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  • The Nordics are positioned in the front. Ann Hermansson on the treatment of ear inflammations in children.

                                       ………… Fact box ……….…

    Ear inflammation is often the result of common cold
    An ear inflammation often starts with a common cold. The cold virus makes it harder for the mucous membrane in the nose and ear to defend against bacteria.  The bacteria can cause an infection in the middle ear and you get an ear infection. The eardrum becomes red and thick and pus starts to build behind the eardrum. The eardrum can bulge outwards and become less mobile. The pain is due to the swelling and the growing pressure in the middle ear. Sometimes the pressure causes rupture of the eardrum.Ear inflammation is the next most common infection in children after the common cold. Especially during the winter many children become sick. Adults can also get ear inflammation but it is not so common. Here the infection is often more severe. Ear inflammation usually starts suddenly and ends in a few days. That is called acute ear inflammation or acute otitis. Small children (less than 1 year old) and children over 12 years of age and adults are always treated with antibiotics in case of ear inflammation. Children between one and 12 years are not treated with antibiotics in case of uncomplicated infection if they are otherwise healthy. First line treatment in Sweden is usually penicillin. If worsening happens or if the patient is not improved in two days after the diagnosis of otitis a new assessment must be done regardless whether the patient has received antibiotics or not.
    Source: Vårdguiden……………………………………………………………………………………………………………………………………..

    Ann Hermansson is an associate professor and consultant physician at the ENT clinic, SUS in Lund. She has a special interest in questions about infectional diseases in the upper respiratory tract in children and especially ear inflammations.


    Ann Hermansson, how do the Nordics compare with the rest of the world when it comes to treatment of otitis in children?

     – Very well! We are skilled at diagnosis and we have good control with prescription of antibiotics. Bacterial resistance is increasing rapidly in many countries towards common antibiotics but in Sweden we have, thus far, a privileged position. We would like to believe it is because we actively work towards using antibiotics in a limited and sensible manner.

    – Antibiotic-restrictive guidelines were introduced by the Netherlands as early as the 1980’s. Sweden and the rest of the Nordics soon followed and today similar guidelines are used all over the world.

    But there are still differences in the treatment traditions between the Nordic countries?

    – Yes, but you shouldn’t make too much of these differences. It is true that Denmark inserts more tubes in the ears of small children than the rest of the world, and that Finland is, or at least has been, eager to even prick a hole in the eardrum in case of ear inflammation.

    – Ear inflammation is a clinical diagnosis; there are no laboratory tests to be had. The doctor must learn how to “know his eardrums” and have good instruments at his disposal. Nowadays, many health centres are equipped with otoscopes and young doctors practice how to make the diagnosis during their training. It is important to be certain of the diagnosis, in order to be able to treat those who need it and refrain in those cases where antibiotics would be of no use.

    How did the Nordic countries achieve this leading position?

    ­– The answer is that few countries in the world have as developed child health systems as we do. We have a population able to read who easily takes in information. The interest in actively seeking knowledge is great, especially among younger people (parents of small children). There is access to directions and advice from Strama and “Vårdguiden 1177” that is tailored for the public.

    – The pressure from parents to get a prescription for antibiotics for ear sick children has decreased, as the knowledge about the dangers of antibiotic overuse has reached the general public, and today very few parents want antibiotics if it can be safely left out.

    So the “otitis-knowledge” of the general public has increased. How did this happen?

    – Through an increased awareness among caregivers, patients and parents and improved information for the general public. If you search for ear inflammation on Strama’s and “Vårdguiden’s” homepages you get all the information you need.

    How has otitis treatment changed during the years?

    – Until the year 2000 all children were given treatment if diagnosed with otitis. Unfortunately quite a few without otitis were also given treatment due to overdiagnosis. That year the first Swedish guidelines came out. They were revised 10 years later.

    – Today, the guidelines can be summarized in this way: By ear inflammation in children between 1 and 12, antibiotics must be avoided if the child is feeling well and no complicating factors are present, presupposing that pain killers and anti-inflammatory drugs have had a good effect.

    – If the symptoms cease after so-called active expectancy for 2-3 days or if the symptoms are worsened, the doctor must be contacted and the child given antibiotics. Children who are younger than 1 year and older than 12 and adults should always be treated with antibiotics in case of otitis. It is important to stress that this does not mean that one should not seek a doctor in case of suspected otitis. The doctor must make an assessment of the severity of the infection and decide on the treatment and follow-up.

    – For children with tympanostomy tubes, local treatment with ear drops is recommended as first line therapy if the patient is undisturbed. If the ear drum is perforated a combination is given of oral antibiotics in tablet form together with local eardrops. Ear drops without oral treatment is recommended in case of external otitis, that is, eczema in the ear canal.

    Mastoiditis is a complication that is feared and not unusual in case of ear inflammation. What is know about its cause?

    – It is important not to forget that there are complications to ear inflammation. The most common is mastoiditis which is an infection of the bone around the middle ear. There are about 70 cases of mastoiditis every year in Sweden. The bacteria, which most often cause both the ear inflammation as well as mastoiditis, are pneumococcus. Since 2009 all children in Sweden have been offered a vaccination against pneumococcus. The vaccine is not a guarantee that the child will not have an otitis or mastoiditis since mastoiditis can also affect children who are vaccinated.

    – This is shown in the doctoral disputation: Acute Mastoiditis in Children – A national study in Sweden from 2015 by Frida Enoksson, Lund. Today most mastoiditis cases can be treated with antibiotics but in some cases an operation is needed.

    The complication is mostly found in children under the age of two with a rapid degeneration of disease.  In Dr. Enokssons disputation you can read:

    “Something unexpected was that the children affected with acute mastoiditis often are very healthy otherwise and that the disease progression is very rapid especially in small children under two. Those children often saw the doctor because a parent saw that the child was red behind the ear and that the ear had started to protrude – the classical signs of mastoiditis. The reason for seeking the care giver was not because the child had ear pains and that ear inflammation was suspected, but that the child had signs of complications.”

    There is talk about “ear children”. How common is recurrence of otitis?

    – A more normal problem is the children who are affected by recurrent otitis so called ear children. Vaccination against pneumococcus has unfortunately not lessened the numbers, which is thought to be between 10 and 15% of all children. It is rare that these children develop serious infections but it is a problem with repeated infections in short intervals both for the child, the parent, the society and the health sector.

    – Unfortunately there is not really effective treatment to take care of both the problem with frequent infections and large amounts of antibiotics. It is in many cases of little consolation that the problems are less frequent after the age of two and that the risk long term is very little for most. What is often tried is to insert a tube in the eardrum. In quite a few studies it is shown that this halves the risk of infections.

    –In many countries they also insert tubes during active infections to release the pus and give the possibility of local treatment. It is a strategy that is not so common in Sweden today. On the other hand, infections are treated exclusively with local antibiotics if a tube is present.

    – The number of children who receive a tube varies very much in the Nordics. In the Nordics tubes are often put in to the improve the hearing in children with non-infectious fluid in the middle ear and more rarely to counter infections. In other countries they are more restrictive with tube placement to improve hearing and more willing in case of infection. Here there is a great variation between the Nordic countries.

    – In Denmark, 3 out of 10 children receive tubes in the ear at least once.  In Sweden the same statistic is 7-10 pct. and in New Zealand, which I recently visited the number is under 1 pct.

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