Frequently Asked Questions – Pediatric Ear Problems
How Does Fluid in the Ear Affect Hearing?
In the normal hearing process, sound travels into the ear canal and vibrates the eardrum. This vibration is then transmitted via tiny bones in the middle ear (ossicles) to the inner ear which sends signals to the brain where the signal is interpreted as sound.
Fluid in the middle ear (behind the eardrum) dampens sound transmission, resulting in hearing loss. The effect is about the same as if you walked around with your fingers in your ears. In children with eustachian tube disfunction, fluid which accumulates in the middle ear, cannot drain properly. If the fluid persists for more than 3 months, the chances of it resolving on its own diminish.
Children with hearing loss from middle ear fluid almost always have perfectly normal hearing otherwise and hearing returns to normal levels after the fluid is gone. The problem is that while fluid persists, hearing and potentially speech & language development is affected. In the short term, children compensate well, but if middle ear fluid persist, drainage and ventilating tubes are recommended.
Why do Children Get Ear Infections?
The two most important factors that causes recurrent ear infections in children are frequent colds and eustachian tube malfunction. The eustachian tube is a passageway connecting the middle ear with the throat. When we swallow, muscles contract to open this tube, equalizing pressure between the middle ear and our environment. This tube allows the air filled middle ear to stay healthy and dry. It also allows fluid to drain from the ear when it is infected.
In children, however, the eustachian tube does not function as well as in adults. It is angled differently, tends to collapse and the muscles that open it are not fully efficient.
Conditions such as colds or allergies can contribute to obstruction of the tube by causing swelling of the lining just as they do to plug the nose. In addition, children have large adenoids – tissue found high in the throat behind the nose, close to the eustachian tube. Adenoids can physically plug the tube or transmit infection through it.
What is the Treatment for Frequent Ear Infections?
Antibiotics are the mainstay of treatment of ear infections. Often, when the usual antibiotics fail because of resistant bacteria, more powerful antibiotics must be used. In cases of recurrent infection, many physicians prescribe preventative prophylactic antibiotics given for a longer period of time (1-3 mo) to prevent new infections from occurring. Antibiotics (e.g. Amoxicillin or Gantrisin) in lower doses are typically used for this purpose.
If the child has allergy symptoms such as watery, itchy eyes, nasal drainage and rash, these should also be addressed. However, allergy medications occasionally used by physicians to treat recurrent ear infection such as steroids, antihistamines and decongestants have not been shown to be effective in patients without other evidence of allergies. As a result, they are not recommended for treatment of ear infection, as they may have undesirable side effects.
If medical management cannot control the child’s ear problems and he/she has more than 6-8 infections per year, surgical management is the next step. Myringotomy (creating a hole in the eardrum) with placement of a ventilating tube is usually the first procedure to help the child. The tube equalizes the pressure between he middle ear and the external air and allows fluid to drain from the ear. PE (pressure equalizing) tubes compensate for eustachian tube’s malfunctioning until it resolves as the child grows (as it usually does).
How do Allergies Affect the Nose?
An allergy is a condition in which the body reacts to the presence of a foreign substance in the environment, resulting in an inflammatory response (e.g., rash, swelling, itching). Common allergens (substances that trigger allergies) are dust, pollen, pets and foods. Allergic reactions can be mild or life threatening depending on the amount of exposure and the vigor of the response.
Nasal allergies are caused by inhaled substances. The lining of the nose reacts to these particles by increasing mucous production and swelling, resulting in a blocked, runny nose. Although symptoms can resemble sinusitis, facial pain is usually absent and the drainage is more clear and watery. Allergies, by causing swelling of the nasal lining, can sometimes lead to sinus obstruction and eventual sinusitis, so the distinction is not always easy to make. A helpful clue is that children with allergies often have other symptoms such as watery, itchy eyes, or rashes. Formal allergy testing can determine which environmental factors are causing the trouble.
What is Sinusitis?
Sinuses (also called paranasal sinuses) are air-filled cavities in the bones of the face whose exact function is not known. They may serve to make the head lighter, to help warm and filter the air we breathe, or to act as resonating chambers for the voice. There are four sets of paired paranasal sinuses, (maxillary, ethmoid, frontal and sphenoid), that all drain into the nose. The maxillary sinuses are large spaces found on either side of the face behind the cheek between the eye and the upper teeth. The frontal sinuses are in the forehead above the eyebrows. The ethmoid sinuses are a honeycomb-like mass of cavities between the eyes while the sphenoids reside deep in the head behind the nose. Children are born with ethmoid and maxillary sinuses. The others develop as they grow older.
Sinusitis is an inflammatory process involving the sinuses in which they become obstructed and fill up with infected fluid (i.e. pus). Sinus infections result in cold-like symptoms (nasal obstruction and drainage) which last for more than 10 days. In addition, children with sinusitis may complain of facial or tooth pain or have a cough that is worse at night. Sometimes, the tissue lining the sinuses becomes thickened and prevents proper drainage, resulting in chronic infection. Both infection and allergies can play a role in this process. Children with this condition have symptoms of nasal obstruction and drainage, which may last several months. Usually this condition resolves after proper management of the infection and the allergies. Surgery is occasionally used as a sinusitis treatment option.
Why Does My Child’s Nose Run?
The nose is a complex structure whose primary purpose is to humidify, warm and filter the air we breathe. A thin layer of mucous covers the entire lining of the nose and helps to trap inhaled particles before they reach the lungs. This blanket of fluid is in constant motion, flowing from the front of the nose towards the back where it reaches the throat and is swallowed. Each day, a large amount of mucous is produced by the tissues of the nose. The major causes of a runny nose are excess mucous production and blockage of the normal flow of mucous. Irritation of the nasal lining from allergy or infection (i.e. cold or sinusitis) causes more mucous to be produced.
There are several causes of nasal obstruction. Anatomic causes such as a deviated septum or an abnormally narrow nasal passage can result mucous drainage. One sided nasal drainage which is chronic is suspicious for a foreign body, such as a piece of plastic or food, blocking the nose. Tissue swelling from allergy and infection can also plug the nose. In many cases in children, chronic nasal obstruction and drainage is caused by excessively large adenoids.
The adenoids are a lump of tissue high in the throat behind the nose which can be likened to a tonsil. Sometimes adenoid enlargement can be treated with antibiotics and/or steroids. Often the child grows out of the problem. If symptoms are severe and conservative treatment fails, surgery is required to correct the problem.
Frequently Asked Questions – Tonsil and Adenoids
What are Tonsils and Adenoids?
If one likens white blood cells to soldiers fighting the human body’s war against infection, then lymphoid tissue is analogous to the fort in which they reside. Tonsils and adenoids are the most well known collections of this lymphoid tissue, although lymphoid tissues are found throughout the body. Tonsils are paired lumps found on either side of the tongue in the back of the mouth while the adenoids are a single mass found high in the throat behind the nose (in an area called the nasopharynx).
Tonsils and adenoids range in size from hardly noticeable to so large that they fill the throat and affect breathing. Children are especially prone to having big tonsils and adenoids, as their immune systems are very active. Occasionally, tonsils and adenoids, by obstructing the airway and/or becoming sites of chronic infection, do more harm than good for the body and need to be removed in a process called tonsillectomy.
What are the Risks of Tonsillectomy and Adenoidectomy?
Tonsillectomy and Adenoidectomy, or surgery on the tonsils or adenoids, is done under general anesthesia, which is often the most frightening aspect of the procedure for both the parents and children. Although there are risks associated with anesthesia, these can be minimized by a well trained staff, which specializes in caring for children. As a result, modern pediatric anesthesia is remarkably safe. To minimize the anxiety for both children and parents, we allow a parent to accompany the child during the induction of anesthesia in the O.R. (until he or she is comfortably asleep). In addition, anesthesiologists are available to answer questions before the tonsillectomy or adenoidectomy surgery.
The most important risk from the surgery itself is bleeding postoperatively. If bleeding occurs, it usually does so about 5-10 days after surgery, when the healing process allows the “scab” to separate from the tissue beneath the surgical site. Noticeable bleeding (i.e. blood in the mouth) happens in 2-4% of the tonsillectomy patients and is extremely rare after adenoidectomy alone. Post-operative bleeding is usually managed in the operating room where, after anesthesia is induced, the source is found and cauterized.
When we speak or swallow, the soft palate seals off the throat behind the nose to prevent air or fluid leaking out of the nose. Rarely, removing the adenoids temporarily affects this seal and results in a nasal voice and/or reflux of liquids into the nose. If this happens, these symptoms usually are very short lived, although occasionally it takes weeks for them to completely disappear.
The other concern after surgery is dehydration from poor fluid intake. The child will have a sore throat after tonsillectomy (usually it is mild with adenoidectomy alone), which usually is controlled with oral pain medications. Rarely, some children have severe pain that compromises their ability to swallow sufficient liquids and they become dehydrated. If this happens, they are admitted to the hospital for IV fluids until they can drink.
Other potential complications such as scarring of the throat, infection or excessive blood loss during tonsillectomy or adenoidectomy surgery all extremely rare. Overall, T and A is a very safe and well-tolerated procedure and kids usually recover fully within 3-7 days.
What is Obstructive Sleep Apnea?
Obstructive sleep apnea is the most severe end of the spectrum of night time breathing difficulties known as sleep disordered breathing. At the other end is simple snoring. When tissue partially blocks the airway to the extent that there is resistance to airflow, it vibrates and produces sound (snoring). As the resistance increases, airflow during sleep can become so decreased that breathing stops despite the body’s efforts (obstructive sleep apnea). This not only deprives the body of oxygen, but also results in broken, non-restful sleep. When it is severe, obstructive sleep apnea can cause heart strain and abnormal rhythms, behavioral problems and growth disturbances. Bedwetting and frequent sleepiness are less dramatic side effects of disturbed sleep.
Although there are many causes of sleep disordered breathing, children with this condition usually have increased tonsils and adenoids and benefit greatly from their removal.