Ear Disorders and Kids: Listening for Advice -- Steven Cook, MD -- 06/19/03
By Steven Cook
From infant ear infections to tubes in your preschooler's ears, worries about ear disorders can be a big part of parenting. We received an earful of advice on ear disorders from pediatric ear expert Steven Cook, MD, when he joined us on WebMD Live.
The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you haves about your health, you should consult your personal physician. This event is meant for informational purposes only.
Member: Are ear infections an inevitable part of childhood? Is there anything that can be done to prevent them?
Cook: Not necessarily inevitable, but they are certainly a common problem, and in fact ear infections are the most frequent reason people go to the doctor in the United States. There are certain things parents can do to help prevent ear infections. There are certain risk factors that are part of an American lifestyle that may make children prone to ear infection:
I give this information not to make families feel guilty, but there are certainly compelling lifestyle issues that physicians recognize.
Member: Do bottle-fed babies have more ear infections because of a lack of something in the bottle milk or because they are often given bottles lying down and liquid gets in the ear more easily? If a baby is carefully fed a bottle in a more upright position, can ear infection risk be reduced?
Cook: Breastfed babies do better because breast milk contains maternal antibodies that boost the newborn's immune system. Bottle propping or lying down with a bottle certainly is associated with an increased frequency of ear infections. The other reason we should never put the baby in bed with the bottle is that it can lead to tooth decay, even at a very young age.
One other thing is that pacifier use beyond the age of six months has also been associated with an increased risk of ear infection.
Member: When should a child be given antibiotics for an ear infection? This is a point of contention between my child's pediatrician and me. She just wants to give my child something for the pain and let the infection run its course. I thought all infections should be treated with antibiotics.
Cook: Antibiotics have typically been the mainstay treatment for ear infections in the United States. We've come to realize that the frequent use of antibiotics can lead to resistant bacteria. This is particularly true for the bacteria that cause ear infections. Since the primary reason people see a doctor is for pain, the idea of initially getting the child comfortable and waiting to see if an antibiotic is subsequently necessary is consistent with current medical recommendations. Research from Europe indicates that this is a medically appropriate form of therapy.
If the child is still uncomfortable, running a fever, or showing signs of ear infection on follow-up 24 to 48 hours later, then prescribing an antibiotic appropriate for the bacteria that are known to cause ear infection would be in order.
In the United States our thinking is often, "if there is an ill, we must give a pill." We basically understand that there are three bacteria that are the most common cause of ear infections in children. There are only a few antibiotics that are most effective in covering these organisms. The challenge to the physician is trying to pick a medication that will treat each of these three bacteria.
Frequent use of antibiotics allows the bacteria to mutate and to become resistant to antibiotics. This can occur in an individual child, in the community, and indeed we're seeing this problem worldwide. Once bacteria becomes resistant, then it becomes more difficult for the physician to empirically select a medication that would cover all three of these bacteria in their resistant forms.
One important thing for parents to remember is that just because an antibiotic is not working at one time, does not mean that the child becomes "immune" to that antibiotic. It does mean that the organism causing the infection has become resistant to that antibiotic.
Member: Are "tubes in the ears" procedures as controversial these days as some say? I've heard they are now not deemed as necessary as they once were.
Cook: The area involved with ear infections is the middle ear. This is an air-containing space that sits directly behind the eardrum. This is the area that is involved with the typical childhood ear infection, that is, otitis media. After an ear infection is treated, although the antibiotic may have killed the bacteria, the liquid may persist for long periods, sometimes as long as months. As long as there is fluid in the middle ear space, the child's hearing may be decreased.
We all have a natural passageway that leads from the back of the nose to the middle ear. This is called the eustachian tube. Many times a day, when we yawn and swallow, the eustachian tube opens and ventilates the middle ear. If you have ever been on an airplane, swallowed, and your ears pop and all of a sudden you can hear, this is the Eustachian tube equalizing pressure and ventilating the middle ear. In young children, the eustachian tube often does not function properly. This is the underlying cause of ear infection.
The purpose of tubes in the ears is to restore middle-ear ventilation, in essence sort of an artificial eustachian tube. This surgical procedure is typically done in an outpatient setting. The child undergoes a general anesthesia, so that he or she is asleep and comfortable and the surgeon can work in an unhurried and controlled fashion. A small incision or cut is made into the eardrum. Any puss or fluid is vacuumed out and the tube is inserted so that it sits directly in that hole in the eardrum. This allows the free exchange of air from the outside world into the middle ear, thus restoring hearing and helping to prevent further ear infections.
A vast body of medical research into ear infections has been gathered over the years. Recommendations for tubes are based on detailed analysis of this research. In general, for the otherwise healthy child without any underlying problems, tubes should be considered if the child has had frequent ear infections. Frequent ear infection can be defined as more than four infections in a six-month period or more than six in a year. Children who have non-infected fluid in the ear for more than three months with hearing loss should also be considered for tubes.
Most children with fluid in the ear will have resolution of that fluid within about 90 days, whether they are treated with medications or not. Antibiotics will not necessarily relieve fluid. Antihistamines and decongestants have not been proven to always help with middle ear fluid. If children have allergies, then antihistamine therapy will help with allergic symptoms and may help improve the ear problems. If the child is not allergic, it is possible that antihistamines may, in fact, worsen symptoms, since one of their side effects is causing thicker secretions.
For certain children, tubes should be considered sooner rather than later. Any child with an underlying hearing loss, such as nerve deafness, should not wait three months for tubes. Also, there are certain medical conditions that make children prone to ear infection, and these children should also be considered for tubes sooner rather than later. Children with Down's syndrome and children with cleft palate will likely have ear problems until they are school age. Certainly if a child has other sensory deficits, such as severe vision problems, we want to restore their hearing as soon as possible. Intervention with tubes, again, should be considered sooner rather than later.
If we consider the risk of development of resistant bacteria in the community by the frequent use of antibiotics, there may be an argument to be made to intervene with tubes rather than having a child on multiple frequent courses of various antibiotics.
Member: I had tubes twice as a child. Is there any chance these surgeries will cause hearing problems later in life?
Cook: An adult who had tubes as a child is unlikely to be suffering with any new hearing loss as a result of those earlier procedures. The risk of hearing loss in an adult primarily would be from noise exposure or the general process of aging.
Member: My 3-year-old son has been having problems with his ears since last October. His pediatrician doesn't feel as if he needs to go to an ENT, but luckily my new insurance doesn't require a referral. He has a doctor's appointment on Monday. My question is, his ears have an awful smell and every day he is digging in his ears. When I take him to his doctor they clean them out and his ears are always full of wax. Does he need tubes put into his ears? Can he lose his hearing over this recurring problem?
Cook: Whereas, I obviously can't specifically address your child, tubes will not impact on the production of earwax. I think that it's a great idea that you're seeing a specialist on Monday. We have to remember that ear wax is normal and has a protective function. For most people, the ear is a self-cleaning organ. We continually produce wax and it travels out of the outer ear canal to the opening of the ear. Little children have short ear canals. You can wipe wax away on Monday and you'll see some more on Wednesday. Unless the child is producing so much wax that it is preventing the doctor from seeing the eardrum or impacting on the child's hearing, specific measures to remove ear wax are not necessary.
Certain individuals, and this can be children, do not produce the moist yellow wax that most of us have. They produce a dense, hard, black wax that the ear cannot clean. These folks may require periodic visits to the doctor to have their ears cleaned, or they may require a regimen of drops to soften the wax. In all instances, Q-tips should never be used. Q-tips can push wax deeper into the ear, abrade the delicate skin of the ear canal, causing bleeding or creating an environment that would allow an outer ear infection (not otitis media). Additionally, we will see in our office one or two people every month with a serious injury to the eardrum from Q-tip use.
Moderator: As a pediatrician once told me, "You should never put anything smaller than your elbow in your ear."
Member: My daughter gets "itchy ears." There isn't an ear infection, but they can get red because of her fingers rubbing the outer ear canal. A friend suggested that she might be feeling the itch due to an allergy. Is this possible? How would you treat this? Should we have her tested for allergies? Is there something, an ointment or cream, we could put on her ear to stop the itching? Telling her to stop rubbing her ears isn't working.
Cook: Itching in the ears can be due to several things, which your question touches on. Allergic disease would certainly be a consideration. A large portion of the population has allergies. The direction your pediatrician might want to go depends on his or her personal philosophy. Many pediatricians are very comfortable with allergy management using antihistamines. Seeing an allergy specialist would certainly allow the opportunity to more definitively determine what specific foods, environmental agents, or other factors might be causing a person's allergies. Also, if allergy shots or desensitization are necessary, the allergist can help determine those things that need to be addressed.
Other causes of itchy ears might be skin problems, such as allergic eczema. If your child is prone to skin rashes the pediatrician can initiate therapy or if he or she deems it necessary, refer the patient to a dermatologist or an ENT doctor.
Member: We spend a great deal of time in the water during the summer. How should I deal with the kids' complaints of water in the ear (swimmer's ear)? Can this cause infections? Should I put in the OTC drops?
Cook: The external ear canal is the site of swimmer's ear or "otitis externa." Water getting into the warm dark ear canal can allow the growth of bacteria to cause swimmer's ear. Swimmer's ear may start with itching that can progress to severe pain and swelling of the ear canal. Typical treatment involves eardrops, cleaning the outer ear of all infected debris, and possible placement of a wick. Sometimes the ear canal is so swollen that drops will not penetrate. Inserting a wick, which is a piece of medical grade sponge, will allow the drops to penetrate into the swollen ear canal and treat the infected surface.
In individuals who are prone to outer ear infections, preventive measures can be taken. The use of over-the-counter swimmer's eardrops can be used at the end of each swim day. The child should lie down, the drops instilled directly in the ear canal, worked in by gently massaging the skin in front of the ear canal; the child should lie there for a minute or so before applying the drops to the opposite ear. If your child has tubes, the over-the-counter swimmer's eardrops may not be appropriate. You should check with your child's ear doctor in that instance for their advice with swimming. Once again, Q-tips should never be used.
Earplugs may not fully prevent swimmer's ear, although some physicians do recommend them after tube insertion.
Member: My son broke his nose playing sports and now is prone to sinus infections. He complains about his ears, too. Could he be getting ear infections as a result of his sinus infections?
Cook: It is possible. If we realize that nasal mucus as it passes down the back of the throat flows past the eustachian tube, inflammation and bacterial seeding of the eustachian tube can occur.
Member: I have a 2 1/2-ear-old who at times does not respond to verbal requests when we are more than 20 feet apart. How can I be certain he is not just ignoring me? How would you determine if your child really does have a hearing problem opposed to the child just not listening and/or answering?
Cook: Hearing can be assessed in any child, even a newborn. It is very important for children to be hearing well so that they can develop speech and language skills and stay in touch with their environment. An audiologist who is trained in testing children should be consulted. Reliable information on hearing levels, even in a 2-year-old, can be obtained.
When we consider that fluid in the ear and ear infections are an extremely common childhood problem and that these conditions are associated with hearing loss, then you have appropriate concerns and you should ask your pediatrician to refer your child for hearing testing. Most hearing loss in children is easily treatable. There are children who may have other forms of hearing loss, and that needs to be diagnosed so that appropriate therapy can be undertaken as early as possible.
Member: Just how early can you determine hearing problems in a child?
Cook: Day one of life. Newborn hearing screening is tremendously important. I'm sure you're aware that newborn nurseries do several types of tests to look for metabolic diseases. Hearing loss in newborns is actually something that is seen not infrequently. If an infant fails newborn screening, they should be followed by an ear, nose, and throat doctor who is comfortable evaluating and managing this problem. Since children's hearing pathways from the ear to the brain are developing throughout their early life, it is very important to restore as much of hearing as we can as early as possible. This will allow the best chance for the child to develop speech, language and communication skills.
Some conditions associated with hearing loss in children can also be associated with other medical problems. Getting an accurate diagnosis of the cause of hearing loss may also allow the doctor to be sure there are no problems with other organ systems.
Moderator: Dr. Cook, we are almost out of time. Before we wrap up for today, do you have any final comments for us?
Cook: Only that parents are their child's advocate. If a parent suspects their child is not speaking well, is not hearing well or not making appropriate milestones, they have every right to address their concerns to their pediatrician so that appropriate testing can be done.
Moderator: Our thanks to Steven Cook, MD, for sharing his expertise with us.
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