Dr. Mike Smith (Host): This is Pediatrics in Practice, a CME podcast. I'm Dr. Mike. And with me is Dr. Laura Neff from Children's Mercy. Today, we're going to dive into pediatric ear infections, focusing on prevention treatment, and when to refer. Dr. Neff, welcome to the show. I want to get right into a big question for, I think, the general public and even, you know, for general practitioners, why are ear infections so prevalent in young kids? And what anatomical or developmental factors contribute to this?

Laura Neff, MD: Yeah. Well, thanks for having me. There are several reasons that young children get ear infections. The first one that I talk to parents about is that their eustachian tube—and the eustachian tube is the tube that drains your ear down to the back of your nose—it is shorter and smaller and more horizontal when they're little. It doesn't really get to adult size and function until you're about 10 years old. So, this makes it harder for little kids, especially seven and under five and under for them to get rid of fluid in their middle ear space. So, that's one.

So, that fluid can trap bacteria, viruses. And then, on top of that, you've got little kids that are in daycare. So, they're getting exposed to lots of different new pathogens. And kids have immune systems that are still developing, so they're not as capable of fighting off infections.

Host: So in a sense, You know, if you think about it—and tell me if I'm wrong—in little kids, you know, the connection between the ear and your sinuses and all that fluid, it's easier for all that fluid to move from sinus to ear, ear to sinus. And then, you add in an immune system that's still learning and growing, and—boom—you get a lot of infection.

Laura Neff, MD: Yeah. Everything in the back of their nose, and you think about all the snot you see in little kids' noses, especially in the ear, nose and throat clinic, all that can go straight into the middle ear pretty easily. And then, another thing is little kids have bigger adenoids. And adenoids are the tissue, same tissue as your tonsils, which most people are familiar with tonsils, but it's at the back of your nose and they can even obstruct those tubes as well. So, little kids have a tough go with ear infections.

Host: Can you walk us through the different types of ear infections? You hear about middle ear, outer ear, and all this kind of stuff. Like, go through that for us.

Laura Neff, MD: Yeah. This is a tough thing to understand, because you can't see any of it. So, we have lots of posters in our offices that show and kind of break down the different parts of the ear. So, what I like to tell parents is that there are really three parts.

So, you have the outer ear, which is the ear canal, which is where like ear wax lives, and that's the part that you can kind of look into. And then, you have the eardrum, which is a wall between the ear canal and the middle ear. And the middle ear is supposed to be full of air and has your ear bones in it, and that is where ear infections—when you think about like an acute ear infection that really hurts, that's where that happens. And then, the inner ear is really all bone. And that's where then the nerve goes from the inner ear to the brain for sound signals.

So, there's always some confusion about otitis externa, which is an infection of the ear canal where the wax is, versus acute otitis media, which is really an infection of that space that's supposed to be filled with air, and that's the space that connects to the back of the nose. So when kids are swimming in a pool and have draining stuff out of their ear, that is usually otitis externa, or an infection of the ear canal.

Host: Yeah. So, I grew up in Southern California as a kid. And we were swimming all the time, and I remember me and my friends with a lot of that otitis externa.

Laura Neff, MD: Yeah, it's really painful.

Host: Yeah. And that was the big thing, Dr. Neff. I remember that. You could hear okay. The ear didn't feel really full. It hurt to touch the ear. And that's a difference between otitis media, which is more like a fullness almost, right?

Laura Neff, MD: Right. And that's something that we always talk to families about, is the treatment is so different, right? So, the treatment for otitis externa or swimmer's ear is drops through the ear canal. And another important factor is to really clean out all the debris that's in the canal. Because if you can't get the drops to the ear canal onto the skin that's hurting, then it won't get better.

So, one of the key treatments for a swimmer's ear is making sure the ear canal is cleared of debris, which is very different than an ear infection in the middle ear, where if you don't have ear tubes, you need to treat with potentially with antibiotics.

Host: When I was young, again, going back to those days, there were a lot of home remedies for otitis externa, different solutions and stuff that people swore about. They're not necessarily true, right?

Laura Neff, MD: You know, there are some kids who maybe have more narrow ear canals or maybe are more prone to having more wax that can trap water and bacteria in their ear canal. So for those kids who are maybe they're getting swimmer's ear once a month in the summer, we do have some preventative things that we'll have them do.

One is keep the ear canal clean as much as possible. And there are actually rinses that you can do with like a white vinegar solution to kind of help dry out the ear. Some kids who are like competitive club swimmers and they swim year round, I'll actually have them hold a hair dryer at arm's length and kind of just try to dry out that ear canal.

Host: Yeah, I remember that.

Laura Neff, MD: Yeah. So, there are certain things you can do to try to decrease the incidence if you have a kid that is prone to it

Host: Now, going from externa to media or otitis media, you mentioned antibiotics, how often do you have to use antibiotics versus watchful waiting?

Laura Neff, MD: For the otitis externa or the otitis media?

Host: Otitis media.

Laura Neff, MD: Oh yeah. So, otitis media, I follow the recommendations of the American Academy of Pediatrics or the AAP, and they support watchful waiting for 48 to 72 hours for mild ear infections. And that's in kids over two, because a lot of times it resolves on their own, especially if it's like a viral. And so, you can support them with pain control, with ibuprofen or Tylenol. They do recommend antibiotics for severe cases, which is high fever, severe pain, or kids that are under two with bilateral infections.

And so, since this change, it's kind of decreased unnecessary antibiotic use. And then, also, you know, a lot of those kids have pretty bad side effects type of rash and everything else from amoxicillin. So, I really follow the AAP guidelines on that.

Host: Well, what are the red flags though that are going to tell you, "Okay, I need to write a prescription here"?

Laura Neff, MD: So, immediate antibiotics are recommended for kids that are less than six months old, and then kids who are six months to two years that have severe symptoms, which is considered high fever or severe pain. And then, also kids who have bilateral infections.

Host: And that right there, those are your red flags. You're going to be getting them on antibiotics.

Laura Neff, MD: Yeah. Yeah. In the ENT clinic, we usually see kids that are being referred from all the primary care physicians who have been treating these acute otitis media episodes. And we also see the complications of where acute otitis media can go with—mastoiditis and other complications. So, if you certainly need to treat, then treat.

Host: What about prevention? Are there any preventative strategies that have proven to be effective?

Laura Neff, MD: They've done studies, kids who breastfeed generally do better. Of course, we promote vaccination. Environmental changes can be helpful too, although sometimes they're not realistic. Secondhand smoke is a known risk factor for ear infections. So, we always encourage parents if they do smoke, to be outside of the house and then change clothes if they're going to come in and hold the child.

Daycare is something that is a constant source of infections and pathogens. But that's not an option for a lot of families to take their kid out of daycare. Sometimes you can have a smaller family-based daycare. It might make a difference. And then, not having bottles in bed. So, laying flat on their back holding a bottle can also be bad for ear infections.

Host: Going back to the breastfeeding that you mentioned, is that really just related to better immune system for the child?

Laura Neff, MD: Yeah, it's really just providing some immune protection for the first four to six months of life.

Host: And so, that's a recommendation. Now, you mentioned vaccination as well. Is there any specific vaccinations you're talking about? Or is the vaccinations that these kids are getting just also helping to train their immune system?

Laura Neff, MD: The pneumococcal vaccine and the influenza vaccine can be helpful for ear infections.

Host: Oh, that's interesting. I didn't know that.

Laura Neff, MD: Yep.

Host: So, breastfeeding, vaccination, and if you can, environmental changes, which is going to be the hard one, I think, for a lot of people.

Laura Neff, MD: Yeah. I think the main thing is really avoid secondhand smoke at all costs for these kids.

Host: That's good for all of us, right?

Laura Neff, MD: Yes. Yeah, for sure.

Host: Let's talk about kids with recurrent ear infections. When should pediatricians consider referring them to an ENT specialist like yourself for ear tubes or, you know, other interventions?

Laura Neff, MD: Yeah. I think about indications for ear tubes involving kind of two reasons. One is the recurrent ear infections. If a kid has had three or four ear infections within six months, it's probably time to think about sending them over. The guidelines mention that if kids are having lots of ear infections, they should have fluid on exam when we see them in ENT clinic to get ear tubes.

That being said, there are some other reasons or indications to go ahead and do ear tubes in kids who have ear infections. One is they're on to like getting Rocephin shots, right? So these are kids who have had amoxicillin, they've had Augmentin, they've had Cefdinir, and now they're getting Rocephin shots. And I think about it, okay, we are putting a kid through that versus a five-minute anesthetic for ear tubes and all the antibiotic exposure that their gut is getting, sometimes at some point it makes more sense to get ear tubes. Other kids that have had like a febrile seizure, when they have ear infections, that's kind of another loose indication. Kids who have eardrum ruptures multiple times, then we think about, "Okay, maybe we should get a tube in for that."

And then, the other reason is fluid that's been there for a long time. And so, chronic otitis media can affect hearing, it can affect balance. The indications to put tubes in for chronic fluid is to have fluid for three months or more and have evidence of hearing loss on an audiogram or hearing test.

Host: You know, in your practice, how often are you placing the tubes? Is this something that's common or not common?

Laura Neff, MD: Oh, very common.

Host: Yeah.

Laura Neff, MD: Yeah. I'm actually going to do a set right after our podcast.

Host: There you go. Yeah. So, this is common. And when you're talking to parents about this, what do you tell them about the ear tubes?

Laura Neff, MD: The main thing I try to stress is that the benefit of ear tubes, if it's for a kid who has recurrent ear infections, I feel like one of the best benefits of the ear tube for a child is to decrease systemic antibiotic exposure, because when you have ear tubes, you can treat ear infections through the ear canal, through the ear tube into the middle ear space. So, you should be able to treat it at home. So, it saves you a visit to a pediatrician. It saves you oral antibiotics. And also, comfort. I mean, I don't know if you've had an ear infection recently, but they hurt. They're really uncomfortable. And so, that takes away that pressure because the ear can drain through the ear tube. So, those are kind of the three benefits I think about.

Host: It's been a long time since I've had an ear infection, but I have had them. And I remember just, yeah, very painful. And it's hard to like sleep.

Laura Neff, MD: Yes. Yes.

Host: It's hard to get comfortable. You know, I do remember all of that. Now, when it comes to kids with frequent infections, what about speech and language development? Do you see issues there?

Laura Neff, MD: You can. It is normal for patient's who have ear infections, even though the infection goes away and the pain gets better, you can actually have fluid in your middle ear space for up to two months after an ear infection. So then, you think about, okay, if they're getting an ear infection every three months, you know, they're only having a little bit of time where they have a clear ear to hear well. And if you have fluid, you can have anywhere from a mild to a moderate hearing loss. And so, it's kind of like they're hearing underwater, so you might be talking to them and they might hear you, but it's muffled. And so, kids, of course, learn by imitating what they're hearing in their environment. And so, it makes it hard for them to pronunciate and hear what they need to hear.

Host: You're listening to Dr. Laura Neff from Children's Mercy. Just to kind of wrap this all up, as a specialist in all of this that we're talking about, are there any emerging treatments, technologies that you're really excited about?

Laura Neff, MD: Yeah. So, one thing that's kind of coming down the pipeline, it's called optical coherence tomography that I'm been interested in. It's a light that helps you see through the eardrums, you can actually see the middle ear space better. And that's something, I guess, that's used more in the eye world than ENT now.

The other cool thing is they've had smartphone apps where you can see into the ear. You can even get them on Amazon for like 20 bucks, and I've gotten some. But now, they're starting to have AI technology also help determine whether or not there's fluid. So for people who aren't used to looking at an eardrum, you could just diagnose it at home almost. And so, that's kind of an interesting tool that's kind of coming down the pipeline, just adding the AI element to the the smartphone otoscopes that already exist.

And there is some technology that people are working on and some people are doing it in office, but doing ear tubes and young children in office. And there's a special technique that perfuses the ear canal with a numbing medicine. And then, it has like a little gun that shoots in the ear tube really quickly. It hasn't been adapted nationwide that much yet just because, in general, ear tubes are so quick and easy in the OR. But it is kind of an interesting concept because it is less anesthesia.

Host: That is very fascinating, Dr. Neff. I want to thank you for coming on the show today. This has been a lot of great information and I really appreciate it. For more information, you can visit cmkc.link/cmepodcast. If you enjoyed this podcast, please share it and check out the entire podcast library for topics of interest to you. This is Pediatrics in Practice, a CME podcast. I'm Dr. Mike. Thanks for listening.