As the Nose Goes, the Ears Follow

We can’t look inside our own ears; but if we could, we would see that what goes on in the ears is intimately connected to the nose, and what goes on in the nose is intimately connected to the ears. Here’s how it works and why it matters.

Three distinct areas make up the human ear: the outer, middle, and inner ear.

The ear canal is part of the outer ear. This is the part we can see, the part that can get blocked with ear wax, and the part that captures sound from outside the body. The ear canal carries sound to a thin, translucent membrane?the eardrum?which a medical provider can easily observe in a clinical setting when evaluating a possible ear infection.

On the other side of the eardrum is the middle ear, an air-filled chamber that contains the ossicles (three tiny bones all linked together). When the eardrum vibrates with sound coming from the ear canal, the ossicles pick up the vibrations and amplify them, carrying them to the inner ear. The inner ear translates those vibrations into electrical signals and sends them to the auditory nerve, which is connected to the brain. When these nerve impulses reach the brain, they?re interpreted as sound.

As the Nose Goes, the Ears Follow

How do ear infections involve the nose? Nasal health is critical for healthy ears because there is a direct connection between the middle ear and the nose.

Just ask Molly, who was brought into my clinic after both her mother and kindergarten teacher expressed concern that she was not paying attention in class. A quick screen in the office indicated a ?conductive hearing loss.? Mom wanted to avoid medications if possible, so she agreed to try nasal rinsing. Soon, Molly was washing like a pro, and two weeks later the repeat hearing test was normal. A simple and safe approach resolved her problem.

Let’s explore the reasons why such a simple approach is so effective.

For sound vibrations to send the signals to the inner ear, the middle part of the ear must be ventilated, allowing the air pressure on either side of the eardrum to equalize. The Eustachian tube is responsible for this ventilation, and for draining mucus from the middle ear into the back of the throat.

The Eustachian tube begins in the middle ear and extends into the back of the upper throat, approximately at the same level as your nostrils. The portion of this tube nearest the eardrum is always open, protecting the middle ear. The end that drains into the back of the throat is normally closed. We open and close this part of the Eustachian tube when we chew and suck.

If air is bubbling up and mucus is flowing down and out into the throat, all is well. But for this to happen, it is vital that the Eustachian tube remain open and free to drain. None of this can be accomplished if there is a mucus plug or if there is swelling, as both plugging and swelling prevent natural drainage. And it doesn’t take much to cause obstruction. Upper airway infections or allergies can cause this tiny tube to become swollen, trapping bacteria and causing middle ear infections.

Americans spend billions of dollars each year treating ear problems in children, much of it on doctor visits, drugs, and surgery. Ear infections are the top reason children visit a doctor’s office, and the number of children coming in with ear infections has risen throughout the past decade. There are several reasons for this, including bottle-feeding, increased allergies, greater pollution, more children in daycare, and exposure to cigarette smoke.

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Children experience far more ear infections then adults, and this is because their Eustachian tubes are immature. Infants and children have a more horizontal Eustachian tube without gravity to assist in drainage. It is also much shorter and collapses more easily compared an adult tube; the opening in the throat is more rounded, making it easier for secretions to find their way up into the middle ear. Additionally, babies tend not to swallow when they are asleep (they drool), and less swallowing means less ventilation of the middle ear. All of these differences result in a buildup of negative pressure, which causes pain and leads to restless nights.

Chronic Nasal Congestion and Solutions

Anyone who has had difficulty clearing their ears after flying in an airplane or has felt the congestion of a cold that clogged their ears knows how Eustachian tube dysfunction feels. Children with chronic nasal congestion feel this way all the time. These children think the world always sounds muffled, and it is no surprise that they cannot speak clearly.

The most common causes of Eustachian tube dysfunction are allergies and respiratory infections. Traditionally, doctors have given antihistamines to dry up secretions and decongestants to clear the passages. However, the side effects of these two medications can be problematic, especially in children.

For years, doctors would automatically prescribe antibiotics when any fluid was found in the middle ear. If the fluid persisted, they would recommend surgical placement of drainage ports, called PE tubes, in the eardrum?a man-made exit for the fluid. These tubes do not correct the original problem, but they do allow the fluid to drain out the ear canal if the Eustachian tube is blocked. More recently, the Academy of Pediatrics acknowledged that routine antibiotics and PE tubes may not be the best approach and has now released new recommendations. A watch-and-wait approach to most ear infections is the newest guideline, but as in the past, it is up to each physician to decide on the necessity of using antibiotics and/or surgery.

These recommendations will hopefully contribute to a decrease in the overuse of antibiotics and a reduction in bacterial resistance. Using fewer medications will reduce the development of adverse drug reactions as well. Sometimes these medications are warranted, but there is a first-line treatment that is much safer and often more effective in addressing the core issue as compared with medication: nasal washing with hypertonic buffered salt water.

In general, a good washing of the nasal cavity is all that is needed to maintain a healthy environment for the tissues. There are three key elements necessary to maintain normal function of the nose and sinuses: keep the cilia (nose hairs) clean enough to keep on sweeping, keep the sinus drainage ports open and free to drain, and keep mucus thin and free-flowing.

Irrigating the nose with a buffered hypertonic solution can accomplish all three of these objectives. It also acts as a natural decongestant, allowing that Eustachian tube to open and drain the middle ear. (Remember: Just ask Molly.)

Research suggests that nasal irrigation is useful in the management of ear infections, with decreases in both symptoms and medication use. If all patients, young and old, use a wash system that encourages effective and comfortable technique, they may be glad to forgo prescriptions for antibiotics, decongestants, antihistamines, nasal steroids, and more.

Be well and happy breathing, naturally.

By Hana R. Solomon, MD

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