Ear Problems 101- Infants and Children
The following article can be found in Understanding Your Child’s Health by Susan K Schulman MD., which will be available in July, 2009 (Hamodia Treasures, distributed by Israel Book Shop)
During infancy and childhood, many problems can arise with the ears. Some, like ear tags and malformed outer ears, are purely cosmetic. Some are painful but usually not serious, like swimmer’s ear or otitis media. Some are painless but very serious, like congenital deafness. The following is an overview of the problems that can arise in children’s ears.
Key points in this article:
- Middle Ear problems-otitis media and serous otits media- are often associated with runny noses
- Dysfunction of the Eustachian tube and enlarged adenoids can cause middle ear disease.
- Fluid in the middle ear space can muffle hearing.
- The Inner Ear has the delicate hearing and balance mechanism, the Cochlea.
- When the cochlea or the auditory nerve cause the hearing loss, the condition is called nerve deafness.
- Hearing aids are glasses for the ears. If they are needed they should be used!
- Cochlear implants can allow a deaf person to hear.
The Outer Ear
The outer ear
When a baby is born, the ears are variable in appearance. Sometimes the left one looks like the father’s and the right looks like the mother’s! The pinna (the “cup” of the outer ear, which is made of cartilage and skin) can be big or small, flat or protruding. The normal variability is astounding.
Some babies are born with malformed outer ears. Most of these are only cosmetic abnormalities, but if the ear does not have an opening to the ear canal, or if it is very small or rudimentary, there may be serious underlying hearing problems.
Many babies are born with ear tags near the tragus (the little bump of cartilage in front of the opening). These little extra pieces of skin can be easily removed by a surgeon. Since the kidneys form in the unborn baby at the same time as the ears, many doctors perform kidney sonograms on babies with ear tags, to make sure the kidneys are formed normally. Only a very small percentage of these sonograms are abnormal.
Another common congenital defect is a tiny hole in the skin in front of the tragus. This is called a puncta. The puncta is actually the opening of a tiny channel. In most cases it never causes a problem, but occasionally a creamy discharge comes out. If this causes an infection with swelling and redness, a physician must be consulted.
The ear lobe is the soft lower extension of the pinna. The most common problems seen with the ear lobes are eczema and contact reactions to earrings. Eczema can usually be treated with moisturizers or 1% hydrocortisone cream.
If the earrings are causing problems it is usually due to sensitivity to nickel. Nickel is mixed with gold and silver to make those precious metals less brittle. Sometimes, switching to earring posts and backs made of stainless steel or 18-karat gold (which has less nickel) can help.
The ear canal
This is the tunnel from the opening in the outer ear which ends at the eardrum. There is a natural wax that forms in the ear canal. In most people it falls out by itself and causes no problem. If there is a lot of hair in the canal, which holds on to the wax, or if the wax becomes dry, it can accumulate and cause a blockage.
It is very important not to stick anything into the ear to remove wax. Q-Tips are very dangerous, and they only push the wax further down. Peroxide-based eardrops such as Debrox, or olive oil instilled into the ear with a dropper will soften the wax and help it fall out. Sometimes irrigation with an ear syringe and warm water is necessary.
After swimming, the ear canal sometimes feels blocked by water that has settled inside. A few drops of diluted rubbing alcohol will immediately cause the bubble that is holding the water to disintegrate, and the water will fall out. Many people use diluted vinegar for this purpose. If the water is not drained out, a skin infection called swimmer’s ear can develop. This condition needs prescription eardrops, and a physician must be consulted.
If severe pain in the ear canal occurs, the ear canal should be examined for a possible skin infection like cellulitis. Another very painful condition is a viral infection of the skin like herpes simplex or shingles. These can be treated with antiviral medication.
The ear drum
This is a thin, translucent window that separates the ear canal from the middle and inner ear spaces. It really looks like the covering on a drum. The bones of the middle ear can be seen through the eardrum. When sound waves enter the ear canal, the eardrum vibrates and conducts the sound to the stapes bone that is sitting on its inner surface.
The middle ear
The part of the ear that is immediately behind the eardrum is called the middle ear. The stapes bone conducts the sound wave to the two connecting bones inside the middle ear, and then on to the Round Window, which separates the middle ear space from the inner ear. In order for this process to function normally, there must be air behind the eardrum, filling the middle ear space. The air gets in via a tunnel which connects the middle ear to the throat. This tunnel is called the Eustachian Tube.
Most of the ear problems in the first three years of life occur in the middle ear. This is the part of the ear where fluid accumulates (a condition called serous otitis media) which can cause dampening of the hearing and can cause infections (known as otitis media). The word “otitis” means inflammation of the ear, and the word “media” means middle.
The Eustachian Tube
The most important factor in the healthy function of the middle ear is the Eustachian tube. When this tunnel is working, air goes up from the throat into the middle ear space, and any fluid that forms in the space drains down into the throat. When the tube is clogged, no air can get in, and fluid accumulates. The clogged tube does not allow the fluid, which forms naturally, to drain.
The result of this clogging is a middle ear that doesn’t conduct sound waves efficiently. The hearing can be reduced dramatically by this problem. This is usually temporary hearing loss, since once the fluid is gone, the hearing returns to normal.
The fluid in the middle ear is usually sterile, but often germs get in and find a very good place to grow. When these germs increase in numbers, an infection develops. The trapped pus caused by the infection causes pain and difficulty eating and sleeping. This is Otitis Media. Even severely painful infections usually do not cause fever, since the space that is infected is very small. If an infection creates a hole (called a perforation) in the eardrum, the pus then drains out into the ear canal.
One condition that causes Eustachian tube problems is a change in atmospheric pressure, such as the one experienced during landing in an airplane. In this condition, the Eustachian tubes can close down, causing painful pressure of the ears.
The other causes for the clogging and dysfunction of the Eustachian tube are the same as those that cause nasal congestion, since areas are lined with similar mucous membranes. Cold viruses, and food or seasonal allergies that cause nasal congestion, are the usual culprits. In fact, it is very rare to see an ear infection in a child who has not had any nasal congestion.
It has recently been shown that gastro esophageal reflux can be a cause for Eustachian Tube dysfunction.
The Adenoids
The adenoids, which are lymphoid tissue similar to the tonsils, sit very close to the opening of the Eustachian tube, behind the nasal passage in the upper throat. When adenoids are infected or chronically swollen, they can be the source of infection and dysfunction of the Eustachian tubes and the middle ear. Surgical removal of the adenoids is sometimes needed to resolve chronic ear problems.
Management of Otitis Media and Serous Otitis Media
When infection develops in the middle ear space, the physician should be consulted. In children over one year of age, with early and not severe infections, it is usually good to wait and just treat the pain for 2 to 3 days, since 80% will recover on their own. If the condition worsens or does not resolve, antibiotics are prescribed. In infants under one year, in severe infections, or in a child who has needed antibiotics within the previous few weeks, antibiotics are usually prescribed.
As the infection clears, the fluid that caused it often clears up as well. It is a good idea to re-check the ear to make sure that the fluid is gone. Persistent fluid in the ears (serous otitis) indicates continued Eustachian tube dysfunction. Chronic fluid that doesn’t drain for months at a time can become very thick, like glue, and the hearing can remain muffled. When this happens, or when infections keep recurring in the fluid, an Ear, Nose, and Throat specialist (ENT) should be consulted.
The ENT surgeon can drain the ear during a surgical procedure and, at the same time, place ventilating tubes in the eardrum that maintain an air passage and drainage channel between the middle ear and the ear canal. These tubes bypass the problem by doing the job of the Eustachian tube. By the time they fall out, about one year later, the Eustachian tube function usually has returned to normal.
Most Eustachian tube problems occur in the first 3 years of life. This is because the Eustachian tubes in a small child are tilted in a vulnerable position. This corrects as the child grows. If a chronic runny nose is part of the problem, investigating the possibility of allergy may help resolve the problem.
The inner ear- The Cochlea
This is the part of the ear that is closest to the brain. It is located just beyond the middle ear space on the other side of the round window. When a sound wave is conducted through the middle ear bones, it is transmitted through the round window and on to the real hearing mechanism of the ear. Inside this space there is a spiral snail-shaped organ called the cochlea. The cochlea is a delicate organ that contains the nerve endings that pick up the sound waves and transmit them via a large nerve (the auditory nerve) to the hearing center of the brain. The balance center of the body is also found in the cochlea, in the structure known as the semi-circular canals.
Dysfunction of the cochlea causes hearing loss and/or dizziness. Unlike the middle ear, this area does not fill up with fluid and does not get bacterial infections. Viral infections can sometimes affect the cochlea, usually causing a circular dizziness called vertigo. The main symptom of cochlear dysfunction is hearing loss.
Nerve deafness
Hearing loss caused by cochlear dysfunction or dysfunction of the nerve connecting the ear to the brain is called nerve deafness. This is sometimes present at birth and sometimes acquired during childhood or adulthood. When this happens, the person’s hearing reception becomes unclear. Sometimes only certain sounds are not perceived, like very low tones or very high, squeaky sounds or very soft sounds like whispers. The more types and intensities of sound that are missed the more severe the hearing problem is. Sometimes the hearing loss is progressive, starting off as mild and progressing to profound.
Hearing Augmentation – “glasses for the ears”
To help a person hear more efficiently, augmentation devices are used. The type of assistance needed depends on the severity of the problem.
FM systems are radio devices that consist of a microphone mounted on the teacher’s lapel and a receiver in the child’s ears. This makes the teacher’s voice louder and blocks out the classroom noises that might interfere.
Hearing aids filter and amplify sounds and transmit them to the ear’s hearing mechanism. Modern hearing aids are tiny and not cosmetically obvious. There is no reason to avoid using them.
When a child who cannot hear well goes to school, it is very much like a child with nearsightedness who goes to school without glasses. He can manage to get around, but he cannot see clearly and cannot read the board. No one would prefer that he not wear his glasses. He cannot function well without them.
The same is true of a child who needs hearing aids. Not having them will consign him to fuzzy, indistinct hearing. This will cause frustration and poor performance. In very young children who have not yet learned to talk, it can cause terrible speech problems.
Cochlear Implants
If the hearing is profoundly impaired, a new device called a cochlear implant can be surgically implanted into the area behind one ear. This computerized modern miracle can give hearing to the deaf child. Since the implant destroys the natural hearing mechanism on that side, it is only used when the hearing is so poor that this will not matter.
Since the invention of cochlear implants, the number of completely deaf people has dropped dramatically. Older implants had infection vulnerability, but the newer models are much safer in this regard.
Now that we understand all of the things that must work normally to have normal ear function, we have a profound appreciation for the Creator of this intricate mechanism.
Final Thought
This overview of ear problems in children only touches on the types of problems that children can encounter with their ears. As with any medical issues in children, a child’s pediatrician should be consulted whenever problems arise.