Letters to the Editor

Volume 71, May 1992.  Permission granted to reproduce the following letter.


Dear Editor,


Almost ten years ago in his article "Otitis Media in Children: To Treat or Not to Treat." Bluestone discussed many aspects of this problem. And he said, "Of the many methods of management that are available for chronic otitis media (OME) with effusion none has been shown to be effective in acceptable clinical trials."


In a guest editorial in the Annals of Allergy, Wientzen said "By age three 33% of children will have experienced repetitive bouts of OME. Fully half of acute care visits to pediatricians in this country in some way involve the diagnosis, treatment and follow up management of OME. With such a high incidence of clinical disease, much has been learned of the pathogenesis, etiology, diagnosis, and therapy of OMR. Much has not!"


An estimated one million tympanostomy tubes are placed in American children's ears each year and perhaps an equal number of children are given "prophylactic antibiotics" in an effort to lessen the frequency of ear problems. In discussing such use of antibiotics in children with recurrent otitis media, Grundfast pointed out that there are a number of drawbacks to such antibiotic therapy, including the development of fungal infections in children who have been treated with prophylactic antibiotics.


Could these antibiotic-induced fungal infections in the gut contribute to the "epidemic" of ear problems in American children? In my opinion the answer is "yes". This possible relationship was first suggested by a Birmingham, Alabama, C. Orian Truss, who said "the problem of candidiasis in infants and children is especially important, not alone as it relates to their health at this period of their lives, but also as it may relate to problems with yeast later in life..."
"The first clinical recognition of infection with Candida albicans often follows an infant's initial encounter with antibiotics... Unfortunately, after the antibiotic ... is discontinued, the previous state of health may not return."
In his discussion, Truss presents a detailed history of a 16-month-old child who had his first ear infection at the age of two months. the child had another ear infections at five months and still another at seven months and at then months. At that time, tubes were put in both ears.


In spite of the tubes, recurrent ear infections and other health problems continued. At the age of 16 months, he was first seen by Dr. Truss, who placed him on Nystatin, 200,000 units four times a day. Within one week, he was completely asymptomatic. His respiratory, digestive and nervous system symptoms had disappeared. he was continued on Nystatin for another 6 weeks and did well. At that point, the Nystatin was stopped and the child's respiratory systems and loose stool symptoms returned. The Nystatin was started again and continued for our months and the child remained well through the winter. A follow-up report six months later showed that the child had remained free of ear infections and significant respiratory or digestive problems.


Dr. Truss commented, "The abruptness of the reversal of so many symptoms once Nystatin was started leaves little doubt that the yeast problem had underlain the vicious cycle .... In my opinion this is not an isolated problem ... it is probably very common. antibiotics save countless lives, but ... some individuals are left with residual problems related to their use.
"An awareness of the yeast problem should allow pediatricians to identify the babies and children with this susceptibility and to treat this infection when it occurs, or to even prevent it with suitable precautionary measures. ..."
"Perhaps the single most fascinating and potentially important aspect of this case was the abrupt cessation of ear infections ... and makes one wonder about the possible relationships of this yeast to what seems almost a national epidemic of otitis and tubes in the ears."


Based on the observations of Truss and my own observations using oral Nystatin and a special diet, I'm writing to suggest a simple non-blinded study of healthy infants in the hope that it will provide information that may help interrupt the vicious cycle of ear infections.


Here's a brief outline of the study:

Here's more support for such a program. In reports published in the 70s, Iwata described experimental work in mice who had been infected with virulent strains of Candida albicans. And he noted a "selective decrease in the number of T-cells in these animals" And he stated, "Upon Candida albicans infection the toxin produced in the invaded tissue may act as an immuosuppressant to impair host defense mechanisms involved cellular immunity ..."


In a subsequent report of a study on women with recurrent vaginal yeast infections, Witkin stated "Candida albicans infection, often associated with antibiotic induced alterations in microbial flora, may cause defects in cellular immunity. This immunospuppression may be the result of suppressor substances generated by macrophages, the induction of candida-specific suppressor T-lymphocytes and/or the accumulation of candida carbohydrates such as mannan>'
Another factor which would appear to be important is the avoidance or limitation of simple carbohydrates from the diets of infants and young children, especially those who are experiencing ear infections. Here's support for this recommendation:


In studies on immunosuppressed mice carried out at St. Jude Hospital in Memphis, researchers found that in the mice who received glucose in their feedings, gastrointestinal growth and invasion of Candida albicans was approximately 200 times greater in the dextrose group than in the control group of mice who received sugar-free feedings.

A final comment:


The relationship of Candida albicans to a diverse group of health problems which affect people of all ages and both sexes has been, in general, greeted with skepticism. yet, because present methods of managing OME are ineffective. I hope otolaryngologists, pediatricians, family practitioners and other physicians will consider the possible relationship of candida overgrowth in the intestinal tract to immune system disturbances resulting in recurrent ear infections in infants and young children.


William G. Crook
PO Box 3493
Jackson TN 38303

References:
Bluestone CD. Otitis media in children: to treat or not to treat. New England Med 1982; 308:1399-1403
Wientzen RL. Otitis media with effusion - more than a pain in the ear. Annals of Allergy 1984
Gundfast K, Carney CJ. Ear Infections in Your Child. Warner Books, 1987, 137-8
Truss CO. The Missing Diagnosis. Birmingham AL, 85225: 77-82
Iwata K, Uchida K. Cellular Immunity In Experimental Fungus Infections in Mice: The influence of  infections and treatment with a Candida toxin on spleen lymphoid cells. Medical Mycology. Flims, January 1997. Mykosen suppl, 1, 72-81 (1978)
Witkin SS. Defective immune responses in patients with recurrent candidiasis. Infections in Medicine.  May/June 1985: 129-32
Vargas Sl, Hughes WT. Substrate Replacement Limits Candida albicans Gastrointestinal (GI)     Overgrowth and Subsequent Invasion in Neutropenic Mice. Presentation. American Society for  Microbiology, September 1991.