorption of ingested food antigens that normal exist in the intestinal lumen."

T.M. Nsouli and associates recently studied the incidence of food allergy in 104 patients with recurrent serous otitis media (RSOM).  An exclusion diet of the offending food(s) for 16 weeks led to a significant amelioration of the RSOM in 86% of the patients

In 1991, J.O. Hunter, of Addenbrooke's Hospital in Cambridge, presented a hypothesis explaining the mechanism which takes place in people who experience adverse food reactions.  He pointed out that health problems caused by food interolerances might be more appropriately named "an enterometabolic disorder."  He stated, "Modern microbiology has opened the way to manipulation of bacterial flora to allow a correction of food intolerances and the control of disease."

Neither Hunter nor Walker mentions the possible role that Candida overgrowth contributes to abnormal gut flora.  yet, the favorable response of many persons with food sensitivities to special diets and antifungal medication suggests that Candida albicans proliferation in the digestive tract contributes to the absorption of food allergens, and it turn, to RSOM.

Are Antibiotics Really Necessary In Treating Otitis Media?

The answer appears to be "yes" and "no".  And the answer you receive may depend on whom you ask.

Antibiotics are indicated in treating children with acute purulent bacterial middle ear infections.   Yet they do not appear to be needed for every children with a mild cold and accompanying "earache".  And they may do more harm than good when prolonged courses are given to the child with RSOM.  Support for such a point of view come from Erdam I. Cantekin, Ph.D. who reported the reexamination of a previously published study that evaluated the efficacy of a two-week course of antimicrobials in children with RSOM.

Cantekin's controversial report was featured in a front page story by Tom Yulsman in the January 18, 1992 issue of Medical Tribune.  Yulsman's article stated that: "Antibiotic treatment is the American standard of care for acute and secretory otitis media, but a recurrent dispute between one time research collaborators has again raised the question whether the standard should be revised". 

Yulsman quoted Cantekin, who said "Watchful waiting is a better course in acute otitis media ... with more than 90% of infections resolving in a few days." 

Yulsman also said "The medical literature contains some support for watchful waiting.  In 1981, a Dutch study showed no difference in the outcome between use of antibiotics and myringotomy, antibiotics combines with myringotomy and placebo."

That study apparently had a major impact in the Netherlands where a 1990 survey found that 31% of Dutch general practitioners treated otitis media with antimicrobials.

Concluding Comments

There may be better ways of managing young children with recurrent otitis media, such as:

1. "Watchful waiting" in the child with mild otitis media.

2. Identification and avoidance of food allergens in the child with recurrent OME.

3. Anti-Candida therapy for the child given a broad spectrum antibiotic.  Such therapy includes "probiotics" (Lactobacillus acidophilus and Bifidus), Kyolic liquid garlic and sugar-free powdered Nystatin.  Daily therapy with one or more of these antiyeast agents may be appropriate for weeks or months, even when the otitis-prone child is not receiving antibiotic drugs.

4. Limiting the intake of sucrose and dextrose in the diet of young infants -- especially those receiving an antibiotic drug.  Here's the rational:  A recent scientific study on mice with weakened immune systems showed that the growth of Candida albicans was 200 times greater in those who received dextrose in their feedings than in a control group.

5. Tympanotomy tubes.  Such tubes may be indicated in some children with persistent serous otitis media, including those with hearing loss.  Before inserting them, attention should be directed toward the factors listed above. 

A special word about prophylactic antibiotics --- Although some studies have shown that children may not develop an ear infection while on antibiotics, ear problems often recur as soon as they are discontinued.  Certainly, if antibiotics are prescribed, anti-Candida therapy should be given at the same time.

Adapted from an article published in the Environmental Physician, Winter 1992-93.   Used with permission