September 18, 2024 • 26 mins
Welcome to Pediatrics Now with Holly Wayment, brought to you by the Department of Pediatrics and University Health's New Women's and Children's Hospital ! In this episode, we delve into the world of ear infections with expert insights from Drs. Erica Sher Nadine Haykel Pediatric Ear, Nose, and Throat Doctors at University Health and the University of Texas Health Science Center at San Antonio.
For this episode, keep in mind that Otitis Media means middle ear infection in medical terms.
Our guests share their passion for working with children and the kindness they encountered in their training that drew them to pediatric ENT.
Join us for this informative and engaging conversation to better understand ear infections and how to manage them effectively. For more resources and to stay updated, visit our website at pediatricsnowforparents.com. Talk to your pediatrician if you have any questions.
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Episode Transcript
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(00:00):
I'm Holly Wayment, and this is Pediatrics Now. Today, we're talking about ear infections.
I'm so excited today because joining me here in our podcast studio are Drs.
Erica Scher and Nadine Haeckel, Pediatric Ear, Nose, and Throat Doctors at University
Health and the University of Texas Health Science Center at San Antonio.
(00:21):
Thank you so much for being here today on Pediatrics Now.
Thank you for having us. Yes. You were drawn to this specialty because you love
children and the child patient, not necessarily the adult.
Yep. Yep. That's exactly it. I think kids are much better as patients.
I'm not particularly a fan of having adults as patients just from like previous
(00:43):
training, but I knew I was going to work with kids even well before medical school.
So it was a no brainer. It was always going to end up there.
The question is in which realm.
So, and Erica, you as well, you love kids and, and you also both were drawn
to the kindness you saw, the people who were training you at the time, the other doctors.
(01:05):
Yeah, I think, and this has been true with other people I've talked to in pediatric
ENT that almost everyone has agreed that the pediatric ENTs they worked with
in training and residency were some of the nicest people they had ever worked with.
And that was a big draw to go into the field. I think that says a lot because
ENT in general, I feel like we're kind of a overall really nice specialty.
And so to have the subset of pediatrics were even like nicer.
(01:28):
It's just, it makes it great. Like it was a great experience.
And I think generally most people, regardless of what, you know,
whether they need general ENT or some other specialty in ENT,
most will probably agree that the pediatric side are probably very nice,
very sweet. And it shows the power of kindness.
(01:49):
There's no reason to be a jerk. Right. It doesn't help anything.
I've definitely seen people be turned off from a field, even in training,
just because someone they worked with was less than pleasant to them. Yeah.
So it can really impact a person.
You can have flu without having an ear infection. You have to have fluid to
(02:09):
have a bacterial ear infection. but we can see viral, kind of like a viral picture
where a kid has an upper respiratory infection.
They're complaining of maybe some ear pain. They have fevers.
When you look in the ear, the eardrum may or may not be a little red,
but if there's no fluid behind there, that is a situation where I wouldn't necessarily
jump to prescribing antibiotics.
(02:30):
I might watch and wait, because if it is viral, it may just pass within a couple of days.
Say you do treat an ear infection, looks like an ear infection,
you give the antibiotic.
And then I will see situations where the providers will see them back in the
office and we'll give them another round of antibiotics and all they'll mention is fluid.
Obviously, we're not there. We can't really see what they're seeing.
(02:53):
You have to remember that after a treatment of an acute otitis media,
a lot of times kids can have fluid behind their ear for up to four to six weeks.
And again, that doesn't necessarily mean it's infected.
It could be usually this clear fluid. It's not super white. The eardrum is not
bulging. It's not really red.
Those are situations I would not do another round of antibiotics,
(03:13):
but instead check back on them maybe after about four to six weeks.
And then if they still have fluid, not necessarily, again, treat them with antibiotics,
but just something to kind of be aware of that you don't have to treat that type of fluid either.
And so it's okay if that fluid is present for what's normal for it to be. It is. It is.
By nature, young children have poor eustachian tube function.
(03:34):
It's just the nature of what they think is the length of the eustachian tube
and the orientation of it.
And as we get older, it tends to get a little longer and it's thought to become
more vertical. So it functions a little bit better.
And so that's why we sort of say kids outgrow their ear infection problems,
Usually around age five to six, because that's when we see those changes in the eustachian tube.
So younger kids, truthfully, that's just the nature of their ears.
(03:58):
Depending on what their symptoms are, you can sometimes try allergy medications for them.
I will be honest, though, our guidelines actually recommend against using that in young kids.
So I wouldn't do that unless they have separate allergy-related symptoms.
So things like antihistamines or nasal sprays.
Older kids, though, so we start to think about in kids six and older,
(04:19):
if they're really still having eustachian tube issues, a lot of ear infections
or ear pain, then it is generally thought to be more of an allergy-mediated phenomenon, probably.
So for them, we do tend to be a little more aggressive starting them on some
nasal sprays like Flonase, nasal saline, maybe some Zyrtec and things like that.
But for children older than 24 months, you could err on the side of waiting?
(04:43):
Watching, yeah. agency. Yeah, particularly if they're having mild symptoms.
I think we get a lot of parents who say when you ask them what their symptoms
were, they'll say, oh, actually, we went in for something else.
And they were just sort of incidentally diagnosed with having an ear infection.
I think in that case, you know, if the kid is, you know, four years old,
and they're not complaining of anything, and they seem otherwise,
well, that's definitely a good case where you could wait on some antibiotics.
(05:06):
When should the child see a specialist? So there's a couple scenarios in in
which they get sent to us.
And the main question for us is always, would this child benefit from having ear tubes placed?
So the first scenario is a kid with what we call recurrent acute otitis media.
So that's the kid who's getting diagnosed with this acute otitis media,
(05:29):
getting treated with ear infections.
And for us, what we're looking for is a child who in either the last six months
has been treated for three ear infections.
And our guidelines are pretty specific that it should be three separate ear
infections, not one ear infection that perhaps they failed a first line of antibiotics
and then they got a second line.
That does not count as two. That should be still one ear infection.
(05:51):
So it'd be three ear infections in six months or in one year, four ear infections.
And at least one of them needs to be in the last six months.
And then the very last part of that guideline is that for us to recommend ear
tubes, they actually should have fluid behind their eardrums on the day that we see them in clinic.
And I think that can be very frustrating for parents because they frequently
(06:12):
come in and say, my child's been treated for 10 ear infections in the last year.
And, you know, I look at their ears and their ears look absolutely pristine
and their hearing test is absolutely perfect.
And so for those kids, the current recommendation would be to not put ear tubes
in, that their benefit is pretty minimal at this time. Yeah.
And, you know, those are the general guidelines, but obviously we take every case by case.
(06:35):
So like if I have a kid that comes to me and they've actually had a couple of
febrile seizures from some of theirs, I'm more inclined to put ear tubes in.
But I do find that a lot of families too aren't super keen to just jump to surgery.
And I think they feel a little happier when I'm like, we don't have to rush to do this right now.
And I think it makes them feel a little bit better. are obviously ones that
are like constantly being pulled out and antibiotics.
(06:55):
And, you know, if the parent is working and the child is in daycare,
it can be, you know, from that standpoint can be very taxing and tiresome and
a big burden so that, you know, they kind of want something to be done.
But also I think parents are super happy. I'll a lot of times try,
even though it is not necessarily part of the guidelines to do some of the allergy
regimen. We do see a lot of kids
(07:17):
who or in daycare with just heavy congestion, runny nose all the time.
They're just kind of exposed to all these germs. Their immune system aren't really strong.
So I will tend to kind of give them allergy medicine for a short course of time
and bring them back pretty soon and see if that had any effect.
And so I think parents have liked that idea of not necessarily rushing to surgery,
(07:38):
but if they do need it, we take them very quickly.
It's not something that we try to wait on either. And then as Dr.
Haeckel mentioned, some of the, there are kind of what we consider like higher
risk kids that we might push to ear tubes a little sooner.
So somebody who may not be able to take a lot of PO antibiotics,
(07:59):
oral antibiotics, some parents just say they cannot get their kid to take oral antibiotics.
So they're getting shots or IV antibiotics every single time.
That's a kid I would be a little more inclined to offer ear tubes to,
as well as kids who are at a higher risk for either they've already been diagnosed
with a speech delay or they have another medical comorbidity that's going to
increase their risk for a speech delay.
We're probably going to be a little more aggressive about making sure they're
(08:20):
ear bit, but if they do have chronic fluid, lots of infections because they
may have a speech delay or are going to have a higher risk, I'm more inclined
to do that as the first thing when I see them.
And so then that kind of brings us into the second group of kids that we are.
So the kids who are maybe have never been diagnosed with an ear infection,
but they've had this mucousy fluid sitting behind their eardrums.
(08:42):
And so for our definition, we say if it's been there for three months or greater,
that's considered chronic.
And it's either three months from the time somebody diagnosed it.
So if the pediatrician has diagnosed it and documented, we can use that or if
we can see it on a hearing test.
But if no one has that, unfortunately, it's three months from the time we meet them.
And then also if they have we want to see that
(09:02):
they are maybe having documented complications for it meaning
is their hearing not perfect perhaps some kids will have balance issues from
it maybe they are having some ear discomfort from it all those things kind of
go into that decision would those children also benefit from ear tubes yeah
something to to say is i get a lot of parents that will be like okay i you know
i've been trying to keep water out of their ears i don't let them swim.
(09:24):
I block their ears when they're baiting them.
And that is not why they're building the fluid. This is more of an internal
fluid, not an external thing.
So I always have to tell parents because they feel so guilty.
And I'm like, it's not your fault.
Water going in the ear is not causing the type of problem that they're having.
Now, if they have a swimmer's ear, that's a whole different type of problem
that can be from water coming into the ear and moisture.
(09:46):
But this is not from it. So I think that's also a good reminder is that it's
not from external exposure to water. That's a great point.
And with ear tubes, is it normal to cause some scarring? What I tell parents,
you know, ear tubes is the most common surgery that we do as otolaryngologists,
especially pediatric otolaryngologists.
Lots of kids have them. My niece and nephew have them. You know,
(10:09):
it's one of the most common. It's the most common surgery we do.
And the risks are generally very low.
You know, the ear tubes lost anywhere from, they say on average,
6 to 18 months, maybe even up to 20 to 24 months.
That doesn't mean, I mean, I've seen tubes fall out earlier.
We've seen tubes stay in there for forever and don't want to come out.
So they're generally self-limited. They fall out on their own.
(10:32):
When they do fall out, they can develop a little scarring in the eardrum.
Most of the time, it doesn't really cause any issues. Now, when the eardrum
does heal back, it does heal back a little thinner. So the eardrum is three layers thick.
When it heals back, it's usually no more than two.
And so it is a little thinner. That means it can be a little floppier in that
area. But not most of the time we find with just one set of ear tubes,
(10:56):
it's not causing that big of a deal or causing them any symptoms or issues.
I will say, too, that, you know, when parents ask me about the scarring issue,
I will also tell them that I have seen kids who have so many just chronic infections,
had so many infections or chronic fluid.
And the fact that they had that put them at risk of developing scarring because
our eardrum is trying to protect itself and will develop kind of a thickness
(11:19):
there. or they've spontaneously perfed before, meaning that they had a rupture of the eardrum.
And so when it healed back, it healed back with some scarring.
So the scarring in and of itself isn't necessarily a problem.
Now, if you have multiple sets of ear tubes and repeated scarring,
that could over time cause some issues with thickened hearing,
poor mobility of the eardrum, sometimes a little bit of hearing loss associated with that.
(11:42):
But generally from one ear tube, you don't really see it.
Even two or three, it's not necessarily an issue. And for the parent listeners,
the parent guilt that everybody feels, like when you say that,
like thinking like, oh, well, maybe that all of those ear infections should
have been treated or before the eardrum burst.
I think there's no way to predict if it's going to rupture. I've seen kids develop
(12:05):
symptoms in like in the same day and rupture.
I've seen I have we have kids that have a million infections and never rupture.
And so the, you know, waiting a couple of days, especially if it doesn't look
overtly infected, is totally fair.
If it ruptures, it's just unfortunate and it is really sad. But it that doesn't
mean that the antibiotics would have changed it necessarily.
(12:25):
It's not necessarily causing scarring or damage or or does it?
So the perforation, just like any hole on the eardrum, could cause a little
scarring on that eardrum.
But like I said, just like with ear tubes, it's not necessarily going to cause a permanent problem.
It's like someone putting an ear tube in the ear because it's a hole.
(12:46):
But, you know, when it does rupture, a lot of times kids feel a whole lot better right after that.
Is there anything that you want to say directly to parents if their child has an ear infection?
I don't think anyone would ever fault a parent for bringing their child in to get their ears checked.
Certainly in an older child. So if you have a six-year-old who's just saying
(13:07):
their ears bothering them, but they otherwise look well, they're not having a fever.
I think for the most part, if parents want to keep them at home,
you know, try to treat with some Tylenol for a couple of days,
you know, maybe 24 to 48 hours, that's going to be safe for most kids.
And then if they're still having symptoms, though, I would recommend having their ears checked.
But certainly younger kids I would not wait I would just bring them in to have
(13:29):
their ears checked because of the risk of the serious infection exactly yeah.
Otitis externa. So that's otherwise known as swimmer's ear.
That's essentially where you have our ear is our ear canals like a dark tunnel.
It's imagined like a cave. And so it's moist and there is heat.
And if the environment is just right, you can get an infection very easily.
(13:53):
And a lot of times what we see is when it kind of arises from kids who are swimming
in the summer a lot or exposed to water, those that are in like swim team,
things like that, that they're just constantly water exposed.
Again, it doesn't necessarily just have to happen with water.
You can just have the right environment, but I think that's the most common
thing that we tend to see.
Oh, I was going to say, we do see also a fair amount of like teenagers and even
(14:15):
in adults, you can get what's called like a chronic eczematous otitis externa.
And so I explain it like your ear skin is like your skin all over your body.
You know, so if you have eczema on your arms and your knees and things like
that, you can also get it in your ear canal and you you can get a similar phenomenon
of that outer ear infection.
So, and then when it gets infected and swollen, it can be very painful.
(14:38):
That's where the ear, just touching the ear can be very painful to just even
moving it a little bit. A lot of times they may see drainage coming out of the ear.
And that's where it can be kind of difficult if you do have a ruptured eardrum
that if it's just draining into the ear canal actually can cause some swelling
in the ear canal. And so then you have kind of a little bit of both.
But that's where the eardrops are really helpful in keeping the ear nice and
(14:59):
dry to help treat those situations.
Swimmers ear or a drop that does, drops that do that. Every time you get in the water.
I wouldn't do the antibiotic drops every time you get in the water.
The dark swimmer's ear prevention drops, the alcohol. Yeah, you can.
Yeah, yeah, do that. Some people will mix like equal parts water and vinegar.
So people who are more prone, you can just kind of do that. You can just kind
(15:20):
of put a few drops in the ear and just kind of let it dry it out.
But equal parts water and vinegar can work just as well? White vinegar and water.
Yeah. Oh, wow. Yeah. And I think they do have some like pre-made formulations
that you can buy at like any Walmart pharmacy or anything like that as well.
And if you have a known hole in your eardrum, that's where I would say you just want to be careful.
And if you're not sure, then go see a medical professional because not necessarily
(15:43):
every drop is safe to put in an ear that has a hole in the eardrum.
You don't want everything going behind that eardrum. Some things are safe,
some things are not. But if a child is getting chronic swimmer's ear,
keeping that ear dry, putting earplugs in, swimming in a body of water.
Yeah. So for those kids, definitely prevention is the best medicine.
Yes, it is. So yeah, definitely keeping the ears dry. And I'll even tell patients
(16:06):
that, you know, they should try to keep them dry when they bathe and, you know, shower.
So either doing earplugs and some people recommend getting like a hairdryer
on a super, super low setting because they don't want them to burn themselves.
And they can hold it over outside their ears after they bathe to help dry the ears.
That's helping with my daughter so much. Thank you.
And then and you can also take so i guess we
(16:28):
should mention but absolutely we are very anti q-tip
no q-tips you can actually hurt the ear even worse
whether that's accidental traumatic perforation of
the tympanic membranes of the eardrum putting a hole right through it that can
cause a lot of damage or in people who have like eczematous like otitis externa
or somersier of any kind when the lining of the skin of the ear canal is sensitive
(16:52):
or the barrier is not as strong,
using a Q-tip can actually cause some scraping and cause an even worse infection.
So we recommend against in any year.
Healthy or not, don't use Q-tips. And why don't people do, I mean,
are there commercials out there showing it? Because it seems like it's so common.
People think that it's used for the ear.
Because they feel great when they clean their ear out. My husband loves it. It drives me crazy.
(17:16):
Yeah. So what you can do, what is safe is that you can get like a tissue and
sort of twist it into like a spear looking thing because a tissue is soft. It's not hard.
It's not going to hurt you. And you can stick that in the ear canal and sort
of twist while it's in there.
That can help catch any extra moisture or wax or, you know, whatever.
And it's, it's not going to hurt anything, especially in kids,
(17:38):
because, you know, kids, you don't want to, they, you don't know which way they're turning.
You don't know what they're going to do. They can flip in a, in a moment.
And so that's not something you want to see, you want to cause trauma to.
And I, I have unfortunately seen a lot of acute trauma and it is never good.
And so avoid, avoid, avoid. Can it require surgery or? Absolutely.
(18:00):
Yeah. But mine. And also to keep in mind, it's normal for kids to have ear infections.
All kids get them, right? Yes, all kids can have ear infections.
Yeah, there's some stat out there that's like by the time kids are age,
like elementary school age, something like 70 to 80% of them have at least had one ear infection.
And that at any given time, I don't remember what the percentage is,
(18:21):
but a very large percentage will have middle ear fluid at any given time.
This has all been so insightful.
And tell me, how did you become known as the she and T? Tell me about your team.
I love that. Well, so I feel like that's like a thing in ENT,
maybe because of the way it flows.
(18:41):
That if there's like, like I remember when I was a resident,
if we were on a rotation and it was just the female residents, it was she and T.
It's like a thing. And so when we joined, it was Dr.
Early and then Dr. Sher joined and I joined shortly after Dr. Sher.
And so we're three girls and shanty and actually our nurse practitioner is also
a female and so we're very shanty a lot of our staff in our clinic happen to
(19:05):
be females and this is not a preference
it just happened to be that way so we love it we do have one guy,
leo oh yeah yeah i was gonna say but he's in the audio he's not he's in the
audio we sort of we adopted yeah we adopted we love yeah but it just i don't
know it just increases is morale we kind of love it not that we don't bond yeah
it's great bonding and there's actually,
(19:26):
i'll shout out dr bow so she's a pediatric ent with
the military program here in town and she's sort of
the head of the san antonio she and t group and she just hosted i unfortunately
could not go but over the weekend had a she and t event at her house that she
tries to host we call them sassy events nice so there's even she and t events
yes yeah but that encompasses And it was all female ENTs in town, not just pediatric,
(19:51):
but it just so happens that we're all female.
And maybe we should mention the new University Health Clinic in Deerfield for
our listeners in the San Antonio area is open now, pediatric ENT.
Yeah, Dr. Sharimana and Dr.
Mo. So Dr. Mo's been here for ages and ages. A lot of people know him.
He's a really nice guy. Yeah, the University Hospital.
(20:12):
Brought them over onto our side. And so they're part of our extended group and
they're still going to be in their same location out in the Deerfield area.
They were under a different private practice kind of domain before,
and now they're with us, but they still have their opening.
And so they're open for business and ready to bring anybody in.
(20:34):
I know, Erica, you recently had a
baby and hopefully are you getting sleep
and how is that going yeah you have time
she is a generally a good sleeper although i
will say the last couple days she's been less good but i think that's has
to do with her trying to figure out how to roll and then she wakes up in the night
and tries to roll and gets mad um but yes she's very cute she's very cute she's
(20:58):
got cheeks for days love that she's a cool dude in the pool when we did our
baby shower after she was born he was just so cute yeah she went swimming for
the first time and was just snoozing, taking a nice nap.
Taking a nice nap in her nice little lounger. That was the best part.
Has she had an ear infection yet? Not that we know of.
(21:18):
I've been trying not to doctor her though. Yeah. Yeah. How does that affect
your doctoring when you become a mom?
In some ways, I think it's made it. It's like, I don't want to know.
Just don't. Yeah, I don't know. I don't look at her ears.
No, but I think in some ways it's been nice because there are things that in
my mind, I always like assumed were kind of normal baby things,
(21:39):
but I had never really experienced them.
And so to actually have the experience of when people talk about,
oh, like my kid gets congested at night.
I'm like, you know, I don't know. I guess that's a thing. But now like my kid
goes to daycare and so she gets very congested at night. That is real.
Yeah. Yeah. That's a whole nother topic of conversation. Another podcast. Yeah.
(21:59):
You both have dogs? Yes. We all have dogs. All the she and tees.
Yes. I have two rescues. One's 13.
She's been with me since my first year of medical school.
The other one's two. And I also have a cat who is my oldest dog's cat.
Do they love each other? They get along very well.
My cat thinks he's a dog, too. So I think that's probably why he's the first
(22:21):
to go to the dog food when I put it down.
So, I mean, he thinks he's one of the gals, actually, because my dogs are girls and he's a boy.
And then dr share here has two i
have two very energetic german shepherds and
then dr early has three labs she has one of every color that was her goal and
she got it all she has a black lab a yellow lab and chocolate i have a black
(22:44):
lab and he's so sweet he was a rescue as well and a border collie and we're
talking about marissa early so we hope to have her on the show,
soon as well yes and i know she would she would
love to be on it yeah she loves this stuff she's she's she's
she can't wait yeah i know she can't wait she was she was she was
sad not to to make it and then in your spare time though to unplug you spend
(23:06):
time with your family animals anything animals hiking dr early and i spend a
lot of time together adventures with our dogs basically so yeah we just we love
being outdoors san antonio is great for outdoor activities so it's i'm I'm originally from Houston,
so I always love the terrain out here. So it's great for being outdoors.
Do you have a favorite hike? I went to Eisenhower Park this weekend.
(23:29):
I love Eisenhower. It's so convenient. It's so nice that it's in the city and
it's very convenient. I want to check out the, what is it, Las Maples?
That is what I'm hoping to do this fall, to see the leaves change.
So I'm looking forward to that. It fills up fast. Get your reservation. Yeah, yeah.
Anything else you want to add before we sign off?
(23:49):
Probably one of the other things that we'll get a lot is I'll get kids that
have entered daycare or school for the first time and they'll have a bunch of ear infections.
And by the time I see them, most of the time it's like they've had the year
and I see them in the summer and I ask them, I'm like, when was the last time you had an infection?
They're like, well, during, you know, April, May, it's been months since they've had another one.
And in those cases, you know, it's great to get plugged in with us,
(24:13):
but I always tell the parents just like, you know, a lot of times kids,
their immune systems are just adjusting to the new environment,
particularly if they were at
home for a long time before and not really exposed to a lot of other kids.
And so a lot of times their immune system kind of takes a big hit that year.
And so I'm a little bit more conservative and I tell them, let's just see what
happens as the new year comes along, because it could have just been a bad year
(24:34):
and really they just needed to adjust.
And I think that's another thing I would just add is that, you know,
in those cases, a lot of times for newcomers to school, newcomers to daycare, they can be bad.
Now, Now, if they're kind of in the crucial speech development phase,
that's maybe a different story.
But especially those kids that are like going to pre-K or kindergarten for the
first time, they're talking.
(24:55):
You know, those are the ones I'm like, it could just be a bad year. They had a bad hit.
Let's see what happens, especially if they haven't really had one in a few months. So I think.
Parents understanding that our immune systems are
developing and so we don't know what kind of we don't
know what's going to happen in the next year when they start their next year at school so
as long as they're not still consistently having issues it could
(25:17):
be something we can monitor okay and we'll be covering more ent
topics down the road we talked about doing an episode on sore throat also tongue
tie am i missing anything big i think we want to talk about hearing loss hearing
loss yeah and then we'll put the other guidelines where it's really all in one
place It's just our American Academy of Otolaryngology has guidelines for everything.
(25:39):
And those look great. It looks very clear. Yes. Yeah. And Eric,
I mentioned earlier before we got on this that there's a lot of resources for,
patients specifically because they can be dense to read.
And so the information that they have for patients and their families is very
easy to read and is very helpful.
I love how that's being done now. That's so great. so
(26:01):
well thank you so much for being here in the podcast studio.
Music.
Thanks for having us hi my name
is Nadine Haeckel I'm a pediatric otolaryngologist through the UT UMA system
we worked at the Huebner clinic the pediatric ENT clinic on Huebner we are happy
to see if you have any ENT related issues I'm Erica Scher I am a pediatric ENT
(26:25):
through UT health at the university University Hospital in San Antonio.
I also work at the Huebner Clinic.
And again, we're happy to see anyone with ENT issues who is under the age of 18.
Our website is pediatricsnowforparents.com.
Pediatrics Now for Parents can also be found wherever you get your podcasts.
I'm Holly Wayment. I'll see you soon.
(26:47):
Thank you so much for listening.
I'm Holly Wayment, and this is Pediatrics Now. Today, we're talking about ear infections.
I'm so excited today because joining me here in our podcast studio are Drs.
Erica Scher and Nadine Haeckel, Pediatric Ear, Nose, and Throat Doctors at University
Health and the University of Texas Health Science Center at San Antonio.
(00:21):
Thank you so much for being here today on Pediatrics Now.
Thank you for having us. Yes. You were drawn to this specialty because you love
children and the child patient, not necessarily the adult.
Yep. Yep. That's exactly it. I think kids are much better as patients.
I'm not particularly a fan of having adults as patients just from like previous
(00:43):
training, but I knew I was going to work with kids even well before medical school.
So it was a no brainer. It was always going to end up there.
The question is in which realm.
So, and Erica, you as well, you love kids and, and you also both were drawn
to the kindness you saw, the people who were training you at the time, the other doctors.
(01:05):
Yeah, I think, and this has been true with other people I've talked to in pediatric
ENT that almost everyone has agreed that the pediatric ENTs they worked with
in training and residency were some of the nicest people they had ever worked with.
And that was a big draw to go into the field. I think that says a lot because
ENT in general, I feel like we're kind of a overall really nice specialty.
And so to have the subset of pediatrics were even like nicer.
(01:28):
It's just, it makes it great. Like it was a great experience.
And I think generally most people, regardless of what, you know,
whether they need general ENT or some other specialty in ENT,
most will probably agree that the pediatric side are probably very nice,
very sweet. And it shows the power of kindness.
(01:49):
There's no reason to be a jerk. Right. It doesn't help anything.
I've definitely seen people be turned off from a field, even in training,
just because someone they worked with was less than pleasant to them. Yeah.
So it can really impact a person.
You can have flu without having an ear infection. You have to have fluid to
(02:09):
have a bacterial ear infection. but we can see viral, kind of like a viral picture
where a kid has an upper respiratory infection.
They're complaining of maybe some ear pain. They have fevers.
When you look in the ear, the eardrum may or may not be a little red,
but if there's no fluid behind there, that is a situation where I wouldn't necessarily
jump to prescribing antibiotics.
(02:30):
I might watch and wait, because if it is viral, it may just pass within a couple of days.
Say you do treat an ear infection, looks like an ear infection,
you give the antibiotic.
And then I will see situations where the providers will see them back in the
office and we'll give them another round of antibiotics and all they'll mention is fluid.
Obviously, we're not there. We can't really see what they're seeing.
(02:53):
You have to remember that after a treatment of an acute otitis media,
a lot of times kids can have fluid behind their ear for up to four to six weeks.
And again, that doesn't necessarily mean it's infected.
It could be usually this clear fluid. It's not super white. The eardrum is not
bulging. It's not really red.
Those are situations I would not do another round of antibiotics,
(03:13):
but instead check back on them maybe after about four to six weeks.
And then if they still have fluid, not necessarily, again, treat them with antibiotics,
but just something to kind of be aware of that you don't have to treat that type of fluid either.
And so it's okay if that fluid is present for what's normal for it to be. It is. It is.
By nature, young children have poor eustachian tube function.
(03:34):
It's just the nature of what they think is the length of the eustachian tube
and the orientation of it.
And as we get older, it tends to get a little longer and it's thought to become
more vertical. So it functions a little bit better.
And so that's why we sort of say kids outgrow their ear infection problems,
Usually around age five to six, because that's when we see those changes in the eustachian tube.
So younger kids, truthfully, that's just the nature of their ears.
(03:58):
Depending on what their symptoms are, you can sometimes try allergy medications for them.
I will be honest, though, our guidelines actually recommend against using that in young kids.
So I wouldn't do that unless they have separate allergy-related symptoms.
So things like antihistamines or nasal sprays.
Older kids, though, so we start to think about in kids six and older,
(04:19):
if they're really still having eustachian tube issues, a lot of ear infections
or ear pain, then it is generally thought to be more of an allergy-mediated phenomenon, probably.
So for them, we do tend to be a little more aggressive starting them on some
nasal sprays like Flonase, nasal saline, maybe some Zyrtec and things like that.
But for children older than 24 months, you could err on the side of waiting?
(04:43):
Watching, yeah. agency. Yeah, particularly if they're having mild symptoms.
I think we get a lot of parents who say when you ask them what their symptoms
were, they'll say, oh, actually, we went in for something else.
And they were just sort of incidentally diagnosed with having an ear infection.
I think in that case, you know, if the kid is, you know, four years old,
and they're not complaining of anything, and they seem otherwise,
well, that's definitely a good case where you could wait on some antibiotics.
(05:06):
When should the child see a specialist? So there's a couple scenarios in in
which they get sent to us.
And the main question for us is always, would this child benefit from having ear tubes placed?
So the first scenario is a kid with what we call recurrent acute otitis media.
So that's the kid who's getting diagnosed with this acute otitis media,
(05:29):
getting treated with ear infections.
And for us, what we're looking for is a child who in either the last six months
has been treated for three ear infections.
And our guidelines are pretty specific that it should be three separate ear
infections, not one ear infection that perhaps they failed a first line of antibiotics
and then they got a second line.
That does not count as two. That should be still one ear infection.
(05:51):
So it'd be three ear infections in six months or in one year, four ear infections.
And at least one of them needs to be in the last six months.
And then the very last part of that guideline is that for us to recommend ear
tubes, they actually should have fluid behind their eardrums on the day that we see them in clinic.
And I think that can be very frustrating for parents because they frequently
(06:12):
come in and say, my child's been treated for 10 ear infections in the last year.
And, you know, I look at their ears and their ears look absolutely pristine
and their hearing test is absolutely perfect.
And so for those kids, the current recommendation would be to not put ear tubes
in, that their benefit is pretty minimal at this time. Yeah.
And, you know, those are the general guidelines, but obviously we take every case by case.
(06:35):
So like if I have a kid that comes to me and they've actually had a couple of
febrile seizures from some of theirs, I'm more inclined to put ear tubes in.
But I do find that a lot of families too aren't super keen to just jump to surgery.
And I think they feel a little happier when I'm like, we don't have to rush to do this right now.
And I think it makes them feel a little bit better. are obviously ones that
are like constantly being pulled out and antibiotics.
(06:55):
And, you know, if the parent is working and the child is in daycare,
it can be, you know, from that standpoint can be very taxing and tiresome and
a big burden so that, you know, they kind of want something to be done.
But also I think parents are super happy. I'll a lot of times try,
even though it is not necessarily part of the guidelines to do some of the allergy
regimen. We do see a lot of kids
(07:17):
who or in daycare with just heavy congestion, runny nose all the time.
They're just kind of exposed to all these germs. Their immune system aren't really strong.
So I will tend to kind of give them allergy medicine for a short course of time
and bring them back pretty soon and see if that had any effect.
And so I think parents have liked that idea of not necessarily rushing to surgery,
(07:38):
but if they do need it, we take them very quickly.
It's not something that we try to wait on either. And then as Dr.
Haeckel mentioned, some of the, there are kind of what we consider like higher
risk kids that we might push to ear tubes a little sooner.
So somebody who may not be able to take a lot of PO antibiotics,
(07:59):
oral antibiotics, some parents just say they cannot get their kid to take oral antibiotics.
So they're getting shots or IV antibiotics every single time.
That's a kid I would be a little more inclined to offer ear tubes to,
as well as kids who are at a higher risk for either they've already been diagnosed
with a speech delay or they have another medical comorbidity that's going to
increase their risk for a speech delay.
We're probably going to be a little more aggressive about making sure they're
(08:20):
ear bit, but if they do have chronic fluid, lots of infections because they
may have a speech delay or are going to have a higher risk, I'm more inclined
to do that as the first thing when I see them.
And so then that kind of brings us into the second group of kids that we are.
So the kids who are maybe have never been diagnosed with an ear infection,
but they've had this mucousy fluid sitting behind their eardrums.
(08:42):
And so for our definition, we say if it's been there for three months or greater,
that's considered chronic.
And it's either three months from the time somebody diagnosed it.
So if the pediatrician has diagnosed it and documented, we can use that or if
we can see it on a hearing test.
But if no one has that, unfortunately, it's three months from the time we meet them.
And then also if they have we want to see that
(09:02):
they are maybe having documented complications for it meaning
is their hearing not perfect perhaps some kids will have balance issues from
it maybe they are having some ear discomfort from it all those things kind of
go into that decision would those children also benefit from ear tubes yeah
something to to say is i get a lot of parents that will be like okay i you know
i've been trying to keep water out of their ears i don't let them swim.
(09:24):
I block their ears when they're baiting them.
And that is not why they're building the fluid. This is more of an internal
fluid, not an external thing.
So I always have to tell parents because they feel so guilty.
And I'm like, it's not your fault.
Water going in the ear is not causing the type of problem that they're having.
Now, if they have a swimmer's ear, that's a whole different type of problem
that can be from water coming into the ear and moisture.
(09:46):
But this is not from it. So I think that's also a good reminder is that it's
not from external exposure to water. That's a great point.
And with ear tubes, is it normal to cause some scarring? What I tell parents,
you know, ear tubes is the most common surgery that we do as otolaryngologists,
especially pediatric otolaryngologists.
Lots of kids have them. My niece and nephew have them. You know,
(10:09):
it's one of the most common. It's the most common surgery we do.
And the risks are generally very low.
You know, the ear tubes lost anywhere from, they say on average,
6 to 18 months, maybe even up to 20 to 24 months.
That doesn't mean, I mean, I've seen tubes fall out earlier.
We've seen tubes stay in there for forever and don't want to come out.
So they're generally self-limited. They fall out on their own.
(10:32):
When they do fall out, they can develop a little scarring in the eardrum.
Most of the time, it doesn't really cause any issues. Now, when the eardrum
does heal back, it does heal back a little thinner. So the eardrum is three layers thick.
When it heals back, it's usually no more than two.
And so it is a little thinner. That means it can be a little floppier in that
area. But not most of the time we find with just one set of ear tubes,
(10:56):
it's not causing that big of a deal or causing them any symptoms or issues.
I will say, too, that, you know, when parents ask me about the scarring issue,
I will also tell them that I have seen kids who have so many just chronic infections,
had so many infections or chronic fluid.
And the fact that they had that put them at risk of developing scarring because
our eardrum is trying to protect itself and will develop kind of a thickness
(11:19):
there. or they've spontaneously perfed before, meaning that they had a rupture of the eardrum.
And so when it healed back, it healed back with some scarring.
So the scarring in and of itself isn't necessarily a problem.
Now, if you have multiple sets of ear tubes and repeated scarring,
that could over time cause some issues with thickened hearing,
poor mobility of the eardrum, sometimes a little bit of hearing loss associated with that.
(11:42):
But generally from one ear tube, you don't really see it.
Even two or three, it's not necessarily an issue. And for the parent listeners,
the parent guilt that everybody feels, like when you say that,
like thinking like, oh, well, maybe that all of those ear infections should
have been treated or before the eardrum burst.
I think there's no way to predict if it's going to rupture. I've seen kids develop
(12:05):
symptoms in like in the same day and rupture.
I've seen I have we have kids that have a million infections and never rupture.
And so the, you know, waiting a couple of days, especially if it doesn't look
overtly infected, is totally fair.
If it ruptures, it's just unfortunate and it is really sad. But it that doesn't
mean that the antibiotics would have changed it necessarily.
(12:25):
It's not necessarily causing scarring or damage or or does it?
So the perforation, just like any hole on the eardrum, could cause a little
scarring on that eardrum.
But like I said, just like with ear tubes, it's not necessarily going to cause a permanent problem.
It's like someone putting an ear tube in the ear because it's a hole.
(12:46):
But, you know, when it does rupture, a lot of times kids feel a whole lot better right after that.
Is there anything that you want to say directly to parents if their child has an ear infection?
I don't think anyone would ever fault a parent for bringing their child in to get their ears checked.
Certainly in an older child. So if you have a six-year-old who's just saying
(13:07):
their ears bothering them, but they otherwise look well, they're not having a fever.
I think for the most part, if parents want to keep them at home,
you know, try to treat with some Tylenol for a couple of days,
you know, maybe 24 to 48 hours, that's going to be safe for most kids.
And then if they're still having symptoms, though, I would recommend having their ears checked.
But certainly younger kids I would not wait I would just bring them in to have
(13:29):
their ears checked because of the risk of the serious infection exactly yeah.
Otitis externa. So that's otherwise known as swimmer's ear.
That's essentially where you have our ear is our ear canals like a dark tunnel.
It's imagined like a cave. And so it's moist and there is heat.
And if the environment is just right, you can get an infection very easily.
(13:53):
And a lot of times what we see is when it kind of arises from kids who are swimming
in the summer a lot or exposed to water, those that are in like swim team,
things like that, that they're just constantly water exposed.
Again, it doesn't necessarily just have to happen with water.
You can just have the right environment, but I think that's the most common
thing that we tend to see.
Oh, I was going to say, we do see also a fair amount of like teenagers and even
(14:15):
in adults, you can get what's called like a chronic eczematous otitis externa.
And so I explain it like your ear skin is like your skin all over your body.
You know, so if you have eczema on your arms and your knees and things like
that, you can also get it in your ear canal and you you can get a similar phenomenon
of that outer ear infection.
So, and then when it gets infected and swollen, it can be very painful.
(14:38):
That's where the ear, just touching the ear can be very painful to just even
moving it a little bit. A lot of times they may see drainage coming out of the ear.
And that's where it can be kind of difficult if you do have a ruptured eardrum
that if it's just draining into the ear canal actually can cause some swelling
in the ear canal. And so then you have kind of a little bit of both.
But that's where the eardrops are really helpful in keeping the ear nice and
(14:59):
dry to help treat those situations.
Swimmers ear or a drop that does, drops that do that. Every time you get in the water.
I wouldn't do the antibiotic drops every time you get in the water.
The dark swimmer's ear prevention drops, the alcohol. Yeah, you can.
Yeah, yeah, do that. Some people will mix like equal parts water and vinegar.
So people who are more prone, you can just kind of do that. You can just kind
(15:20):
of put a few drops in the ear and just kind of let it dry it out.
But equal parts water and vinegar can work just as well? White vinegar and water.
Yeah. Oh, wow. Yeah. And I think they do have some like pre-made formulations
that you can buy at like any Walmart pharmacy or anything like that as well.
And if you have a known hole in your eardrum, that's where I would say you just want to be careful.
And if you're not sure, then go see a medical professional because not necessarily
(15:43):
every drop is safe to put in an ear that has a hole in the eardrum.
You don't want everything going behind that eardrum. Some things are safe,
some things are not. But if a child is getting chronic swimmer's ear,
keeping that ear dry, putting earplugs in, swimming in a body of water.
Yeah. So for those kids, definitely prevention is the best medicine.
Yes, it is. So yeah, definitely keeping the ears dry. And I'll even tell patients
(16:06):
that, you know, they should try to keep them dry when they bathe and, you know, shower.
So either doing earplugs and some people recommend getting like a hairdryer
on a super, super low setting because they don't want them to burn themselves.
And they can hold it over outside their ears after they bathe to help dry the ears.
That's helping with my daughter so much. Thank you.
And then and you can also take so i guess we
(16:28):
should mention but absolutely we are very anti q-tip
no q-tips you can actually hurt the ear even worse
whether that's accidental traumatic perforation of
the tympanic membranes of the eardrum putting a hole right through it that can
cause a lot of damage or in people who have like eczematous like otitis externa
or somersier of any kind when the lining of the skin of the ear canal is sensitive
(16:52):
or the barrier is not as strong,
using a Q-tip can actually cause some scraping and cause an even worse infection.
So we recommend against in any year.
Healthy or not, don't use Q-tips. And why don't people do, I mean,
are there commercials out there showing it? Because it seems like it's so common.
People think that it's used for the ear.
Because they feel great when they clean their ear out. My husband loves it. It drives me crazy.
(17:16):
Yeah. So what you can do, what is safe is that you can get like a tissue and
sort of twist it into like a spear looking thing because a tissue is soft. It's not hard.
It's not going to hurt you. And you can stick that in the ear canal and sort
of twist while it's in there.
That can help catch any extra moisture or wax or, you know, whatever.
And it's, it's not going to hurt anything, especially in kids,
(17:38):
because, you know, kids, you don't want to, they, you don't know which way they're turning.
You don't know what they're going to do. They can flip in a, in a moment.
And so that's not something you want to see, you want to cause trauma to.
And I, I have unfortunately seen a lot of acute trauma and it is never good.
And so avoid, avoid, avoid. Can it require surgery or? Absolutely.
(18:00):
Yeah. But mine. And also to keep in mind, it's normal for kids to have ear infections.
All kids get them, right? Yes, all kids can have ear infections.
Yeah, there's some stat out there that's like by the time kids are age,
like elementary school age, something like 70 to 80% of them have at least had one ear infection.
And that at any given time, I don't remember what the percentage is,
(18:21):
but a very large percentage will have middle ear fluid at any given time.
This has all been so insightful.
And tell me, how did you become known as the she and T? Tell me about your team.
I love that. Well, so I feel like that's like a thing in ENT,
maybe because of the way it flows.
(18:41):
That if there's like, like I remember when I was a resident,
if we were on a rotation and it was just the female residents, it was she and T.
It's like a thing. And so when we joined, it was Dr.
Early and then Dr. Sher joined and I joined shortly after Dr. Sher.
And so we're three girls and shanty and actually our nurse practitioner is also
a female and so we're very shanty a lot of our staff in our clinic happen to
(19:05):
be females and this is not a preference
it just happened to be that way so we love it we do have one guy,
leo oh yeah yeah i was gonna say but he's in the audio he's not he's in the
audio we sort of we adopted yeah we adopted we love yeah but it just i don't
know it just increases is morale we kind of love it not that we don't bond yeah
it's great bonding and there's actually,
(19:26):
i'll shout out dr bow so she's a pediatric ent with
the military program here in town and she's sort of
the head of the san antonio she and t group and she just hosted i unfortunately
could not go but over the weekend had a she and t event at her house that she
tries to host we call them sassy events nice so there's even she and t events
yes yeah but that encompasses And it was all female ENTs in town, not just pediatric,
(19:51):
but it just so happens that we're all female.
And maybe we should mention the new University Health Clinic in Deerfield for
our listeners in the San Antonio area is open now, pediatric ENT.
Yeah, Dr. Sharimana and Dr.
Mo. So Dr. Mo's been here for ages and ages. A lot of people know him.
He's a really nice guy. Yeah, the University Hospital.
(20:12):
Brought them over onto our side. And so they're part of our extended group and
they're still going to be in their same location out in the Deerfield area.
They were under a different private practice kind of domain before,
and now they're with us, but they still have their opening.
And so they're open for business and ready to bring anybody in.
(20:34):
I know, Erica, you recently had a
baby and hopefully are you getting sleep
and how is that going yeah you have time
she is a generally a good sleeper although i
will say the last couple days she's been less good but i think that's has
to do with her trying to figure out how to roll and then she wakes up in the night
and tries to roll and gets mad um but yes she's very cute she's very cute she's
(20:58):
got cheeks for days love that she's a cool dude in the pool when we did our
baby shower after she was born he was just so cute yeah she went swimming for
the first time and was just snoozing, taking a nice nap.
Taking a nice nap in her nice little lounger. That was the best part.
Has she had an ear infection yet? Not that we know of.
(21:18):
I've been trying not to doctor her though. Yeah. Yeah. How does that affect
your doctoring when you become a mom?
In some ways, I think it's made it. It's like, I don't want to know.
Just don't. Yeah, I don't know. I don't look at her ears.
No, but I think in some ways it's been nice because there are things that in
my mind, I always like assumed were kind of normal baby things,
(21:39):
but I had never really experienced them.
And so to actually have the experience of when people talk about,
oh, like my kid gets congested at night.
I'm like, you know, I don't know. I guess that's a thing. But now like my kid
goes to daycare and so she gets very congested at night. That is real.
Yeah. Yeah. That's a whole nother topic of conversation. Another podcast. Yeah.
(21:59):
You both have dogs? Yes. We all have dogs. All the she and tees.
Yes. I have two rescues. One's 13.
She's been with me since my first year of medical school.
The other one's two. And I also have a cat who is my oldest dog's cat.
Do they love each other? They get along very well.
My cat thinks he's a dog, too. So I think that's probably why he's the first
(22:21):
to go to the dog food when I put it down.
So, I mean, he thinks he's one of the gals, actually, because my dogs are girls and he's a boy.
And then dr share here has two i
have two very energetic german shepherds and
then dr early has three labs she has one of every color that was her goal and
she got it all she has a black lab a yellow lab and chocolate i have a black
(22:44):
lab and he's so sweet he was a rescue as well and a border collie and we're
talking about marissa early so we hope to have her on the show,
soon as well yes and i know she would she would
love to be on it yeah she loves this stuff she's she's she's
she can't wait yeah i know she can't wait she was she was she was
sad not to to make it and then in your spare time though to unplug you spend
(23:06):
time with your family animals anything animals hiking dr early and i spend a
lot of time together adventures with our dogs basically so yeah we just we love
being outdoors san antonio is great for outdoor activities so it's i'm I'm originally from Houston,
so I always love the terrain out here. So it's great for being outdoors.
Do you have a favorite hike? I went to Eisenhower Park this weekend.
(23:29):
I love Eisenhower. It's so convenient. It's so nice that it's in the city and
it's very convenient. I want to check out the, what is it, Las Maples?
That is what I'm hoping to do this fall, to see the leaves change.
So I'm looking forward to that. It fills up fast. Get your reservation. Yeah, yeah.
Anything else you want to add before we sign off?
(23:49):
Probably one of the other things that we'll get a lot is I'll get kids that
have entered daycare or school for the first time and they'll have a bunch of ear infections.
And by the time I see them, most of the time it's like they've had the year
and I see them in the summer and I ask them, I'm like, when was the last time you had an infection?
They're like, well, during, you know, April, May, it's been months since they've had another one.
And in those cases, you know, it's great to get plugged in with us,
(24:13):
but I always tell the parents just like, you know, a lot of times kids,
their immune systems are just adjusting to the new environment,
particularly if they were at
home for a long time before and not really exposed to a lot of other kids.
And so a lot of times their immune system kind of takes a big hit that year.
And so I'm a little bit more conservative and I tell them, let's just see what
happens as the new year comes along, because it could have just been a bad year
(24:34):
and really they just needed to adjust.
And I think that's another thing I would just add is that, you know,
in those cases, a lot of times for newcomers to school, newcomers to daycare, they can be bad.
Now, Now, if they're kind of in the crucial speech development phase,
that's maybe a different story.
But especially those kids that are like going to pre-K or kindergarten for the
first time, they're talking.
(24:55):
You know, those are the ones I'm like, it could just be a bad year. They had a bad hit.
Let's see what happens, especially if they haven't really had one in a few months. So I think.
Parents understanding that our immune systems are
developing and so we don't know what kind of we don't
know what's going to happen in the next year when they start their next year at school so
as long as they're not still consistently having issues it could
(25:17):
be something we can monitor okay and we'll be covering more ent
topics down the road we talked about doing an episode on sore throat also tongue
tie am i missing anything big i think we want to talk about hearing loss hearing
loss yeah and then we'll put the other guidelines where it's really all in one
place It's just our American Academy of Otolaryngology has guidelines for everything.
(25:39):
And those look great. It looks very clear. Yes. Yeah. And Eric,
I mentioned earlier before we got on this that there's a lot of resources for,
patients specifically because they can be dense to read.
And so the information that they have for patients and their families is very
easy to read and is very helpful.
I love how that's being done now. That's so great. so
(26:01):
well thank you so much for being here in the podcast studio.
Music.
Thanks for having us hi my name
is Nadine Haeckel I'm a pediatric otolaryngologist through the UT UMA system
we worked at the Huebner clinic the pediatric ENT clinic on Huebner we are happy
to see if you have any ENT related issues I'm Erica Scher I am a pediatric ENT
(26:25):
through UT health at the university University Hospital in San Antonio.
I also work at the Huebner Clinic.
And again, we're happy to see anyone with ENT issues who is under the age of 18.
Our website is pediatricsnowforparents.com.
Pediatrics Now for Parents can also be found wherever you get your podcasts.
I'm Holly Wayment. I'll see you soon.
(26:47):
Thank you so much for listening.
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