The first important question – is it truly recurrent middle ear infections?

Middle ear infection is a condition that is often overdiagnosed. For example, a doctor sees some redness over the eardrum, starts Amoxicillin, but after 4 days of high fever, the fever resolves and the child develops a characteristic rash – which means they most likely had roseola and did not truly have an ear infection.

In other words, if every time you go to see the doctor you leave with an antibiotic prescription for an ear infection, then we have a problem.

The second important question is – is it truly recurrent ear infections or one long infection?

If the infection recurs 2 days after the completion of an antibiotic course, then this is most probably the same infection, and not a recurrence. The management needs to be slightly different. It is not a recurrent ear infection but rather an otitis media that did not improve.

What needs to be done when there are truly recurrent episodes of middle ear infections?

If you have come to the conclusion that your child is suffering from recurrent middle ear infections, then it is important to keep in mind the following points and risk factors:

1. Is the child vaccinated? Routine vaccines (such as Prevnar 20) and vaccines for respiratory viral infections (like influenza) reduce the prevalence of ear infections.
2. Does the child have an enlarged third tonsil, and could this be one of the risk factors for recurrent ear infections? Find out more about third tonsils here.
3. Is the child exposed to cigarette smoke? I don’t buy it when parents tell me they smoke only on the balcony or in the backyard. It is easier said than done, I know, but if your child has recurrent ear infections and you are a smoker, then you are one of the risk factors for their infections.
4. Does your child feed while lying on their back? If so, get them to stop doing that.
5. Early weaning from soothers can reduce the number of episodes.
6. Also, taking them out of daycare…
7. Find out whether your doctor thinks your child warrants a brief immune workup to check for immunoglobulin deficiencies (IgA and IgG).

When is it necessary to get a pediatric ENT assessment for recurrent ear infections?

This is a tricky question, in my opinion. On the one hand, a pediatric ENT specialist who is good and accessible can be truly helpful in detecting and managing recurrent infections. Their ability to visualize the eardrum is much higher and better than that of pediatricians, and that is very important. Another advantage that ENT doctors have is the ability to discuss one of the risk factors: an enlarged third tonsil.

On the other hand, and I write this with a heavy heart, I hear about many ENT specialists who are not efficient and often press for unnecessary surgical interventions. They also tend to use broader spectrum antibiotics than what pediatricians recommend. This is, of course, a generalization and does not apply to every single ENT specialist out there.

It is therefore important to try and find a good pediatric ENT specialist who is pleasant and does not just push for surgeries.

When looking for a specialist, I suggest you use the list I have on my website of recommended physicians by Dr. Efi.

What about ventilation tubes?

Find out more about these in the chapter about purulent ear infections. When there are recurrent episodes of ear infections with discharge, ventilation tubes should be considered. They are not used so much in regular ear infections, even if they are recurrent.

What about prolonged antibiotic treatment?

I am aware of the approach that includes prolonged treatment with antibiotics (for several months) for children with recurrent ear infections. This is a very controversial approach. I personally adopt this approach only in very extreme cases, and very rarely—maybe once a year.

I know that ENT specialists tend to favor this approach. I believe this is not the right approach generally speaking, but I understand that cases should be reviewed individually.

In summary, recurrent ear infections are very prevalent and a common reason for antibiotic use in childhood. I believe that with more accurate diagnosis, better management, and a reduction in the risk factors explained above, we can reduce the overall number of recurrent episodes, their severity, and their implications.

Good luck!