Prevention and Treatment of Acute Otitis Media in Children and Adults from the Perspective of Anthroposophic Medicine

Acute otitis media (AOM) is one of the most common reasons for consulting a doctor in childhood (particularly in early childhood). This paper addresses the question of how the therapeutic use of antibiotics and antipyretics can be reduced in AOM treatment, in both children and adults.
The integrative approach of Anthroposophic Medicine (AM) described below extends the therapeutic interventions of standard conventional treatment safely and effectively and offers an added value for the therapeutic management of AOM.

Introduction

Acute otitis media (AOM) is one of the most common reasons for medical consultation in childhood. Current guidelines recommend antibiotic therapy only for children under 6 months of age, or if there are additional risk factors, or for severely impaired, febrile children (1). The risk of mastoiditis is not significantly changed by general immediate antibiotic therapy (2).
At times of increasing development of antibiotic resistance, it is important to communicate that anthroposophic and integrative approaches are sufficient and effective in most patients, avoiding the use of antibiotics and antipyretics (3, 4, 5, 6). This experience is similar with adult patients.

Definition and leading symptoms

Tube ventilation disorders and the accumulation of middle ear secretions lead to an effusion of the middle ear and an impairment of hearing because the flexibility of the eardrum is limited. Secondary bacterial or viral infections of the effusion may lead to inflammation and suppuration, sometimes resulting in bursting of the eardrum and the otorrhea that follows (8).
More than 2/3 of children suffer from AOM before their 3rd year of life. AOM is often associated with a mild cold or teething (9, 8). Noticeable symptoms usually last 3–4 days. AOM is self-limiting spontaneously within 1–2 days in 2/3 of all cases and in most cases within 7–8 days (even in case of perforation) (1, 10, 11, 12, 9). Pain in the beginning of AOM can be very intensive and pain relief is one of the main objectives in AOM management.

a. In childhood

Otitis media usually begins suddenly. AOM should be taken particularly seriously in early infancy when there is a marked impairment of the infant’s general condition. The older the child, the more the leading symptom becomes clearly locatable pain. Bilateral otitis media indicates a more severe course.

In general, the following can occur concomitantly:

• fever
• irritability
• whininess, restlessness (especially at night)
• touch sensitivity (ears and head)
• hearing loss
• loss of appetite
• diarrhea, vomiting
• cold, cough (11, 9, 12, 7, 13)

The frequency of complications (perforation, mastoiditis) decreases with increasing age. Antibiotics increase the incidence of diarrhea (14).

b. In adulthood

the following symptoms are clearly indicative:

• earaches
• headaches
• hearing loss

In the case of perforation, the pain decreases significantly.

Predisposition, triggers

Toddlers and young children are particularly susceptible to the development of AOM for anatomical reasons. After birth, the middle ear is gradually ventilated (pneumatized) via the Eustachian tube. This process is very individual, especially for the mastoid (8, Chap. 5.1.3).
In most cases a swelling of the nasal mucosa precedes the obstruction of the Eustachian tube. In infants and toddlers this is usually the result of hypothermia or a respiratory infection. With increasing age allergic inflammations of the respiratory tract play a role.
In the course of recurrent infections of the upper respiratory tract, the palatine and lingual tonsils can swell and block the Eustachian tube partially or completely. The disposition for AOM is increased especially in case of adenoids and tonsil hypertrophy (“lymphatic constitution”). AOM is much more common and more individual to treat in children with cleft lip, jaw and palate.
Risk factors are pacifiers, premature birth, passive smoking, food intolerance, low humidity (15), male gender, low socio-economic status (9, 12). Breastfeeding is preventative. The importance of the healthy biofilm and microbiome is discussed (16).

Diagnosis and differential diagnosis

The otoscopic examination is the key to a correct diagnosis. Effusion, curvature, redness, turbidity and immobility or pulsation of the eardrum are predictive for AOM (12).
AOM can be distinguished from serous otitis media with effusion (OME) and chronic otitis media (COME) (17, 18): 

• OME: after an infection has subsided, the serous-mucilaginous fluid effusion remains in the middle ear. The child may experience a feeling of fullness in the ear and hearing loss.
• COME: over a longer period of time, effluences in the middle ear return again and again, even if there is no infection.

Conventional therapy

If the course of the illness is uncomplicated, then conventional treatment is limited to observant waiting, nasal hygiene, and pain relief with antiphlogistics (NSAID).
The avoidance of complications is an important aspect of accompanying the course of the disease.
A perforation of the eardrum usually heals in isolated cases without further complications.
Antihistamines, local decongestants and steroids are pointless (11).

Vaccination against pneumococcus and H. influenzae and selective antibiosis (see below) can reduce the rate of severe invasive complications (meningitis, sepsis, intracranial abscess, sinus thrombosis and n. facialis paresis) (1, 9, 19).

The cautious, careful use of antibiotics is well described using evidence-based algorithms (4, 20). Antibiotics have little effect on the rate of common complications such as hearing loss, perforated eardrum and recurrent infections (10). Antibiotics weaken the vital process of the organism and impair the natural maturation of the child’s microbiome and immune system, especially in the first year of life (21, 22). In view of the growing threat posed by antibiotic resistance, first-line therapy concentrates on holistic self-care. Antibiotics should be considered if

• there is no improvement after 3-5 days
• the patient’s general condition is persistently impaired
• continued high fever, CRP increase and a reduced general condition persist
• several levels of the airways are inflamed simultaneously (e.g., pneumonia and otitis)
• mastoiditis or invasive complications threaten to occur or have already occurred

Principles of sustainable integrative therapy

• Pain treatment with efferent therapies directed at local hyperemia of the middle ear (e.g., onion bags, footbath).
• Pain treatment by promoting ventilation of the middle ear.
• Promotion of a healthy diet, breastfeeding.

Integrative therapy promotes the organism’s own activity in overcoming the disease. For this purpose,

• the we strengthen the warmth organism overall and at the same time aim to draw away the acute hyperemia from the middle ear area using external applications.
• We also support the ventilation of the upper respiratory tract and the middle ear. Active speaking and singing are encouraged, to stimulate nasal breathing.

This approach is complemented by loving care, healthy nutrition, appropriate clothing and responsible fever management (www.feverfriend.eu, www.feverapp.de). Suppression of the inflammatory activity of the organism accompanied by fever may contribute to a chronic state of stagnation without fever. Consumption or work in front of a monitor worsens the blood circulation in the midface and favors dysfunctional flat breathing patterns, which in turn promotes inflammatory processes in this area in an undesirable way.

Elements of integrative therapy in childhood and adulthood

a) Local pain therapy

• Onion bags on both ears
  This measure is a tried and tested household remedy for uncomplicated middle ear inflammation. The effect is rapid; failure indicates a more severe inflammation. For instructions, see http://www.pflege-vademecum.de/zsohr.php.
• Skin stimulation therapy by placing a cut garlic clove in the opposite elbow for a few minutes 3–4 x daily has also proven itself.

Anti-inflammatory effects of onions are well known (23, 24). Both onions and garlic indirectly release hydrogen sulfide as a gas transmitter.

If the eardrum is intact:

• Aconitum comp. ear drops WALA (also available as Aconit Ohrentropfen) 3–5 x daily at body temperature drip into the ear canal (the composition corresponds to Aconite Nerve Oil WALA) (25).
• Interventions to ensure warm feet.
• Ginger footbath especially for patients with cold lower extremities. For instructions, see http://www.pflege-vademecum.de/ingwerfussbad.php.
• Warm footbath with water or 1% NaCl solution and rising temperatures (37 to 40°C or 98.6 to 104°F).
• Lavender 10% oil or Solum oil WALA or Mallow oil WALA (also available as Malvenöl) for mild cases and small children < 4 years, especially before sleep.
• Copper ointment WELEDA or Red Copper Ointment WALA (also available as Kupfersalbe rot) 1–2 x per day (24). 

b) Promoting pneumatization

• Nasal sprays with physiological saline solution or similar;
  especially in the case of a history of respiratory allergies or adenoids use the decongestant.
• Gencydo 1% Nasal Spray WELEDA (similar to Heuschnupfenspray WELEDA), 1 – 2 bursts 3 x daily. 

c) Medication to accompany inflammation

In case of acute otitis media, frequent administration of medication initially proves effective, in the case of severe pain initially up to 4 x per hour. A widely proven basic medication for uncomplicated AOM is

• Apis/Levisticum II (= D 3/4) pillules/ampoules WALA
  Start with 3–5 pill. every 15–30 min., then less frequently after this has started to have an effect. Pain-relieving and decongestant, especially for pale red, possibly edematous eardrum, also for bullous AOM. Promotes ventilation of the middle ear.

In case of very painful AOM in adults, also 0.5 ml. s.c. above the mastoid.

This is usefully augmented with

• Silicea comp. pillules/ampoules WALA, 5 pill. 3x/d
  Contains Quarz D21, Argentum nitr. D 20 and Atropa Belladonna ex herba D14.

Silicea comp. is a basic remedy for acute inflammatory diseases in the area of the paranasal sinuses and the middle ear, especially during the advancing pneumatization of this area (8, Chap. 5.1.2.4.3.). In case of acute, very painful symptoms in childhood, 0.3–0.5 ml can be injected s.c. above the mastoid at the beginning of therapy (8, Chap. 5.1.3.1.1.) and contribute to rapid improvement.

As an alternative to Silicea comp., when the otoscopic examination shows a bright red, sharply marked eardrum with severe pain, and in case of vesicles on the eardrum, possibly treat in alternation with Apis/Levisticum

• Erysidoron 1 Weleda or Apis/Belladonna pillules WALA, initially every two hours, then less often: 2 drops (<2 years old), 3–5 drops (2–6 years), 5–8 drops (>6 years), or 3 pill. (<2 years), 5 pill. (>2 years), 7–10 pill. (>6).

Suppositories have proven to be effective for more progressive forms of AOM, impaired general condition, recurrent AOM and constitutional weakness of the immune system (e.g., trisomy 21), among others.

• Echinacea/Mercurius comp. suppositories/suppositories for children WALA
  1 suppository for children (<7 years) 1–3x/d (25)

For AOM with increasing pain in the evening and at night, fever, pronounced restlessness, especially for toddlers in the teething age, the following are suitable:

• Fever and teething suppositories Weleda (also available as Fieber- und Zahnungszäpfchen)
  1 suppository 1–3x/d for toddlers. (Note: Off label use for infants <12 months. “In the first year of life, especially for infections or susceptibility to infection because of teething. Broad positive experience with this age group”, 25, p. 319)

For further differentiated treatment with anthroposophic-homeopathic medications (25, 8 Chap. 5.1.3.) 

d) Otitis media with perforation of the eardrum, otorrhea:

Antibiotics may not be immediately mandatory. Important are

• daily monitoring in the first days, 
• treatment of the entire external auditory canal with 3% H2O2 solution for 4-5 minutes 3-4x/d., a well-established measure (26).

Supplementary treatment with

• Quartz D6 trit. Weleda, 1 saltspoon (~¼ tsp.) 4 x daily

Composition of the medicinal products mentioned: Aconitum comp. ear drops: Aconitum napellus e tubere ferm 33c Dil. D9 oleos.; D-Campher 0,1 g; Lavandulae aetheroleum 0,1 g; Quarz Dil. D9 oleos. Gencydo 1% Nasal Spray: fresh lemon juice 8–12 mg; aqueous extract of 9,7 mg fresh quince fruit. Silicea comp.: Argentum nitricum Dil. D20 aquos. 0,1 g; Atropa bella-donna ex herba ferm 33a Dil. D14 0,1 g; Quarz Dil. D21 aquos. 0,1 g. Erysidoron 1: Apis mellifica Dil. D2 1 g / Belladonna Dil. D2 1 g; Ethanol 96 %. Echinacea/Mercurius comp. Supp.: Apis mellifica ex animale toto Gl Dil. D3 2 mg, Argentum metallicum Dil. D18 aquos. 2 mg, Atropa belladonna e fructibus ferm 33a Dil. D2 2 mg, Echinacea pallida e radice ferm 33d 2 mg, Mercurius solubilis Hahnemanni Dil. D13 aquos. 2 mg

Follow-up

After 3–4 weeks, a follow-up otoscopic examination of the middle ear and control of middle ear pneumatization (tympanometric) is recommended, with a hearing test (at least a bilateral whisper-test).
The P.E.A.N.U.T. method has proven to be effective in cases of persistent middle ear effusion (27, 28).

Before birth, the tympanic cavity is filled with a clear liquid. The middle ear and the mastoid cells must first be actively pneumatized by the soul’s own activity in respiration. Primary pneumatization progresses to the mastoid in the first 3–4 years. But this is not stable, the balance must always be found anew. The respiratory epithelium “fights” against the richly perfused connective tissue, which is pushed back further and further and can assume an epithelial phenotype (29, 30). If the fluid persists, a thick, vascular mucous membrane remains in the middle ear – which is prone to inflammation. At the time of dentition, the middle ear is at risk of falling back physiologically into an “embryonic stage” (eustachian catarrh, mucoid otitis media). The acute inflammatory process in the middle ear, on the other hand, not only aims to kill possible pathogens, but also to advance the pneumatization process. Spontaneous perforation of the eardrum counteracts mucoid otitis media.

The primary predispositions of AOM are pneumatization disorders of the middle ear and hypothermia. Secondarily then it can come to a penetration of pathogens (viruses, bacteria).

That is why the care of the patient’s warmth organization has priority in the prevention of AOM, through appropriate clothing, foot baths, oil embrocations (8, 31). Breastfeeding strengthens the warmth organization and has a positive effect on the aeration of the middle ear. The opposite applies to pacifiers.

The promotion of respiration, especially nasal breathing is also essential (see Rhinosinusitis https://www.anthromedics.org/PRA-0685-EN). Every disturbance of nasal breathing, every catarrh, and passive smoking endangers the presence of air in the middle ear. Of course, infections of the upper respiratory tract cannot be avoided in principle, although the group size in nurseries and kindergartens can have a significant influence on this. Swimming pools and baby swimming in early childhood have a negative effect on the development of the respiratory tract (32).

Acute middle ear inflammation often impresses us with a highly acute experience of pain, a state of excitement of the sensory organization, which can also be accompanied by strong anxiety, even of relatives (parents). Here it is important to inform the patient calmly about the clinical picture and, if necessary, the person caring for him or her. In the vast majority of cases, the above-mentioned external and therapeutic measures and medication make it possible to dispense with analgesics/antiphlogistic agents and antibiotics.

Suppression of the inflammatory activity of the organism accompanied by fever may contribute to a chronic state of stagnation without fever. Active speaking and singing are encouraged, to stimulate nasal breathing (28). Consumption or work in front of a screen worsens the blood circulation in the midface and favors dysfunctional flat breathing patterns, which in turn promotes inflammatory processes in this area in an undesirable way.

It is necessary to control and limit the element of aqueous vitality in the upper respiratory tract and in particular in the middle ear. Suitable for this are extracts from the root of lovage (Levisticum), which contain essential oils, resins, mucilage sugar and various plant acids. It stimulates diuresis and digestive activity, as well as stimulating respiration (33).

As with nutrition for any acute inflammation, food and drinks containing sugar/glucose syrup should be avoided. The consumption of milk can increase the mucus in the respiratory tract. Sweetness weakens the activity of bitter substance receptors (34), which stimulate breathing and pneumatization. Slightly bitter foods as well as medicinal bitter substances (Gentiana, Absinthium, Cichorium) can have a beneficial effect. Chewing should be encouraged; the food should support the child’s warmth organization.

With regard to the promotion of middle ear pneumatization through eurythmy therapy and anthroposophic therapeutic speech, similar exercises are effective as are used in treating rhinosinusitis (https://www.anthromedics.org/PRA-0685-EN).

Conflicts of interest: David Martin sometimes gives lectures out of conviction at events organized by AM manufacturers, but he does not take an honorarium and he pays his own travel expenses. He has also not yet accepted any money from AM manufacturers for research.
All other authors and co-authors declare to have no conflict of interest.

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