To Ear Plug or Not to Ear Plug

Seems like a fairly simple question... but oh what controversy it stirs up when regarding a patient with ear tubes who wants to go swimming.

There are two schools of thought...

1) Based on evidence and research, no need to wear ear plugs... ever.

The argument... Well, here's the research:

• A meta-analysis of swimming and water precautions.
• Water precautions and tympanostomy tubes: a randomized, controlled trial.
• A meta-analysis of swimming and water precautions.
• The effect of water exposure after tympanostomy tube insertion. 

 2) Based on personal experience, ear plugs should be worn.

The argument:

When there's a tube present through the eardrum, any water that gets into the ear canal can potentially go through the tube and into the middle ear space and cause an infection (otitis media). The middle ear space should remain sterile, but if the water is contaminated with germs, this sterile space becomes violated.

Remember, germs found in swimming pools, lakes, rivers, and oceans can be quite funky to say the least. Think of all the birds and animals that go potty in such bodies of water (let alone humans).

Furthermore, there is a type of ear infection called Swimmer's Ear (otitis externa) which is an infection of the skin lining the ear canal. If swimming can cause Swimmer's Ear, than by golly, it certainly can cause middle ear infections as well.

Also, if swimming can cause life-threatening brain eating amoebic infections (amoeba travels into the nose and up into the brain), than by golly, such water getting into the ear can certainly cause ear infections.

Though research does not necessarily bear this argument out, many ENTs have noted from personal experience that it is not uncommon that a patient with ear tubes presents with a draining ear infection within a few days of swimming.

Given water precautions take minimal effort and costs little ($10 ear plugs or swim cap or ear bands... see below), it seems worth it to play it on safe side.

Conclusion?

What do I typically recommend? Ear plugs when swimming, but not necessary when taking a bath (given tap water is theoretically clean).

Many will disagree depending on who you ask, but that's my personal opinion.

Cancer Drug to Treat Glue Ear in Kids??!

I read with astound that a class of cancer drugs known as VEGF Inhibitors (ie, Avastin and Erbitux) used to treat colorectal, lung, breast, and kidney cancers can also be used to potentially treat a type of chronic ear infection known as glue ear... at least in theory and in mice. Glue ear is when an individual suffers from repetitive ear infections or upper respiratory infections to the point where the fluid in the ear turns into a maple syrup consistency. It's thick, sticky and tough to get rid of with standard antibiotic medications. Standard treatment to address glue ear is placement of ear tubes to allow ventilation and drainage of the ear as well as antibiotic/steroid ear drops.

British researchers using the mouse model have determined that an underlying hypoxic (low oxygen) environment in the middle ear leads to glue ear and that by mediating aniogenesis (blood vessel growth) by regulating VEGF receptors (Vascular Endothelial Growth Factor), may prevent glue ear from occurring by addressing the root cause (hypoxic environment). VEGF inhibitors are typically monoclonal antibodies that prevent new blood vessels from forming via blocking VEGF receptors.

Given a vial of anti-VEGF costs on upwards of $10,000 versus not even $100 for an ear tube, the economics of this potential treatment just does not make sense at this time. Even if the costs were more comparative, I'm not sure most people will go for a treatment normally used to treat cancer to address a benign condition.

However, to be fair, this class of cancer medicine has been repurposed to treat other benign conditions including age-related macular degeneration (AMD) and diabetic retinopathy, so who knows?

It's also been considered for use to treat severe nosebleeds due to HHT (Osler-Weber-Rendu).

Maybe someday in the near future after further research, not only will we have antibiotic ear drops, but also anti-VEGF ear drops!!!


Reference:
HIF–VEGF Pathways Are Critical for Chronic Otitis Media in Junbo and Jeff Mouse Mutants. PLoS Genet 7(10): e1002336. doi:10.1371/journal.pgen.1002336

Novel Treatment for Glue Ear?

Glue ear is the layman's term for thick mucoid effusion of the middle ear, usually due to chronic ear infections.

The fluid itself is like maple syrup and usually treated with ear tube placement followed by suctioning as much of the fluid out as possible. However, given there is always some residual present, antibiotic ear drops with steroids is often prescribed.

Unfortunately, these patients are at higher risk of requiring repeated sets of tubes after the body spits them out.

Why?

Because of a phenomenon called biofilms... Think of it as teflon armour made of slime for infections. You can put antibiotics and steroids on it, but they kind of just slip off. Such biofilms make infections nearly 1000 times LESS susceptible to medications. In order to truly eradicate the biofilm (and underlying "hidden" infection), you either have to "scrape" it off which is not possible in the middle ear or use very high concentrations of antibiotics... much greater than that obtained using oral or IV antibiotics.

Though ear drops containing high concentrations of antibiotics are possible, the drops tend to come out of the ear just as easily as they go in preventing prolonged and enduring contact.

That's were the recent innovation comes in...

Scientists in England have developed a biodegradable antibiotic "pellet" that can be inserted into the middle ear during surgery where it will slowly release high concentrations of antibiotics to target any infections present (active or inactive) over 3 weeks continuously. Furthermore, the pellet contains N-acetylcysteine which effectively breaks apart the biofilm.

In essence, this pellet is like an armour-piercing bullet.

Of course, it is not available in the US yet... nor is it FDA approved.

Read more about this here.