Pediatric Ear, Nose, and Throat

Dr. Nina L. Shapiro

Assistant Professor, UCLA School of Medicine

Ear Infections

Why does my child get ear infections? Ear infections, or otitis media, are very common in children as well as infants. Otitis media is an infection of the middle ear, behind the eardrum. Fluid may accumulate in the middle ear, and become infected from bacteria or viruses which reside in the back of the nose or the throat. The middle ear is connected to the nose and throat by the eustachian tube, one on each side. This muscular tube is immature in both its size and orientation in young children. As they grow, the tube changes direction from a horizontal angle to more of an acute angle, allowing for better drainage and pressure equalization in the middle ear. Children may also have enlarged adenoids contributing to recurrent ear infections. Adenoids are a mass of lymphoid tissue that sit behind the nose. If they are enlarged, they may block the ability of the eustachian tube, which extends from the middle ear to the adenoid region, to allow fluid drainage from the middle ear. Bacteria may also remain in the adenoid region, and may further lead to risk of recurrent ear infections.

There are certain 'risk factors' which have been shown to put a child at increased likelihood of having recurrent ear infections. For infants, taking the bottle to bed at night may result in bottle feeding 'refluxing' into the back of the nose, and even eustachian tubes. This may cause swelling; or even fluid accumulation, in the middle ear. Breast feeding is associated with a lower incidence of recurrent ear infections in infants. The combination of feeding in an upright position and exposure to protective maternal antibodies contribute to this.

Tobacco exposure is known to increase the incidence of otitis media in infants and young children. You should not smoke. It is bad for you and for those around you. That goes without saying, but still needs to be said. Higher incidence of recurrent ear infections in children of smokers is yet another reason to stop.

Daycare is a catch 22. It is an integral important part of society in families with two working parents. However, there has been an increased overall incidence of recurrent otitis media in children in daycare. Exposure to many children with a multitude of infections has been associated with higher incidence of recurrent ear, nose, and throat infections in young children.

Antibiotics yet another catch 22. Many ear infections are treated with antibiotics. This is the standard treatment. However, the more antibiotics that are used, the more likelihood that 'resistant' bacteria can grow. These 'resistant' bacteria are organisms that have 'seen' certain antibiotics before, and select out 'stronger' strains that can survive despite antibiotics.

What are ear tubes? Ear tubes are small plastic or metal tubes that are inserted in the eardrum. A tiny opening, the size of a dash on this page, is made in the eardrum to drain the fluid. The tube, which looks like a tiny spool, is placed in the eardrum opening and rests in the eardrum by itself. The central opening of the tube is approximately one millimeter. The tube will in most cases fall out on its own within 8 24 months. (average of one year). Tubes act as 'mature' eustachian tubes that allow fluid drainage from the middle ear to the outside in the event of ear infections. They do not prevent ear infections, but allow drainage when infections occur. They may also significantly improve hearing.

Complications of otitis media: Like any illness, there are 'major' and 'minor' complications from ear infections.

Hearing loss: Recurrent ear infections, either from persistent fluid in the ear, or from recurrent acute infections, may cause hearing loss. An infant under 12 months who does not seem to respond to sound may have hearing loss. An infant at 18 24 months who does not speak single words yet may have hearing loss. Toddlers and young children who seem to 'ignore' you may have hearing loss. This may be hard to evaluate, as a certain degree of 'selective' hearing may be normal in this age group. If the television or radio is at rock concert levels in order for your child to hear it comfortably, he or she may have hearing loss. If there is an attention problem at school, your child may have hearing loss.

Major complications: High fever, stiff neck, swelling behind the ear, foul drainage from the ear, or weakness of the muscles of the face are some of the major complications from Otis media that should be attended to on an emergency basis.




Most nosebleeds in children originate from the front part of the nose. The nasal cavity is divided into right and left sides by the nasal septum. This structure has many small arteries and veins that can bleed from minimal trauma. In children, trauma may be 'digital' (nose picking), from dry air, or frequent nose blowing. Nosebleeds may take place while your child is asleep, or spontaneously during the day.

Basic measures to try to control nosebleeds are first to see if your child is picking his or her nose. Check their fingernails! If the air is dry where you live, a humidifier may help. Over the counter sprays that have saline (saltwater) only are potentially beneficial and safest for children. Nasal decongestant sprays, especially for more than a day or two, can be drying and make bleeding more problematic.

For acute nosebleeds, gently but firmly pinching the nostrils together may control bleeding. Ice wrapped in a washcloth placed over the bridge of the nose may also help.

For the most part, nosebleeds may simply be an annoyance. HOWEVER, recurrent severe nosebleeds (those that don't stop on their own or with gentle pressure) need to be evaluated. There are several rare, although not unheard of, nasal growths that can present themselves as nosebleeds in children. There are also some rare, although not unheard of, bleeding disorders that may first present as nosebleeds.



Snoring in children can be mild, with some occasional noisy breathing during sleep, to severe, whereby loud snoring is intermixed with actual difficulty breathing. The most common cause of snoring in children is enlarged adenoids and/or tonsils. The adenoids are lymphoid tissue that sits directly behind the nose, above the roof of the mouth. Enlargement may cause your child to be a 'mouth breather' while awake as well as while asleep. During sleep, the combination of lying flat and the relaxation of the tissues in the back of the throat result in the noise of snoring as the soft palate vibrates against the back of the mouth. The tonsils are lymphoid tissue that sit in the back of the mouth. If they are enlarged as well, the snoring may be more significant.

'Sleep apnea' is a more severe form of snoring whereby loud snoring may be mixed with gasping, grunting, or actual pauses in breathing during sleep. You may hear your child snoring, struggling for air, followed by periods of silence and then even choke to resume breathing. Children with various degrees of sleep apnea may have restless sleep patterns, frequent wakening at night, or bedwetting. They may be lethargic during the day, fall asleep during daytime activities, and have an overall lower energy level than you would expect in young otherwise healthy children.

Mild snoring is common and not necessarily a significant concern. Loud snoring or any signs of breathing difficulty while awake or asleep needs to be evaluated.



There are four sets of sinuses that develop around the nose (paranasal sinuses). They are fully developed by early teenage years. At birth, the maxillary sinuses (cheek area) are small but present, and the ethmoid sinuses (behind the nose, between the eyes) are present as well. In later childhood, the frontal (forehead) and sphenoid (most posterior, behind the ethmoids) sinuses develop. Sinus problems in children most often involve the maxillary and ethmoid sinuses.

It is often difficult to diagnose sinusitis in children. When is it a cold, cough, flu, or bronchitis, and when is it a sinus infection? During the first week of a respiratory tract illness, it is nearly impossible to distinguish a 'cold' from sinusitis. Certain signs may be more indicative of acute sinusitis, such as foul yellow or green drainage from the nose, high fevers, headache or facial pain, swelling around the eyes, or persistent cough. Actual sinusitis, beyond a cold or flu, usually needs to be treated with antibiotics.

If your child seems to have recurrent problems with nasal congestion, nasal drainage, headaches, persistent cough, or fevers, he or she may have chronic sinusitis. There are many possible causes of this. Children's sinuses tend to be very small in relation to their face, and the slightest inflammation preventing their drainage may result in chronic or recurrent sinus infections. Environmental allergies, such as those to dust, mites, or pollen, may trigger inflammation in the nose and sinuses and lead to chronic sinus infections. Children with medical problems such as asthma, cystic fibrosis, or immune deficiencies have a higher likelihood of suffering from recurrent sinus infections. Enlarged adenoids may contribute to sinus problems, especially in young children.



Why is my child hoarse? A hoarse or rough voice can be very common in children. It may be a self limited voice change due to a cold or cough resulting in laryngitis. A hoarse voice in a child, or a weak or rough cry in an infant may be caused by other factors.

Children with other young siblings, or those who spend a lot of time with other children may develop a hoarse voice from voice 'overuse' or voice 'abuse'. This may put strain on the vocal cords, which are the muscles of the voice box responsible for creating the sound of voice. Just like other muscles in the body, the strain of misuse may result in swelling or inappropriate use of other muscles. Prolonged misuse may result in vocal nodules, or 'screamer's nodules'. These are the vocal cord equivalents of blisters or calluses that may form on one's feet by wearing poorly fitting shoes.

Another possible cause of hoarse voice in children is gastroesophageal reflux. This consists of tiny amounts of regurgitated food or liquid from the stomach that may irritate the voice box. The opening to the esophagus ("food pipe") is just behind the opening to the voice box. Given that these openings are so close, it is not uncommon that acid or food particles from the stomach or esophagus may enter the voice box, causing chronic irritation to the vocal cords. This may even result in chronic cough or breathing problems. This entity tends to be more common in younger children and infants, although it can certainly be seen in older children as well as adults.

There are growths that may develop on the vocal cords of children, most of which are uncommon, but are seen occasionally by ear, nose and throat physicians.

Any child or baby that is hoarse, or has a change in their voice for a prolonged period of time, merits an evaluation by an ear, nose and throat physician before therapy should be recommended.

Dr. Nina Shapiro may be contacted at:
UCLA School of Medicine
Pediatric Otolaryngology
Division of Head and Neck Surgery
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