Dr. Aaron Moberly, professor of otolaryngology at the Vanderbilt University Medical Center, talks about
Interview conducted by Ivanhoe Broadcast News in 2023.
Ear problems in kids are pretty ubiquitous. Why is that so? Why do so many of them come down with infections?
Moberly: So ear infections are incredibly common in children, in part due to the anatomy that children are born with. We start with eustachian tubes, which are the tube that connects the ear to the back of the nose, being not fully developed and at an angle that leads to a predisposition to fluid buildup in the ear and ear infections. So the majority of kids- over 80% of kids have an ear infection at some point in their life. Usually, this problem tends to clear up as the child grows up and our anatomy changes. The majority of these patients end up outgrowing this problem, so they don’t have chronic issues with infections. But it’s very common as a child to have an ear infection based on incompletely developed anatomy that really changes over childhood and into adulthood.
And I think we hear the term tubes in the ears quite often. Can you give us a brief explanation on what that looks like and feels like?
Moberly: So tubes refer to tympanostomy tubes. So these are tubes that are surgically placed into the eardrums, typically under anesthesia for children, sometimes in the clinic for adult patients, that basically are ventilating the middle ear space. So they- you create a hole in the eardrum, you place a tube in that’s keeping that hole open, and that allows us to ventilate the middle ear and remove any fluid that might be behind the eardrum. So in children, this is very commonly performed, one, to remove fluid from the middle ear or to address children who have very frequent ear infections.
Are they simultaneously on antibiotics on those two different stages?
Moberly: So typically, tubes are placed once a child has had a persistent infection with fluid behind the eardrums for a duration of time over a number of months, or if they’ve had recurrent infections that continue to happen even when they’re on antibiotics. So most of the time, by the time a child gets to having ear tubes placed, they’ve had a number of ear infections treated with oral antibiotics, typically.
You said a number of your patients are teenagers and grown-ups, but the teenagers have gotten these ear infections as little kids, and it just hangs on like a bad dream. Why does that stay a problem?
Moberly: Yeah. So as I mentioned, a child’s anatomy predisposes it to getting ear infection and fluid behind the eardrum very frequently. And as people grow up, the tubes that connect the back of the nose to the back of- let me start that over. So as we get older, our eustachian tubes grow in length and they actually change in the direction of their orientation. So again, the eustachian tube is the tube that connects the ear to the back of the nose. So as we get older, that elongates and changes in angulation and that hopefully leads to decreased fluid buildup in the ear as well as decreased infections. However, some teenagers going onto adults continue to have eustachian tube dysfunction problems. And actually, a lot of adults out there have mild form so that that you feel pressure, pain popping, muffled hearing in that ear. That’s a mild form of eustachian tube dysfunction. But in more severe forms, we see that continue to present as either recurrent or chronic infections of the ears.
If left untreated, how do they present as an adult?
Moberly: So as an adult, these infections often present with a chronically draining ear, chronic pain in the ear or the mastoid, which is the bone back behind the ear. Hearing loss can be a part of that picture. There are more severe things. Situations like cholesteatoma, which is a skin cyst that builds in the ear that tends to go along with chronic ear infections and eustachian tube dysfunction, which is a completely surgical management issue. So once you get to that point, that’s something that requires a surgery. So holes in the eardrum can come from chronic infections. This chronic mastoid, an ear infection issue, hearing loss, cholesteatoma. In very severe situations, you can actually get a brain abscess as a result of this. So that’s rare, but we do see it from time to time in patients who were inadequately treated for their ear infections.
Why is it not more at the forefront of exams?
Moberly: So I think that’s a really interesting question. I think there’s a few reasons for this. One is that the standard handheld otoscope has been around for many decades. This still tends to be the primary way that people diagnose ear diseases. It looks very straightforward. It’s one of the first skills that we learn in medical school, but it’s actually very hard to get a really clear, good otoscopy examination. So there’s many studies out there that show that doing otoscopy through a handheld otoscope, there’s a lot of errors that occur. And this is even true at people who are specialists like myself in ear disease. Getting good lighting, getting good focus, visualization of that eardrum and getting a complete view of the eardrum is actually quite hard. So I think we overlook the difficulty of doing a good ear exam. A second thing I would mention is, it’s very easy for a clinician to just take a look and get a partial view of the eardrum and report that it’s normal without really having any check on their ability to perform a good diagnosis. So I can’t look over my primary care doc’s shoulder as he’s looking, let’s say, in my son’s ear to get a good ear exam. So I’m trusting that that clinician really knows that they’re getting a full, good, clear exam of the eardrum.
So, you have the beginning problem and that is that ears are not at the forefront of examinations. And you’re going to get into the software development to change that. Would you then turn around, or your profession, turn around and raise that level of care with the standard of tube exam and look at the ear for a moment or you’re going to move right ahead almost to AI and the applications?
Moberly: So I think there’s two phases to the development of this software that we’re trying to build. One is to improve our ability to get a good examination of the eardrum and provide- using a video clip and a digital otoscope, provide a more composite and complete view of the eardrum. So a- part of our project is to take video clips and create a composite image out of that. So one full image that looks at the entire eardrum, that could be used for telemedicine purposes, it can be put into the electronic medical record. With the goal being that you’re able to provide a better view of the eardrum that could be used for diagnostic purposes. And that in itself may help in terms of training clinicians to do otoscopy in terms of providing some input or some information to the patient or the family about what they’re actually seeing during the examination. So on a number of fronts, that could be useful. The second broader part of the project is to use machine learning approaches and artificial intelligence to develop software that provides diagnostic support for the clinician. So in this case, they do a little short video otoscopy examination of the ear, about a 15-second or 5-10 second video of the eardrum. The software then takes that, creates a composite image, but then also provide some feedback back to the clinician and says, this is a 90% chance that this isn’t a normal looking ear, or this is a 75% chance that there’s fluid behind the eardrum. And that feedback to the clinician could help not necessarily make the diagnosis, there’s no reason to replace the clinician, but to help provide some assistance hopefully to improve diagnostic accuracy.
Now it’s coming to the forefront. Is this something that you weren’t looking at or is it going along with it’s becoming a thing?
Moberly: I would say so. The evolution of this particular project really came through collaboration with other people on the team, in particular, Dr. Met and Gherkin who’s at Wake Forest now. He’s an expert in artificial intelligence and imaging and its application for medicine. So as we started discussing some of the limitations of otoscopy and challenges in getting good ear exams and performing accurate diagnosis, this project really evolved out of that collaboration. I would say I did not necessarily initially have an interest in AI or machine learning, but recognize that there’s great value in applying it to this thing to help with diagnostic support that clinicians can use. Again, I think there’s a danger in overstepping or over pushing AI. I don’t think it’s ever going to or should replace the diagnostic judgment of a clinician, but I think these are tools that can really improve our ability to serve our patients well and perform accurate diagnosis and treatment.
If you have hearing aids, you have an app on your phone to control it, do you envision that the consumer or the patient will have an app on their iPhone to help?
Moberly: So there are a number of these types of devices. You can actually buy an otoscope, small digital otoscope on Amazon for about 50 bucks or less. And you can hook that up to your phone and have it connect to an app and get in your exam. The challenge is doing that well, so as we- as I mentioned before, clinicians struggled to do a good otoscopic ear exam. So putting this in the hands of a parent and having them try to examine their child with it, some people might be able to do that, some people may need a decent amount of training to be able to get good images of the ears. So we’re certainly starting at the level of trying to include trained providers, nurse practitioners, physician assistants, physicians, to use our software to improve their ability to obtain diagnostic information on the ears. There may be a place for this to expand out to consumers and to parents in households. I’m more skeptical that that’s a good long-term solution based on that learning curve that we see in terms of the ability to actually get a good image, but we’ll see how that pans out.
How do you envision machine learning like this and your new software developments are going to cut down on that usage and also minimize the length that the child is treated with traditional methods?
Moberly: So we know that overtreatment with antibiotics is a major issue. And basically, all of the medical societies that have anything to do with this topic all say the same thing. We’re prescribing antibiotics too much and that’s creating these superbugs, it’s creating antibiotic resistance, it’s also leading to children and adults having adverse reactions to these medications at times that maybe it was a medication they didn’t need. So we need objective- more objective measures and ways to approach this problem so we’re not over diagnosing and over treating with your- overtreating ear infections with antibiotics.
This is an exciting development or breakthrough. You’re at the forefront of it at Vanderbilt. How do you feel when you’re actually working on this project and knowing how much of help this is going to be for kids, teens, and grownups?
Moberly: It’s an exciting area. So I would say it may be- it may turn into the most impactful part of what I do in my career. I have several other research interests and clinical interests. But I could see this really- if we can make this work, it’s going to be a really impactful approach because it’s such a common problem. You talk to anyone who has kids or has nieces and nephews or knows anybody that has had ear infections, you know how common this problem is. And the fact that we’re still in the 21st century struggling to do good diagnosis of ear disease, it’s shocking actually. So if we can touch that a little bit and make any dent in it, that’s going to be a huge impact. The other part that’s really exciting is potentially using this for telemedicine approaches, extending care to either rural communities or even international care of populations who are underserved for ear care. There’s a lot of potential to really improve how we treat patients with ear disease across the world, which is wild to think this started from a very small conversation among a few physicians and scientists a few years ago.
END OF INTERVIEW
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