Mark Vecchiotti, MD, Chief of Pediatric Otolaryngology at Tufts Medical Center and Floating Hospital for Children, and Andrew Scott, MD, Pediatric Otolaryngologist at Tufts Medical Center, answer some common questions about pediatric ear, nose and throat issues.
Q: How can I tell if my child has an ear infection?
A: Most ear infections happen to children before they’ve learned how to talk. If your child isn’t old enough to say “My ear hurts,” here are a few things to look for:
- Tugging or pulling at the ear(s)
- Fussiness and crying
- Trouble sleeping
- Fever (especially in infants and younger children)
- Fluid draining from the ear
- Clumsiness or problems with balance
- Trouble hearing or responding to quiet sounds
Q: How many ear infections are too many, and when is surgery considered?
A: In general, surgical placement of ear tubes is considered after three or four ear infections within a six-month period, or more than four episodes in a 12-month period. These are flexible guidelines and usually depend on a patient’s overall condition, ear exam, and hearing status. For patients with medical conditions that predispose them to recurrent ear infections such as Down’s syndrome, cleft palate or immune system problems, the threshold for placing ear tubes is lower. In addition, for children who have underlying hearing problems, speech problems, or learning disabilities, surgery may be indicated sooner. There are also cases where antibiotics simply do not work on a particular patient’s ear infection, or an infection is starting to spread outside the confines of the ear into the neck or brain. In these situations, earlier or urgent placement of ear tubes is indicated. But in general, healthy children who have normal hearing are typically observed through a watchful waiting strategy, especially during summer months, a time when kids often experience an increase in ear infections.
Q: If my child snores, should she be considered for a sleep study?
A: Children may snore for a variety of different reasons, and not all of them are medically concerning. What we worry about in our practice is snoring that could be a sign of an underlying breathing problem during sleep. We screen all of the patients who come into our practice for obstructive sleep apnea (OSA), which is a reduction or interruption in the ability to get air into the lungs during normal respiration while sleeping. OSA can cause a variety of medical and behavioral/developmental problems, including but not limited to chronic strain on the heart or lungs, hyperactivity and difficulty at school. Many times, snoring is the symptom that initially brings families to see us, and further medical evaluation reveals more concerning symptoms of upper airway obstruction. Sleep studies are most often recommended for very young children with this type of breathing problem. Sleep studies are also indicated for children with craniofacial abnormalities, neuromuscular problems, sickle cell disease or obesity. Not all children who snore need a sleep study, but many of these patients would likely benefit from a medical screening for obstructive sleep apnea and an exam of the head and neck.
Q: My child has large tonsils; do they need to be removed?
A: Our field has moved away from taking tonsils out just because they look large. The overall number of tonsillectomies performed in this country has declined over the past 10 years. The general rule of thumb is that if tonsils, small or large, are not causing any problems, they should be left alone. However, large tonsils can be a clue to possible breathing problems at night, and should guide a physician to ask about symptoms of obstructive sleep apnea (as noted earlier). In addition, there is new evidence that points to large tonsils contributing to some types of swallowing difficulties. Lastly, if tonsils are large due to repeated infections, whether from strep or other types of bacteria, removal may be a consideration, but not a necessity.
Q: My toddler has a constant runny nose; could this be a sinus infection?
A: The important distinctions to consider are whether the child has a common cold or virus, a bacterial sinus infection, or just a basic runny nose. Sinus infections in children are often difficult to diagnose. This stems from the fact that viral and bacterial infections of the nose and sinuses are virtually indistinguishable in their early stages. Both types of infections can manifest with fever, stuffy/runny nose, sore throat, cough, and irritability. Viral infections peak and start to resolve within five to seven days, while bacterial infections typically last longer and are present for more than seven to ten days without improvement. One important myth to dispel is the thought that viral infections are associated with clear nasal drainage while bacterial infections are associated with yellow/green nasal drainage. Clear mucus from the nose can be caused by bacterial infections, and yellow/green drainage can be caused by viral infections. Usually, the only real way to tell between the two types of infections is the duration of symptoms. So, what does a parent do if their child appears otherwise healthy, yet has clear drainage from the nose for weeks on end? Unless this runny nose is associated with other signs of illness, it is unlikely to be an active bacterial infection and will not need medical attention. One has to think of other sources of nasal drainage such as rhinitis (an inflammation of the nasal passages), anatomic obstruction by large adenoids, or simply a clustering of mild colds (especially among children in daycare or preschool). If a runny nose does turn out to be bacterial, there is new evidence that many uncomplicated bacterial sinus infections may resolve on their own without the use of antibiotics.
This conservative strategy in children obviously has to be performed under
the supervision of a physician to avoid possible complications.