Nina S. Yoshpe, M.D., FACS, F.A.A.P.--Dr. Yoshpe is a Clinical Associate Professor of Otolaryngology at the University of California at Irvine School of Medicine. She has been in the practice of Pediatric ENT in Long Beach, California since 1982.
Ayal Willner, M.D., F.A.A.P.--Dr. Willner joined Dr. Yoshpe in the practice of Pediatric ENT one year ago. Prior to that, he served as Clinical Assistant Professor of Pediatrics and Pediatric Otolaryngology at Le Bonheur Children's Medical Center, Tennessee. He will serve as Clinical Assistant Professor of Pediatric ENT at the University of California at Irvine School of Medicine.
Moderator: Louis P. Theriot, M.D., F.A.A.P.--Executive Editor to The Informed Parent.
Moderator: Thank you both for taking time away from your busy schedules to join me in discussing this important topic. I think that one of the most often asked questions in pediatrics is, "How do children get ear infections?"
Dr. Yoshpe: While this seems like a straight forward question, the answer is exceedingly complex.
Moderator: How is that?
Dr. Yoshpe: As you are well aware, textbooks have been written to try and explain the patho-physiology of ear infections...the mechanics of how and why they occur. Research into ear infections is going on every day.
Moderator: Could you give a model, or a scenario, to explain this in simple terms?
Dr. Willner: I'll go first. The area behind the ear drum, the middle ear space, has to have air in it. It is basically an air filled chamber. This air reaches the middle ear space by traveling from the back of the nose through a tube called the Eustachian tube.
Dr. Yoshpe: The cells in the middle ear space normally produce fluid. This fluid must drain down the Eustachian tube, away from the ear space, to the nose in order to prevent the fluid from accumulating in the ear space.
Moderator: Does this have something to do with the fact that some children seem to get ear infections all the time...and why adults rarely get ear infections?
Dr. Yoshpe: Exactly! The Eustachian tube of a child is very different from that of an adult. It is much smaller and shorter in the child. The walls are also much more pliable...not as strong.
Dr. Willner: When a child gets a cold, the soft moist lining inside the nose becomes swollen. This lining is continuous with the lining of the Eustachian tube. Consequently, if the swelling and edema is sufficient, the opening of the Eustachian tube can become closed off. It will not function properly to equalize the middle ear pressure, or allow for fluid to drain.
Dr. Yoshpe: And when this occurs, air cannot get from the nose to the middle ear space and fluid is unable to drain from the ear. The fluid gets trapped in the middle ear space, and along with it, bacteria. The bacteria begin to multiply and this results in an ear infection.
Dr. Willner: Not to be facetious, but when the bacteria get trapped in the ear space, it is like one big party. It is a perfect environment for them to thrive.
Moderator: Why is it that some children get so many ear infections, and others don't?
Dr. Willner: Many factors go into this answer. We have found that the Eustachian tube does not function properly in children who get recurrent ear infections. It tends to be plugged, or it closes more easily than it should...certainly a lot more readily than in children whose ears do not get infected.
Dr. Yoshpe: As a child grows from 2-6 years of age, the Eustachian tube becomes longer, stronger and it functions more efficiently.
Moderator: Doesn't the angle or position change also?
Dr. Yoshpe: That's correct. In infants and young children the position of the Eustachian tube is almost straight...essentially parallel to the ground. It doesn't allow for drainage of the fluid by gravity. As the child grows, the "angle" of the tube drops. In other words, the middle ear space sits higher than the opening at the back of the nose. The fluid is forced to drain by virtue of gravity. This partly explains why adults rarely get ear infections when compared to a child.
Dr. Willner: We also have to mention a child's exposure to agents that can lead to ear infections. Some children are exposed to more viruses than others. Also, children have more colds in the winter months than the summer months. Children under 5 years are more susceptible to a particular bacteria, Hemophilus influenza, that is an important "player" in ear infections.
Dr. Yoshpe: So it really is a combination of factors: age, status of immune system, and exposure to infectious agents that will determine if a child will be prone to ear infections.
Moderator: Can you comment on other "outside factors", such as day-care, bottle-propping, environmental agents etc.?
Dr. Willner: Day-care use, and day-care enrollment has significantly increased in recent years. It is widely accepted that children who attend day care are much more likely to have ear infections.
Dr. Yoshpe: One recent journal article showed an increased chance of a child developing an ear infection as the number of day care participants increased.
Moderator: What can you say about cigarette smoke?
Dr. Yoshpe: There is no question that second hand cigarette smoke plays a large role in children getting ear infections. There are many published articles in reputable journals that support this.
Dr. Willner: Along these lines, one has to mention allergies...food or airborne. Clearly a child whose allergies are out of control is much more susceptible to ear infections because of the inflammation and swelling in the nose, plugging of the Eustachian tube, poor drainage of the middle ear...and so on.
Dr. Yoshpe: That pretty much covers it with the exception of one more thing.
Dr. Willner: I know where you are going with this, and I was just about to mention it myself...the age-old practice of bottle-propping. Some parents put their infants in the crib with the bottle propped in their mouths, sort of like a pacifier. This is an absolute No-No! Studies have shown that whatever fluid they are drinking can track right up into the middle ear space.
Dr. Yoshpe: This practice should really be discouraged by everyone involved in child care. It is just asking for ear problems. That's not to mention how it takes away from successful bonding with the mother.
Moderator: Well, you were quite right. A simple question with a very complex answer. Perhaps next time we could discuss the surgery for recurrent ear infections, "ear tubes", from the perspective of the surgeons who do them routinely. I want to thank you both for your time and enlightening our readers about a common, but most complex problem.