Child ear infection. Info required.

[sinbin]

My daughter has had this ear discharge for a number of years now. The ENT doctor has tried every oral antibiotic medicine available to him. The last being 'Cefdinir' and this hasn't relieved the problem. A discharge sample has been taken and shown to be bacterial and not a virus. He now wants to admit my daughter and give her 3 antibiotic injections per day for 2 weeks. My wife never really asked questions as to why and what for.

I'd be obliged if some medically trained person would inform me as to what is she likely to be injected with etc, and in the event of this not working what happens next? Thanks.

[jrtmedic]

Seek a second opinion.

Oral/systemic (injected) antibiotics do not usually form the basis of treating a discharging ear.

If the child has had a "discharging ear" for a number of years the problem needs to be identified and resolved.

This may involve an examination under sedation/anaesthetic (It can be VERY difficult to examine a wriggly child's ear !)

Make sure that the "discharge" is sent for " microscopy, culture and sensitivity" --- which will result in an appropriate antibiotic being identified ( If needed).

There are a number of diagnostic possibilities but it would be wrong of me to speculate on the basis of very limited information.

Be prepared for the possibility of attending the hospital on a daily basis for aural toilet (ear cleaning) and the installation of medication.

Other people here may have suggestions as to where you can seek advice ---- but it would be easier for them to do so if you were to indicate your location.

Edited June 19, 2013 by jrtmedic

[Sheryl]

From my reading of what you say, they have already done a culture and sensitivity and it is based on the results that the are now recommending parenteral (intramuscular or intravenous -- probably the latter) antibiotics. Presumably the drug it is sensitive to cannot be given orally.

Odds are that the culture and sensitivity were not done at the start of treatment but rather only after a pot-luck approach with multiple antibiotics had been taken, leading to drug resistance. A common (but wrong) practice in Thailand and one that contributes to drug resistance, which is likely what has occurred here.

If you can get a copy of the culture and sensitivity report and post it here, can advise further. You would need that in any event if seeking another opinion.

But I won't be surprised if it shows multiple drug resistance with the only effective agent being one that has to be given IV.

On the positive side, now that treatment is being based on culture results, there is a good chance of it being successful provided a full course is given.

For future reference, need to insist ion cultures being done whenever your child is treated for a presumed bacterial infection. And it will take insistance, as Thai doctors habitually skip this. It is reasonable enough to start treatment with a drug pending cultural results, but a culture should be done first whenever possible .

Also need to look at the duration of antibiotic therapy prescribed as another common practice here is to give to short a course, which really contributes to resistance developing.

[jrtmedic]

Whilst not wishing to disagree with anything Sheryl has said , the point I was trying to make and perhaps failed to adequately explain is this:-

The youngster needs a diagnosis ----"discharging ear" is NOT a diagnosis it is an observation.

Children's ears do not "discharge" over an extended period of time for no reason ---------something is causing the problem !

As I said before there are a number of possibilities and treatment is unlikely to be successful until the root cause of the discharge is identified.

Again, as I attempted to say previously - oral or parental(systemic) antibiotic treatment for an Aural discharge is unusual.

Aural infections are usually treated with local (in the ear) antibiotic drops ( which enables some antibiotics which can never be given orally or by injection to be used safely). There are of course exceptions which I recognise.

I would seriously suggest you ask the child's ENT Surgeon what s/he believes the diagnosis is ---you should receive a specific answer.

Always remember that you have the absolute right to seek a second opinion.

If you choose to seek a second opinion ensure that any letters/test results/ etc are available

[givenall]

My son had the same problem and he had to put ear tube in his ear. This was done in US. He had tube put in three time till he got older and his station tubes became larger and the problem went away

Sent from my ST18a using Thaivisa Connect Thailand mobile app

[jrtmedic]

givenall

I suspect your son had a condition known as "glue ear" which was treated with "grommets" or a "T" tube --------

Anyway ---- I am pleased he recovered !

[sinbin]

Odds are that the culture and sensitivity were not done at the start of treatment but rather only after a pot-luck approach with multiple antibiotics had been taken, leading to drug resistance. A common (but wrong) practice in Thailand and one that contributes to drug resistance, which is likely what has occurred here.

You got it spot on Sheryl. After a number of years the only culture sample taken was last month. In all we've seen 3 doctors over the last 2+ years. Every doctor just starts my daughter on a different antibiotic to the last one prescribed. I fully understand about building up an immunity to antibiotics and have raised the matter with the doctors in the past. I've now fell out with the current doctor due to differences of opinion. He doesn't like it when I ask questions. I now won't go in when he examines my daughter.

I can't get a copy of the culture sample but I can tell you it was 'Pneumococcus' on the paper that I saw. As it stands the ear infection isn't a problem to our daughter. She never complains about it and she leads a normal life. How we first noticed was that she was getting thrush like syptoms in her mouth causing soreness when eating. When the ear discharge does dry up, on occasions, then the mouth symptoms disappear also. And when her mouth symptoms return then so do her ear problems. I understand the connection.

Quote from 'Jrtmedic'

I would seriously suggest you ask the child's ENT Surgeon what s/he believes the diagnosis is ---you should receive a specific answer.

Done that a few times, but the current doctor just side steps the question. Unfortunately my wife does the Thai thing and just accepts what's thrown at her.

If the child has had a "discharging ear" for a number of years the problem needs to be identified and resolved.

But that ain't happened to date, and that's why I'm asking on here out of desperation. Thanks to all replies so far.

PS. Currently living out Nang Rong, Buriram way. The 2 previously seen doctors were at 2 different hospitals in Korat.

Edited June 20, 2013 by sinbin

[Pormax]

just a thought from my previous experiences as an trained Audiometician and Hearing Aid Specialist..

Firstly where is the discharge coming from? I would suspect from what you say, this is from the middle ear and not the outer ear.

So is there a perforation in the eardrum? If so probably a grommet ('T' shaped tube) should be inserted to allow the fluid/puss to drain out fully.

Many ear infections can be caused by nose and throat problems as they are connected via the Eustacion tube which gets blocked easily because this runs very shallow, plus it is very small in diameter in small children , This causes infections from the throat to travel to the inner ear very easily.

It is many years ago I worked in this area, my memory not so clear now (age problem), plus procedures, treatments have moved on. However I can remember in many cases Adenoids and Tonsils were removed in some who had recurring ear infections.

You mentioned mouth infections which could be the root of the problem.

[sinbin]

just a thought from my previous experiences as an trained Audiometician and Hearing Aid Specialist..

Firstly where is the discharge coming from? I would suspect from what you say, this is from the middle ear and not the outer ear.

So is there a perforation in the eardrum? If so probably a grommet ('T' shaped tube) should be inserted to allow the fluid/puss to drain out fully.

Many ear infections can be caused by nose and throat problems as they are connected via the Eustacion tube which gets blocked easily because this runs very shallow, plus it is very small in diameter in small children , This causes infections from the throat to travel to the inner ear very easily.

It is many years ago I worked in this area, my memory not so clear now (age problem), plus procedures, treatments have moved on. However I can remember in many cases Adenoids and Tonsils were removed in some who had recurring ear infections.

You mentioned mouth infections which could be the root of the problem.

She does have a perforated ear drum. It has been known to heal up but soon returns. I've really asked all the questions I can possably think of to doctors but they just go down the antibiotics route everytime.

[Sheryl]

It's a bit of a trip but I suggest you take her to Khon Kaen University hospital and see an ENT specialist there. And certainly stop, forever, seeing the doctor who doesn't like to answer questions. Not only is this the wrong attitude, it is often indicative of underlying incompetence.

The thrush is most likely secondary to antibiotic therapy.

You really should INSIST on a copy of the culture and sensitivity report, telling the doctor you are taking her to KKU. By law medical records have to be given to patients on request. Otherwise they will have tor repeat the test in KK and it takes several days to get the results so waste of time and money. It is not just a question of what the organism was but of which antibiotics it is sensitive to which, given all the abx she has received in the past, will probably not be typical.

[FBN]

This condition is known as CSOM (Chronic Suppurative Otitis Media) and the treatment is usually first a cleaning of all the debris from the ear canal, followed by examination and bacterial sampling from the inner ear and then appropriate treatment which usually is a local antibiotic and not systemic. Cultures taken from just the ear canal usually shows mixed infection with pneumococcus and pseudomonas most common. Infection becomes chronic when an acute otitis media causes a rupture of the ear drum if it is inadequately managed; the perforation in the eardrum then gets blocked by the thick secretions and the infection starts up again in the middle ear until it drains again.

For this reason, grommet tubes (or T-tubes) are inserted to keep the inner ear drained; the infection clears up with local antibiotic drops, the drum heals and the tube falls out. (Ideally)

Systemic antibiotics orally or IV in acute infections usually reserved for when there are signs of mastoiditis (infection of the bony sinus behind the ear.

She needs ENT specialist examination and treatment..

[sinbin]

Systemic antibiotics orally or IV in acute infections usually reserved for when there are signs of mastoiditis (infection of the bony sinus behind the ear.

How would her doctor check for 'mastoiditis'? What happens if we let the doctor go ahead and hospitalises her and the infection still remains? All we know of her hospitat treatment is that she has 3 injections daily for 2 weeks. No mention, as far as I'm aware, of sedating her and giving her ear an indepth examination and clean.

[Sheryl]

I would not advice continuing treatment with the current doctor, full stop. He has not followed a proper standard of care, to say the least, so no reason to think he would suddeny commence to. Get her to KKU if you can and see an ENT there, bringing the C&S report with you.

If it is mastoiditis there id often (but not always) some swelling and tenderness over the mastoid bone which is directly behind the ear. And fever and an elevated white blood count would be expected. MRI can be useful if the clinical picture is unclear.

[sinbin]

I would not advice continuing treatment with the current doctor, full stop. He has not followed a proper standard of care, to say the least, so no reason to think he would suddeny commence to. Get her to KKU if you can and see an ENT there, bringing the C&S report with you.

If it is mastoiditis there id often (but not always) some swelling and tenderness over the mastoid bone which is directly behind the ear. And fever and an elevated white blood count would be expected. MRI can be useful if the clinical picture is unclear.

Tomorrow we go see another doctor. I will put all my concerns to her and ask her opinion. I want no treatment for my daughter, just an honest opinion. If I'm still not happy then KKU is on the cards for next Friday. Due to our family situation, and the distance to get to KK, it makes things really difficult if she has to be hospitalised in KK.

As for the symptoms of mastoiditis. She shows no sign of this, as far as I can tell. No 'white blood count' test has ever been taken.

[Sheryl]

A white blood count would be measured through a CBC, or complete blood count. It does indeed sound like bad management.

[jrtmedic]

Sheryl -----totally agree !

The OP should, if at all possible, take the child to KK.

It is unlikely they will wish to admit the child unless she is acutely unwell.

In the event of it being necessary to sedate the child to enable cleaning and examination a stay of one night may be involved and similarly if it is determined that grommet insertion would be beneficial only a day's stay would normally be required.

Edited June 24, 2013 by jrtmedic

[sinbin]

Update to my daughters ear infection. We managed to go and see a ENT doctor at the Mararat Hospital in Korat. Not a patient friendly doctor but what the heck. He diagnosed our daughter as having a 'Cholesteatoma Cyst' of the Middle Ear. Treatment to be antibiotics and creams for the ear. He said the treatment would be a lengthy process.

When I got home I went onto the internet and looked up on the cyst. A video on there said that 'Cholesteatoma Cysts' of the Middle Ear cannot be treated with medication and requires surgery. Off to KK teaching hospital today. Spoke to the person overseeing the ENT dep't and she agreed with surgery part. But only after our daughter has a CT scan first. Went and did that privately at a cost of 5,500 Baht. She goes back next week for the findings. In the meantime, more antibiotics.

Got home from the hospital only to be told by the mother in law that some women in the village had been discussing our daughters problem. Their conclussion was that we find a pregnant woman who would spit 3 times into our daughters ear and that would cure it. This is true I kid yous not. If all else fails.............

Edited September 18, 2013 by sinbin

[Sceptict11]

Looking back on this thread it would seem advise was actually given which suggested the child be taken to KK.

Not sure about the spitting !

Many such "cures" to be found in rural Thailand !

[sinbin]

I agree that KK was recommended in an earlier post but without checking I think I did point out that KK was a last resort due to our geographical locations. I had no choice but to exhaust all other venues first before undertaking the journey. KK is over 350km from where we live,we have 2 other children to consider,we have no geographical knowledge of KK,the teaching hospital is government so chances are it's an all day affair. So timing is essential and that's why KK was a last resort.

What I have found to be consistant with Thai doctors is their lack of courage. By that I mean they are reluctant to pass you on to another level of care. May be this is down to feeling embassased because they couldn't solve the problem? A loss of face so to speak. If so, then it's not a good thing as it is putting peoples lives in danger.

[Sheryl]

I agree that KK was recommended in an earlier post but without checking I think I did point out that KK was a last resort due to our geographical locations. I had no choice but to exhaust all other venues first before undertaking the journey. KK is over 350km from where we live,we have 2 other children to consider,we have no geographical knowledge of KK,the teaching hospital is government so chances are it's an all day affair. So timing is essential and that's why KK was a last resort.

What I have found to be consistant with Thai doctors is their lack of courage. By that I mean they are reluctant to pass you on to another level of care. May be this is down to feeling embassased because they couldn't solve the problem? A loss of face so to speak. If so, then it's not a good thing as it is putting peoples lives in danger.

Absolutely true, unfortunately. Even with something as simple as needing a lab test that they don't have the facility to perform, they'll skip the test rather than tell the patient to get it done elsewhere.

Not all Thai doctors of course but a very high percentage. Preservation of "face" trumps all other concerns in most spheres of Thai life. And most Thai doctors seem to feel that referring a patient elsewhere for any reason, or saying openly they don't know something/need to look it up or ask, will cause them to lose face in the patient's eyes. Not in fact the case from my dealings with Thai patients, but they assume it to be so. Actually Thai patients are under no illusions about doctors being omnipotent, though they may hesitate to openly question due to the need to show "proper respect" to a person higher up in the social pecking order.

Can't begin to say how many neighbors have come to me to express doubts about treatments given them by doctors or seek validation that it was correct. And they are not in the least put off by the fact that I often have to refer to a book or internet before replying to them. So I think in this as in many other things the assumptions Thai doctors have about what patients really want may not be on the mark.

[sinbin]

Unfortunately I couldn't go to the hospital yesterday with my wife so I couldn't ask questions as to our daughters condition. I'd be grateful if a medical trained person could give me a breakdown as to the 'good and the bad' of this report. All I got from the missus was that they want to operate but they're struggling to find someone capable of carrying it out. I assume this is because of her age (4.5 years) and her size. Thank you.

CT SCAN OF TEMPORAL BONE

History: Right chronic otitis media with granulation tissue at right TM. R/O choleseatoma.

Non-contrast CT scan was performed through temporal bone and base of skull with coronal and sagital reconstruction.

FINDINGS:

The study reveals soft tissue density lesion at Prussak's space of right middle ear cavity, size about 3x2 mm. Mimimal erosion of right scutum is noted. The soft tissue lesion abut on lateral aspect of melleolus without bony displacement. Thickening of right tympanic membrane is also seen. Fluid within posterior aspect of right epitympanium and minimal fluid at hypotympanum is noted. Sclerosis of right mastoid air cells with fluid in air cells is seen. No bony destruction of mastoid bone is observed.

.. Normal appearance of bony part and cartilaginous part of bilateral external auditory canal. Normal turn of cochlear is seen. Normal appearance of vestibule and all semicircular canals is noted. Unremarkable of facial nerve tract is noted. No labyrinthine fistular os observed. Normal position and complete bony wall of jugular bulb and carotid canal is seen.

Symmetrical bilateral IACs are noted. The visualized base skull appear unremarkable.

IMPRESSION:

- Tiny soft tissue lesion (3x2mm) at right Prussak's space with minimal erosion of right scutum:-- Suspected cholesteatoma.

- Thickening of right tympanic membrane.

- Chronic right otitis media with effusion.

- Right mastoiditis.

[jrtmedic]

The CT scan reveals the presence of a very small (suspected) cholesteatoma together with evidence of chronic infection.

The good news is that (as yet) there is only minimal "damage" resulting from the infection/cholesteatoma.

Treatment is (as you know) surgical and involves the use of an operating microscope and micro-surgical technique.

The surgeon will aim to remove the cholesteatoma and reconstruct the eardrum whilst preserving/improving hearing.

In the West this surgery is often undertaken on a day case basis but given that you are situated some distance away from the hospital you may have to be prepared for a 2-3 day stay in KK.

I wonder if your wife's "understanding" is somehow related to interpretative difficulty.

If there is indeed no paediatric ENT surgeon at KK you should secure a referral elsewhere possibly Bangkok.

I hope this short note is helpful and I of course send my best wishes for an early resolution to your little girls problem.

[sinbin]

Thank you for those reasuring words 'Jrtmedic'. You make it sound less serious than what me and the missus have been thinking. 2+ years of this and we're begining to see light at the end of the tunnel at last. As for

I wonder if your wife's "understanding" is somehow related to interpretative difficulty.

I think it's down to fear of questioning a person with higher status than herself. A norm thing for Thais, from my observations. Thanks again.

[Sheryl]

Is the hospital in question KKU? As that is the only place i nthe region likely ti have the proper capacity to treat this.

Cholesteatoma sounds scarier than it is. It is a benign (but abnormal) growth of cells in the ear. It does need to be removed, but it is not cancerous. Here is a good overview http://www.nhs.uk/conditions/cholesteatoma/Pages/Introduction.aspx

The presence of mastoiditis means that a very long course of antibiotics, possibly by IV, will be needed.

[sinbin]

The hospital is the Government teaching hospital in KK. I dont know its full title.

The presence of mastoiditis means that a very long course of antibiotics, possibly by IV, will be needed.

That was a suggestion by one doctor in the past. He wanted to put her on an antibiotic drip for 2 weeks in hospital. But at the end of the day the Cholesteatoma has to be surgically removed and he didn't detect that on his examinations. Hopefully, if she does have to have a 2 week course of IV antibiotics we can get them to do it at an hospital much closer to home? So all's looking good now. Thanks.

Edited September 26, 2013 by sinbin

[Sheryl]

Yes, that's the hospital. Best in the region by far. (actual name is Srinigarind).

They may be able to arrange for long course of abx closer to home but make sure it is all per the direction of the docs at KKU. If you stick to govt hosp that should be do-able.

[sinbin]

I'd like to say I give up with Thai doctors, but I'm not in a position to give up. My wife took our daughter to KK again today to see the doctor that was going to operate/investigate her ear problem as detailed in the CT scan. He checked her ear, and due to the hole in her eardrum having closed he said he couldn't see a cyst. He said that the CT scan wasn't conclusive and therefore wouldn't operate. He said operating would probably make thing worse anyway. So no operation and told to go back in a month. He said that the cyst on the CT scan may be just hard wax. Does wax get into the middle ear?

This is exactly what has been happening for 2+ years now. The doctors give her antibiotics. The hole closes, and a week or so after the antibiotics are finished, back comes the discharge. Our next stage is Bangkok Hospital Korat.

[Sceptict11]

Oh !

Sorry to learn about that.

I wonder if your daughter was seen by a Senior member of the medical staff ?

We are limited in the advice which can be given here as I am sure you will understand.

I have read this thread from the beginning and clearly your daughter has a problem .

Jrtmedic observed early in the thread that there has to be a cause and diagnosis associated with your daughters continuing and chronic problem.

The CT scan report appears to be diagnostic but it may well also be the case that if the eardrum has healed the problem may not be visible due to scarring .

It is unlikely that "ear wax" was the cause of the CT findings which went beyond the diagnosis of Cholesteatoma and also identified a chronic infective process and a mastoiditis which would be consistent with the finding of a Cholesteatoma.

Your next move should ensure your daughter is seen by a Specialist ENT surgeon not a junior doctor or someone still in training.

I am unaware of the skills/qualifications of the ENT surgeon(s) at the Bangkok Korat hospital but ideally you should seek someone who has had postgraduate education in the West.

Make sure you take all test results and the CT report (and CD) with you when attending any future appointment.

Sorry not to be able to provide more assistance.

[sinbin]

I wonder if your daughter was seen by a Senior member of the medical staff ?

Initially we saw a junior doctor who immediately passed us on to her supervisor. That supervisor sent us for the CT scan after re-checking the ear. The doctor who saw her yesterday was the doctor that was supposed to operate/investigate. So I assume he was "Senior".

I have read this thread from the beginning and clearly your daughter has a problem .

Yes we know, as her parents, that she has a problem but we can't seem to convince anyone. I've lost count of the doctors I've fell out with. One even told me I was over protective. Well, shouldn't I be as a parent?

Jrtmedic observed early in the thread that there has to be a cause and diagnosis associated with your daughters continuing and chronic problem.

We agree, but as I wrote "we can't seem to convince anyone".

Your next move should ensure your daughter is seen by a Specialist ENT surgeon not a junior doctor or someone still in training.

Unfortunately we can only do that once the infection re-appears and perferates the eardrum again. No signs, no symptoms, no point.

Sorry not to be able to provide more assistance.

Any advice is good and we thank you for taking the time to respond.

Just a quick bit of useful information to anyone who requires a CT scat in Khon Kaen. The government hospital sent us to the private clinic "Rachapreuk Hospital" for the CT scan. Waiting list at the government hospital was too long. CT scan cost us 5,500 Baht. In and out within the hour.

Yesterday a senior doctor asked my wife how much we paid for the CT scan? When she told her she said that that was cheaper than what they charge at the government hospital. Which seems suprising.

[Sheryl]

That is an excellent price for a CT.

Sinbin, you say your wife took her to the doctor -- did you also go? I ask because in Thai culture it is very hard for patients to question doctors. Before giving up it may be worth you going back, records in hand and insisting in seeing the acharn in charge of the clinic.

Unfortunately I don't know anything about the ENTs at Bkk Hosp Korat and their website is only in Thai.