Ears, Nose, Throat/Speech & Hearing

Auditory processing disorder (APD), also known as central auditory processing disorder (CAPD), is a hearing problem that affects about 5% of school-aged children.

Kids with this condition can’t process what they hear in the same way other kids do because their ears and brain don’t fully coordinate. Something interferes with the way the brain recognizes and interprets sounds, especially speech.

With the right therapy, kids with APD can be successful in school and life. Early diagnosis is important, because when the condition isn’t caught and treated early, a child can have speech and language delays or problems learning in school.

Trouble Understanding Speech

Kids with APD are thought to hear normally because they can usually hear sounds that are delivered one at a time in a very quiet environment (such as a sound-treated room). The problem is that they usually don’t recognize slight differences between sounds in words, even when the sounds are loud and clear enough to be heard.

These kinds of problems usually happen when there is background noise, which is often the case in social situations. So kids with APD can have trouble understanding what is being said to them when they’re in noisy places like a playground, sports events, the school cafeteria, and parties.

Symptoms

Symptoms of APD can range from mild to severe and can take many different forms. If you think your child might have a problem processing sounds, ask yourself these questions:

• Is your child easily distracted or unusually bothered by loud or sudden noises?
• Are noisy environments upsetting to your child?
• Does your child’s behavior and performance improve in quieter settings?
• Does your child have difficulty following directions, whether simple or complicated?
• Does your child have reading, spelling, writing, or other speech-language difficulties?
• Are verbal (word) math problems difficult for your child?
• Is your child disorganized and forgetful?
• Are conversations hard for your child to follow?

APD is often misunderstood because many of the behaviors noted above also can accompany other problems, like learning disabilities, attention deficit hyperactivity disorder (ADHD), and even depression.

Causes

Often, the cause of a child’s APD isn’t known. Evidence suggests that head trauma, lead poisoning, and chronic ear infections could play a role. Sometimes, there can be multiple causes.

Diagnosis

If you think your child is having trouble hearing or understanding when people talk, have an audiologist (hearing specialist) exam your child. Only audiologists can diagnose auditory processing disorder.

Audiologists look for five main problem areas in kids with APD:

1. Auditory figure-ground problems: This is when a child can’t pay attention if there’s noise in the background. Noisy, loosely structured classrooms could be very frustrating.
2. Auditory memory problems: This is when a child has difficulty remembering information such as directions, lists, or study materials. It can be immediate (“I can’t remember it now”) and/or delayed (“I can’t remember it when I need it for later”).
3. Auditory discrimination problems: This is when a child has difficulty hearing the difference between words or sounds that are similar (COAT/BOAT or CH/SH). This can affect following directions and reading, spelling, and writing skills, among others.
4. Auditory attention problems: This is when a child can’t stay focused on listening long enough to complete a task or requirement (such as listening to a lecture in school). Kids with CAPD often have trouble maintaining attention, although health, motivation, and attitude also can play a role.
5. Auditory cohesion problems: This is when higher-level listening tasks are difficult. Auditory cohesion skills — drawing inferences from conversations, understanding riddles, or comprehending verbal math problems — require heightened auditory processing and language levels. They develop best when all the other skills (levels 1 through 4 above) are intact.

Since most of the tests done to check for APD require a child to be at least 7 or 8 years old, many kids aren’t diagnosed until then or later.

Helping Your Child

A child’s auditory system isn’t fully developed until age 15. So, many kids diagnosed with APD can develop better skills over time as their auditory system matures. While there is no known cure, speech-language therapy and assistive listening devices can help kids make sense of sounds and develop good communication skills.

A frequency modulation (FM) system is a type of assistive listening device that reduces background noise and makes a speaker’s voice louder so a child can understand it. The speaker wears a tiny microphone and a transmitter, which sends an electrical signal to a wireless receiver that the child wears either on the ear or elsewhere on the body. It’s portable and can be helpful in classroom settings.

A crucial part of making the FM system effective is ongoing therapy with a speech-language pathologist, who will help the child develop speaking and hearing skills. The speech-language pathologist or audiologist also may recommend tutoring programs.

Several computer-assisted programs are geared toward children with APD. They mainly help the brain do a better job of processing sounds in a noisy environment. Some schools offer these programs, so if your child has APD, be sure to ask school officials about what may be available.

At Home

Strategies applied at home and school can ease some of the problem behaviors associated with APD.

Kids with APD often have trouble following directions, so these suggestions may help:

• Reduce background noise whenever possible at home and at school.
• Have your child look at you when you’re speaking.
• Use simple, expressive sentences.
• Speak at a slightly slower rate and at a mildly increased volume.
• Ask your child to repeat the directions back to you and to keep repeating them aloud (to you or to himself or herself) until the directions are completed.
• For directions that are to be completed later, writing notes, wearing a watch, or maintaining a household routine can help. So can general organization and scheduling.
• It can be frustrating for kids with APD when they’re in a noisy setting and they need to listen. Teach your child to notice noisy environments and move to quieter places when listening is necessary.

Other tips that might help:

• Provide your child with a quiet study place (not the kitchen table).
• Maintain a peaceful, organized lifestyle.
• Encourage good eating and sleeping habits.
• Assign regular and realistic chores, including keeping a neat room and desk.
• Build your child’s self-esteem.

At School

It’s important for the people caring for your child to know about APD. Be sure to tell teachers and other school officials about the APD and how it may affect learning. Kids with APD aren’t typically put in special education programs, but you may find that your child is eligible for a 504 plan through the school district that would outline any special needs for the classroom.

Some things that may help:

• changing seating plans so your child can sit in the front of the classroom or with his or her back to the window
• study aids, like a tape recorder or notes that can be viewed online
• computer-assisted programs designed for kids with APD

Keep in regular contact with school officials about your child’s progress. One of the most important things that both parents and teachers can do is to acknowledge that APD is real. Its symptoms and behaviors are not something that a child can control. What the child can control is recognizing the problems associated with APD and using the strategies recommended both at home and school.

A positive, realistic attitude and healthy self-esteem in a child with APD can work wonders. And kids with APD can go on to be just as successful as other classmates. Coping strategies and techniques learned in speech therapy can help them go far.

When you think about balance, the role that ears play might not come to mind. But ears are crucial to maintaining balance thanks to their vestibulocochlear nerve. This nerve sends signals to the brain that control hearing (auditory function) and help with balance (vestibular function).

But the ears aren’t the only organs that help us balance. Ears, eyes, joints, and muscles work together to keep us steady and upright. When one or more of these systems is out of whack, it can be hard to get around and just function, day to day. The simplest things — like walking, riding a bike, doing school work, even playing — can become difficult and frustrating.

Balance disorders are considered uncommon in kids and teens, but might be underestimated — symptoms could be misdiagnosed as something else or missed altogether. But resolving kids’ balance problems can make a big improvement in their overall quality of life — their ability to play, learn, and feel as happy and healthy as possible.

How Balance Works

To understand balance problems, it’s important to understand how balance works normally. Basically, the body relies on three separate systems, each sending nerve impulses to the brain:

• In the neck, torso, leg joints, and feet are pressure sensors that send information to the brain about where the body is in relation to the world (known as proprioception). Messages are sent when we do things like turn our heads, move, and walk on different surfaces.
• In the front of the inner ear, or labyrinth, are the cochlea, involved in hearing; in the rear are semicircular canals, which affect balance. Connecting them is the vestibule (with sensory organs known as the utricle and saccule), which affects balance and equilibrium. When we turn our heads rapidly, the liquid in the semicircular canals moves the tiny hairs lining the cochlea, sending a message (through the vestibulocochlear nerve) to the brain about the movement. In less than a second, the brain sends messages to the muscles needed to maintain balance and help the eyes stay focused.
• In the eyes, the nerve endings in the retina (at the back of the eye) have light-sensitive cells called rods and cones. When we look at something, light hits the retina, and the rods and cones send electrical signals to the brain through the optic nerve. The brain uses these signals to interpret what we’re seeing and create visual images. Each eye gets slightly different images of (and information about) the same object, which aids depth perception (how far away an object is) and is vital to maintaining balance.

If any of these systems isn’t working right, it can affect balance.

Symptoms

Depending on the type of balance disorder and what’s causing it, symptoms can vary from child to child. Some kids and teens may experience severe symptoms, making it hard for them to function. Others might only have mild symptoms that are barely noticed.

In general, though, children with balance disorders have symptoms of disequilibrium — an unsteady, “woozy” feeling that makes it hard to stand up, walk, turn corners, or climb the stairs without falling, bumping into things, stumbling, or tripping.

They also might walk with their legs too far apart or be unable to walk without staggering. Walking in the dark or over uneven surfaces can be tricky, too. All of this can make them seem uncoordinated and clumsy.

Another common symptom of a balance problem is vertigo. Most people think of this as a sudden sensation that the room is spinning or whirling or that you’re moving when sitting or standing still. But kids may describe it as feeling like they’re rocking, floating, or “on a merry-go-round.” Kids also might feel dizzy, lightheaded, or disoriented.

Balance disorders can cause vision problems, too. Kids may see images that bounce or look blurry whenever they move their heads. This is called oscillopsia, which can make reading and writing really tough.

Symptoms also can include:

• involuntary eye movements (called nystagmus)
• discomfort or difficulty looking at sun glare or lights (especially fluorescent, flashing, or moving lights)
• discomfort in situations with “busy” visuals (patterns, crowds, heavy traffic, and jam-packed areas like shopping malls)
• depth perception disruptions that can affect hand-eye or eye-foot coordination (making things like catching or kicking a ball difficult)

Balance issues also can impact hearing. Sounds might seem muffled, especially amid background noise. Kids might also have bothersome, distracting ear problems like ear pain, pressure or “fullness”in the ears, and tinnitus (ringing or other sounds like whirring, humming, or buzzing).

These kinds of balance-related symptoms can take a real toll on kids — physically and emotionally — and cause other symptoms like:

• frequent headaches or migraines
• nausea, vomiting, and diarrhea
• motion (car) sickness
• changes in heart rate and blood pressure
• fatigue
• seizures
• fear, anxiety, or panic
• depression

Of course, symptoms involving kids’ movement, sight, hearing — and just how they feel, day to day — can affect their ability to keep up in class, whether in preschool or high school. Balance problems can make it hard to remember things, concentrate, pay attention, and follow directions. Kids might not be able to hear the teacher or focus their eyes on the chalkboard or their books. And they might become frustrated in gym class and with sports.

Some kids and teens with balance disorders might seem like they’re being lazy or not paying attention or trying in school. Probably the most aggravating part for them is feeling like they’re trying their very best, but being unable to do some things they want or need to do — and not knowing why.

Types of Balance Disorders

Although balance disorders aren’t common in kids and teens (again, probably because they’re so hard to catch), the most frequently diagnosed vestibular conditions are:

• Benign paroxysmal torticollis of infancy, which usually starts during a child’s first 6 months. Torticollis literally means “twisted neck” and kids with this condition tend to keep their heads tilted from feeling so dizzy. They might also have headaches, sweat a lot, vomit, look pale, seem fussy, and walk or toddle strangely. Some may have BPV, too.
• Benign paroxysmal vertigo of childhood (or BPV, sometimes also called childhood paroxysmal vertigo), in which fluid or tiny particles can detach and build up in the inner ear. This may cause vertigo that comes on suddenly (often when rapidly moving the head) and disappears in a matter of minutes. Kids may seem momentarily scared and unsteady and also may have nausea, vomiting, involuntary eye movements, or headaches. BPV, which usually affects kids ages 2 to 12, can go away on its own as kids grow or continue into adulthood to become benign positional vertigo or migraine-associated vertigo.
• Vestibular neuronitis (or neuritis), an infection that causes inflammation of the vestibular nerve, might cause a sudden case of vertigo, nausea, vomiting, and involuntary eye movements.
• Labyrinthitis can be caused by a viral (or, rarely, a bacterial) infection of the inner ear’s labyrinth, which also can bring on sudden vertigo, tinnitus, and temporary mild hearing loss in some kids.

Other conditions are far less common; for example, perilymph fistula (PLF) is an abnormality (often a tear or defect) in the connections between the inner ear and middle ear that may cause vertigo, unsteadiness, hearing loss, and ear pressure. And an inner ear disorder called Meniere’s disease can bring on tinnitus, hearing loss, ear fullness, and lengthy episodes of vertigo that may last anywhere from 30 minutes to an hour or longer.

Causes

Doctors can’t always pinpoint the cause of a balance problem. But balance-related symptoms may be brought on by any number of things, such as:

• ear, head, or neck injuries
• ototoxicity (when certain medications, including specific antibiotics and chemotherapy drugs, damage the inner ear)
• migraines
• hearing loss
• chronic middle ear infections (otitis media)
• other infections (like the cold, flu, meningitis, measles, mumps, or rubella)
• depression
• alcohol abuse
• motion sickness or sensitivity
• seizure disorders

Children who have a family history of hearing or vestibular problems, dizziness, or motion sickness might be more prone to balance disorders, too.

Diagnosis

Detecting and diagnosing balance disorders in kids and teens can be tricky. Unfortunately, kids with many common balance problems may be so young that they can’t describe how they’re feeling or respond to certain tests. And to parents, they might just seem clumsy and fussy.

If you think your child might be having balance problems, call your doctor, who will do a physical exam and look at your child’s symptoms and medical history. If the doctor thinks that your child’s balance is affected, you might be referred to an audiologist (a hearing specialist), an otolaryngologist (an ear, nose, and throat specialist, or ENT), and/or a neurolotologist (a specialist in ear disorders).

Tests can include:

• imaging tests, like an MRI or a CT scan
• motor function tests to look at fine and gross motor skills
• behavioral hearing tests. These involve careful observation of a child’s behavioral response to sounds like pure tones. Pure tones are the distinct pitches (frequencies) of sounds. Sometimes other signals are used to obtain frequency information.
• otoacoustic emissions (OAE) test. A tiny probe is placed in the ear canal, then many pulse-type sounds are introduced and an “echo” response from cells in the inner ear is recorded. A normal recording is associated with normal inner ear function and reflects normal hearing. This test, along with the ABR, is usually used on infants and young children.
• electronystagmogram (ENG). To assess balance, electrodes are placed around the eyes and a computer monitors involuntary eye movements while a child is asked to focus on a visual target or while hot or cold water is injected into the ear canal. The head may also be manipulated into different positions while doctors observe eye movements.
• videonystagmography (VNG). This test is similar to an ENG, only the child has to focus on the visual target while wearing special video recording goggles. Then the eye movements are evaluated as cool and warm air is gently blown into the ear canals.
• auditory brainstem response (ABR) test. Tiny earphones are placed in the ear canals. Usually, click-type sounds are amplified through the earphones, and electrodes measure the auditory (hearing) nerve’s response to those sounds.
• vestibular evoked myogenic potential (VEMP). This fairly new test assesses parts of the inner ear that the ENG, VNG, and ABR tests don’t. Like the ABR, earphones are placed in each ear to listen to loud clicks. And electrodes put on the head and neck record the child’s response to the clicks as he or she contracts neck muscles.
• posturography. This test measures a child’s ability to balance while standing on a stable or unstable platform.
• balance questionnaires. Kids who are old enough to describe a medical problem may be asked questions about the level of dizziness experienced throughout the day while performing different activities.

Treatment

Kids can just outgrow some balance disorders. For example, both BPV of childhood and benign paroxysmal torticollis of infancy usually go away, without treatment, by the time a child is 5 years old. And vestibular neuronitis and labyrinthitis often disappear on their own, too.

Still, doctors can help manage kids’ symptoms and make their lives a little easier with rehabilitation and sometimes medicine or surgery.

Balance therapy (also called vestibular rehabilitation) with a physical or vestibular therapist may include training exercises that help strengthen balance skills and coordination. Exercises might involve things like bending down, standing or walking with eyes open and then with eyes closed, swimming, or walking barefoot on various uneven surfaces. Kids often do very well with vestibular therapy because they’re better able to adapt to balance problems than adults.

For kids with BPV of childhood, a therapist can sometimes relieve vertigo and dizziness by gently repositioning the head at different angles to move fluid or the tiny particles floating around in the inner ear (this is known as the canalinth repositioning or Epley maneuver).

And kids with significant hearing loss that’s affecting their balance may need one or more of the following:

• a hearing aid (that fits inside or behind the ear and make sounds louder)
• an FM system or “auditory trainer” (specialized devices that block out background noise)
• a cochlear implant (a surgically implanted device that helps overcome problems in the inner ear, or cochlea)
• listening therapy with an audiologist (which uses music and sounds to help kids adapt their hearing and balance)

When to See a Doctor

It’s important to remember that although things like dizziness and clumsiness are common signs of a balance disorder, on their own these symptoms aren’t necessarily a sign of a balance problem — or any other chronic problem, for that matter. For example, it’s perfectly normal for kids to feel woozy if they’re dehydrated or they stand up too fast. And lots of kids stumble and fall sometimes, especially toddlers just learning to walk and preschoolers getting used to how their bodies move.

However, if you’re seeing a pattern — if you notice one or more possibly balance-related symptoms happening regularly — it’s a good idea to call your doctor to find out what’s going on. Diagnosing and treating balance disorders can help kids develop more normally, become more steady and coordinated, and just function and feel better physically and emotionally.

All kids strain their voices every now and then: cheering for the home team at a ballgame; belting out a favorite song in the shower; calling out to friends on the playground.

Most of the time, this doesn’t do any real harm to the vocal cords, the delicate bands of tissue in the larynx, or voice box. But chronic misuse of the vocal cords — such as repetitive screaming, yelling, or using the voice in an unnatural way — can lead to hoarseness. When this happens, the voice crackles and sounds rough, raspy, or breathy.

Sounding hoarse for a few hours or the day after a big game is probably nothing to worry about, and usually resolves on its own. But chronic hoarseness that lasts for days, weeks, or even months needs to be checked out by a doctor. Speech therapy may be needed to get the vocal cords back into perfect pitch.

How Vocal Cords Work

When we inhale, oxygen travels through the nose or mouth and down the throat (pharynx), passing through the voice box and windpipe (trachea), to get to the airway passages in the lungs. This route is reversed when exhaling carbon dioxide from the lungs or talking.

To speak, air is pushed out of the lungs. In the larynx, the vocal cords — a “V”-shaped band of muscle — prepare for making sound by tightening up and moving closer together. As air passes through the vocal cords, they vibrate. This vibration, combined with the movement of the tongue, lips, and teeth, is what makes the sound of the voice.

Chronic misuse of the voice can cause excess wear and tear on the vocal cords. They may stretch too far or rub together, causing small irritations that, if not allowed to heal, turn into small calluses, or vocal cord nodules.

Causes of Chronic Hoarseness

Vocal cord nodules are the primary cause of chronic hoarseness in children. They happen when kids do any of the following for a long period of time:

• yelling, screaming, cheering, or crying
• raising or lowering the pitch of the voice
• speaking in a strained voice, like imitating animals or cartoon characters
• repetitive coughing or throat clearing
• singing or talking without adequate breath (diaphragm support)
• talking extremely loud or fast
• starting words forcefully

Other causes of hoarseness include growths, vocal cord paralysis (when vocal cord nerves lose their function), smoke inhalation, chronic sinusitis or allergies, hypothyroidism, gastroesophageal reflux disease (GERD), and radiation therapy (in those being treated for throat cancer).

Detecting Vocal Cord Nodules

A child with chronic hoarseness will be referred to an otolaryngologist (also called an “ears, nose, and throat” specialist, or ENT) for evaluation. The doctor will ask for a medical history, listen for strain or breathiness in the voice, and do a diagnostic test that provides an internal view of the voice box and vocal cord function.

Tests include:

• Flexible laryngoscopy. During this exam, a tiny, flexible fiber-optic tube with a camera attached to the end (called a scope) is passed through a nostril and into the throat to let doctors get a magnified view of the larynx. Kids are asked to speak, sing, sniff, cough, and make other sounds that cause the vocal cords to vibrate. Movements are recorded on a computer monitor so that specialists can analyze them later.
• Rigid laryngoscopy. This can be done in the office for older kids, but very young children and others who cannot tolerate a flexible laryngoscopy will have this test in an operating room under general anesthesia. The rigid scope is passed through the mouth to provide the best view of the vocal cords. Images of the vocal cords (at rest) are recorded.
• Laryngeal stroboscopy. To get a more accurate view of the vocal cords in action, doctors pass either a rigid or flexible scope attached to a strobe light into the throat. The strobe light flickers in sync with the vibration of the vocal cords as a person speaks, making it easier for doctors to determine the frequency of movement. Because individual vibrations are too fast for the naked eye to see, the strobe technology projects the vibrations in slow motion.

Practicing Vocal Hygiene

Treatment for hoarseness caused by vocal cord nodules involves making behavioral changes so that the vocal cords can heal. Speech therapists work one-on-one with kids and their families to promote good vocal habits, or what’s called “vocal hygiene.”

A typical vocal hygiene program will consist of:

• isolating medical conditions (like GERD) that aggravate vocal problems, then undergoing treatment
• modifying behaviors that cause distress to the vocal cords, like yelling
• learning how to take deep breaths and relax the muscles in the throat
• taking time to speak slowly and clearly
• staying properly hydrated throughout the day
• avoiding caffeinated beverages, like soda, which dry out the vocal cords

For kids with established bad habits — like talking loudly when they’re excited or clearing their throats when they’re nervous — it might be hard to make changes in the beginning. The first step is to make kids aware of the behavior and see how often they do it.

Older kids might learn to keep track of how often they engage in the behavior (perhaps keeping notes in a diary), which many do without realizing. Then they can practice the skills they’ve learned in therapy when at home, at school, and spending time with friends.

It’s up to parents and other family members to encourage good vocal habits by setting a good example themselves. For example, rather than calling to kids from another room, walk into the other room to talk to them. Promote quiet times (perhaps for half an hour each day) and using an “inside voice” when indoors.

Reward systems that encourage these new behaviors usually are successful in elementary schoolers. Parents can offer stickers, tokens, extra TV time, a later bedtime, or similar incentives to get kids on board with the new, healthier habits.

An orofacial (or-oh-FAY-shul) cleft is when a baby is born with an opening in the lip and/or roof of the mouth (palate). Cleft lip and cleft palate happen in about 1 or 2 of every 1,000 babies born in the United States each year, making it one of the most common birth defects.

Both cleft lip and cleft palate are treatable. Most kids can have surgery to repair them within the first year or two of life.

How a Cleft Lip or Palate Forms

During the first 6 to 10 weeks of pregnancy, the bones and tissues of a baby’s upper jaw, nose, and mouth normally come together (fuse) to form the roof of the mouth and the upper lip. A cleft happens when parts of the lip and mouth do not completely fuse together.

A cleft lip may just look like a small opening on the edge of the lip, or it could extend into the nose. It may also extend into the gums. A cleft palate can vary in size. It could affect just the soft palate, which is near the back of the throat, or it also could make a hole in the hard palate toward the front of the mouth.

A cleft can be on one side of the mouth (unilateral clefting) or on both sides of the mouth (bilateral clefting).

Most clefts fit into one of three categories:

1. cleft lip by itself — most common in boys
2. cleft palate by itself — most common in girls
3. cleft lip and cleft palate together — more common in boys

Usually, cleft lip is found when a baby is born, although some are seen on a prenatal ultrasound. A cleft palate is more difficult to see until the inside of a child’s mouth is examined carefully after birth.

Causes

Doctors don’t always know why a baby develops cleft lip or cleft palate, but many clefts are thought to be a combination of genetic (inherited) and environmental factors (like certain medications or vitamin deficiencies). Both mothers and fathers can pass on a gene or genes that cause cleft palate or cleft lip. Clefts happen more often in children of Asian, Latino, or Native American descent.

Taking certain medicines (such as some anti-seizure medications) during pregnancy can increase a woman’s chances of having a baby with a cleft lip or palate. Similarly, moms who don’t get the right amount of prenatal nutrients (for example, not enough folic acid) may increase their baby’s risk of having a cleft. A mother’s exposure to certain chemicals also may cause a cleft.

Women who smoke cigarettes, use drugs, or drink alcohol during pregnancy also increase their baby’s risk for birth defects. Research has shown that moms who binge drink (drinking four or more drinks in a short period of time) during the first weeks of pregnancy have a higher risk of having a baby with a facial birth defect like a cleft lip or cleft palate.

Related Health Problems

As you might imagine, cleft lip and cleft palate can affect many actions of the mouth and face. Children born with cleft lip or cleft palate might have issues related to their feeding, hearing, teeth, and speech.

Feeding Problems

Babies with just a cleft lip don’t usually have feeding problems. But when the palate is involved, feeding can be a bigger challenge.

Normally, the palate prevents food and liquids from entering the nose. A cleft palate causes babies to swallow a lot of air and regurgitate food into the nose. It also makes it harder for babies to latch on and suck during breastfeeding or bottle feeding. As a result, a baby with a cleft palate may need a special nipple and bottle to receive pumped breast milk or formula. Breastfeeding moms might want to talk with a lactation consultant, who can offer more guidance and suggestions.

Babies with feeding issues should be seen regularly by a doctor to make sure that they’re gaining weight well.

Middle Ear Fluid Buildup and Hearing Loss

Many children with cleft palate are at risk for fluid buildup in the middle ear. This fluid can’t pass through the Eustachian (yoo-STAY-shun) tube as it should, which can lead to ear infections and even hearing loss. So kids with cleft palate usually need ear tubes placed in their eardrums to help drain the fluid and improve hearing.

Kids with cleft palate should have their ears and hearing checked once or twice a year, or more if they are having hearing problems.

Dental Problems

Children with a cleft lip and palate often have dental problems. These can include small teeth, missing teeth, extra teeth (called supernumerary), or teeth that are out of position. They may have a defect in the gums or alveolar ridge (the bone that supports the teeth). Ridge defects can displace, tip, or rotate permanent teeth or prevent permanent teeth from coming in properly.

Regular visits with a pediatric dentist who specializes in cleft lip and palate are important. The dentist will check a child’s mouth growth and development, identify any problems, and make treatments when needed.

Speech Problems

Kids with cleft lip have fewer speech problems than those with cleft palate. About 1 in 5 kids with cleft palate have speech problems after surgical repair. Most often, this means that a child’s voice is hypernasal (sounding like the child is talking through the nose). This happens because the palate doesn’t move well enough to prevent air from leaking out of the nose.

Children with clefts also can have other types of speech problems that aren’t to the cleft; for example, age-related errors such as saying “wed” instead of “red.” Sometimes, the dental problems associated with the cleft will distort some sounds, particularly “s,” “sh,” “ch,” and “j.”

A speech-language pathologist can check a child’s speech and language skills and recommend treatment if needed.

Treatment Team

If your child has a cleft lip and/or palate, your pediatrician will talk to you about a cleft lip and palate treatment team. This team of health care professionals will work together to meet your family’s needs and, ultimately, help your child transition to adult care.

Besides the pediatrician, your child’s treatment team may include:

• plastic surgeon
• ear, nose, and throat physician (otolaryngologist)
• oral surgeon
• orthodontist
• dentist
• speech-language pathologist
• audiologist
• nurse
• social worker
• psychologist or therapist
• geneticist
• team coordinator

Your child might visit this care team a few times a year, depending on his or her needs. Who is seen during a visit depends on the care team’s structure and your child’s needs. The team coordinator will help organize the visits, and the team should communicate with your doctor about the treatment plan.

Surgical Treatment

A cleft lip is usually surgically repaired in the hospital using general anesthesia when a child is 3 to 6 months old. If the cleft lip is wide, special procedures like lip adhesion or a molding plate device might help bring the parts of the lip closer together before the lip is fully repaired. Cleft lip repair usually leaves a small scar on the lip under the nose.

At 9-12 months of age, a cleft palate usually can be repaired. Plastic surgeons connect the muscles of the soft palate and rearrange the tissues to close the cleft. This surgery requires general anesthesia and a short hospital stay for recovery.

The goal of surgery is to create a palate that works well for speech. Some kids, however, will continue to sound nasal after cleft palate repair, and some may develop a nasal voice later on.

More surgeries may be needed as children grow older and their facial structure changes — this can include surgeries like pharyngoplasty, which helps improve speech, or alveolar bone grafts, which help provide stability for permanent teeth. A bone graft closes gaps in the bone or gums near the front teeth and is usually done when kids are between 6 and 10 years old.

As children become teens, they will likely want to (and should) be more involved in their care. They may want to have their scars made less noticeable, improve the appearance of their nose and upper lip, or improve their bite with orthognathic surgery. These operations may improve speech and breathing, overbites/underbites, and appearance.

Dental and Orthodontic Treatment

Maintaining healthy teeth and preventing cavities is very important for kids with cleft lip and palate, who can have more dental problems than other kids. They should see a dentist regularly and brush and floss every day.

Kids with cleft lip and palate may begin orthodontic treatment as early as 6 years of age. It may start with palatal expansion, a process that makes the width of the palate normal. Later, it may involve braces to position the teeth. Your orthodontist will discuss these issues with you.

Some kids with a cleft might be missing a permanent tooth, which can be replaced with a removable appliance or, in early adulthood, a dental implant.

Speech Therapy

Some kids will need speech therapy after a repair is done. The speech-language pathologist will closely monitor your child’s progress and talk with you about whether therapy is needed.

Dealing With Emotional and Social Issues

It can be hard when kids miss school for frequent doctor’s appointments, or when speech problems prevent them from communicating well with their peers. In spite of these and other social, psychological, and educational challenges, kids with clefts just want to be treated like everyone else.

Children may face teasing and bullying because of how a cleft lip and palate look. If your child is teased, talk about it and be a patient listener. Try to give your child tools to confront teasers. Find out what your child would like to say to them and practice it together.

Some kids struggle growing up with a cleft lip or cleft palate and might need help handling certain situations. The psychologists and social workers on the treatment team can help guide you through these difficult times, so turn to them if your child needs added support. The good news is that most kids with cleft lip or cleft palate grow up to be healthy, happy adults.

As your child nears the teen years, remember that your interactions may change. You could be his or her greatest confidante, or your child may not share his or her worries with you. Either way, stay open to communication and support your child with these tips:

• Encourage your child to be confident and not allow the cleft to define who he or she is.
• Make your home a warm, supportive, and accepting place where individual worth and accomplishments are celebrated.
• Encourage your child’s friendships and relationships. Make friends with people who are different from you and lead by example.
• As for all kids, being involved in sports, music, and other activities will go a long way toward helping kids with clefts realize their self-worth.
• Give your child the freedom to make decisions and take appropriate risks. Having chances to make decisions early on — like picking out which clothes to wear or foods to eat — gives kids the confidence and skills to make bigger decisions later. It will help them become more independent.
• If your child — especially a young child — wants to talk to the class about cleft lip and palate, set up something with the teacher. Consider asking someone from the treatment team to attend. But remember that your child may need an extra boost of confidence to get up in front of the class, so give lots of encouragement.

Sometimes called a “bionic ear,” the cochlear implant offers the hope of gaining or restoring the ability to sense sound for some people with significant hearing loss.

What Is a Cochlear Implant?

A cochlear implant is a surgically implanted device that helps overcome problems in the cochlea (KO-klee-uh). The cochlea are snail-shaped, curled tubes near nerves in the ears. They transform sound vibrations reaching the ear into signals that can be sent to the auditory nerve (or hearing nerve). The auditory nerve then sends these signals to the brain, where they’re translated into recognizable sounds.

If important parts of the cochlea aren’t working as they should and the auditory nerve isn’t stimulated, there’s no way for the sounds to get to the brain. As a result, hearing doesn’t happen. This is called sensorineural hearing loss.

By completely bypassing the damaged part of the cochlea, the cochlear implant uses its own electrical signals to stimulate the auditory nerve, allowing the person to hear.

About Normal Hearing

The ear is made up of three parts, and in normal hearing, sound passes through all three on the way to the brain:

1. The outer ear: This is the outer, visible part of the ear and the ear canal. When a person hears a sound, the outer ear captures the sound vibration and sends it through the ear canal to the middle ear.
2. The middle ear: This consists of the eardrum and three tiny bones (the malleus, incus, and stapes). The sound vibration from the outer ear causes motion in these bones.
3. The inner ear: This is where the cochlea are. The motion of the bones in the middle ear makes the fluid in the cochlea move, which stimulates the hair cells (the thousands of tiny hearing receptors inside the cochlea). The hair cells bend back and forth and send chemical signals to the auditory nerve, which carries these signals to the brain, where they’re interpreted.

Hair cells can be damaged or destroyed through aging, heredity, disease, infection, or repeated or severe exposure to loud noise. If the hair cells don’t work, the auditory nerve can’t be stimulated and can’t send information to the brain. So, the person won’t be able to hear.

Hearing loss can be mild, moderate, or severe, depending on the number of hair cells that are defective, damaged, or destroyed. People with mild or moderate hearing loss may find that hearing aids help (hearing aids make sounds louder). Those with profound or severe hearing loss might even have trouble understanding loud sounds. A hearing aid won’t help in these cases, so a doctor might recommend a cochlear implant.

What a Cochlear Implant Does

The cochlear implant artificially stimulates the inner ear area with electrical signals, which sends those signals to the auditory nerve, letting a person hear.

Although sound quality from a cochlear implant is different from that in normal hearing, the cochlear implant lets someone sense sound that he or she couldn’t hear otherwise. And regular improvements to the way the implants work are helping to make the sound even more natural. Most infants, even if they never heard before, will be able to make sense of these sounds and develop speech and language.

A cochlear implant consists of an implant package, which is secured inside the skull, and a sound and speech processor, which is worn externally (outside the body). Several components of the cochlear implant work together to receive sound, transfer it to the auditory nerve, and send it to the brain.

The cochlear implant package is made up of:

• a receiver-stimulator that contains all of the electronic circuits that control the flow of electrical pulses into the ear
• an antenna that receives the signals from the external sound and speech processor
• a magnet that holds the external sound and speech processor in place
• one wire containing electrodes that are inserted into the cochlea (the number of electrodes can vary depending on the cochlear implant model type used). The electrodes act much like normal functioning hair cells and provide electrical charges to stimulate the auditory nerve.

The sound and speech processor is a minicomputer that processes sound into digital information, and then sends that information to the implant package in the form of electrical signals. This is worn externally and looks a lot like a normal hearing aid. Depending on the type of sound and speech processor used, it can either be worn as a headset behind the ear or in a belt, harness, or pocket.

The sound and speech processor is made up of:

• a sound and speech processor (which can either be a body-level model that can be clipped onto clothing like a portable radio, or an ear-level model that’s hooked over the ear)
• a microphone
• a transmitter that sends the signals to the cochlear implant package. The transmitter also includes a magnet.

For the cochlear implant to work, the implant package and the sound and speech processor must be aligned — that’s what the magnets are for. By lining up the magnets, both the implant package and sound and speech processor are secured and work together. If they aren’t completely aligned, the device doesn’t work and the person can’t hear.

How a Cochlear Implant Works

Knowing how a cochlear implant works may help kids better understand their new bionic ear and the cool technology behind it that allows them to hear better.

Here’s how the implant works:

• The microphone picks up sound.
• Sound is sent to the sound and speech processor.
• The processor analyzes the sound and converts it into an electrical signal. (The signal contains information that determines how much electrical current will be sent to the electrodes.)
• The transmitter sends the signal to the implant package, where it’s decoded.
• The implant package determines how much electric current should pass to the electrodes and sends the signal. The amount of electric current determines loudness, and the position of the electrodes determines the sound’s pitch.
• The nerve endings in the cochlea are stimulated and the message is sent to the brain along the auditory nerve.
• The brain interprets the sound and the person hears.

Cochlear Implant Surgery

Surgery for a cochlear implant takes 2–4 hours and uses general anesthesia (which keeps a patient completely unconscious). The surgeon will place and secure the implant package under the skin and inside the skull, then thread the wires containing the electrodes into the spirals of the cochlea.

To secure the implant, the surgeon first drills a 3- to 4-millimeter bed in the temporal bone (the skull bone that contains part of the ear canal, the middle ear, and the inner ear). Then, the surgeon opens up the bone behind the ear to allow access to the middle ear. A small hole is drilled in the cochlea and the wires containing the electrodes are inserted. The implant package is then secured and the incision is closed with stitches.

After cochlear implant surgery, a child:

• will probably be able to go home the next day
• will have to wear a dressing over the implant area for 24 hours
• might be off-balance or dizzy for a few days
• may have mild to moderate pain (the doctor may recommend giving pain medicines)
• won’t have to have the stitches removed (they’re absorbable and dissolve on their own)
• can lie on the side of the cochlear implant in a few days

About 2 to 4 weeks after surgery, the sound and speech processor is matched with the implant package and is programmed and fine-tuned to meet the child’s individual hearing needs.

Nowadays, children who are born deaf or with a profound hearing loss in both ears can even receive two cochlear implants, one for each ear, at the same time. This is a great advance as it requires only one surgery.

Learning to Use a Cochlear Implant

Because the hair cell damage, electrical signal patterns, and sensitivity of the auditory nerve are different for each person, a specialist must fine-tune the sound and speech processor for every patient.

By measuring the lowest and highest current for each electrode, the clinician finds the softest and loudest sounds that will be heard (each electrode produces a different sound with different pitch). The sound and speech processor matches sounds on different electrodes with different volumes and attempts to create an accurate version of the original sound. However, because a limited number of electrodes are taking over the function of the thousands of hair cells in a normal ear, sounds won’t be totally “natural.” However, infants who never heard before will be able to make great sense of these sounds and will quickly learn language.

After the first few programming sessions, the user begins to pick up sounds with the implant, but giving the implant full power is a gradual process that takes several months. In children who are born deaf, the stimulation from the implant will allow them to develop the brain pathways necessary to hear sounds and develop speech and language. This is an extended process with programming and intensive therapy that often lasts for several years.

During the programming process, the user attends speech and language therapy sessions to help identify and interpret the new sounds he or she is hearing. An important part of the therapy is parent education and training.

Therapy will help a child develop and understand spoken language through detecting, imitating, and associating meanings of sounds. These sessions last at least a year, along with parent education and training programs. In many cases, therapy has helped kids with cochlear implants develop speech and language on par with their peers.

Some families choose to have implants in both ears. This can help with speech detection when there is background noise.

Can an Implant Restore Hearing for Everyone?

Cochlear implants are very successful for some people, but not everyone is a candidate to receive one. Children 12 months of age or older with profound hearing loss in both ears are usually excellent candidates, but not every child is eligible.

Common reasons that a child might not be eligible for a cochlear implant include:

• the child’s hearing is “too good” (meaning the child can hear some sound and speech with hearing aids)
• the hearing loss isn’t due to a problem with the cochlea
• the child has had profound deafness for a long time
• the auditory nerve itself is damaged or absent

Each potential candidate must be evaluated by a cochlear implant team to see whether a cochlear implant is the best option.

Benefits of an implant can vary. The rehabilitation period can be long, and many factors (such as the condition of the auditory nerve or the presence of scar tissue in the cochlea) can affect the success of the implant.

The doctor or surgeon will help parents understand what an implant can reasonably achieve for their child.

Falls, blows to the head, sports injuries, and even listening to loud music can cause ear damage, which can affect hearing and balance. That’s because the ear not only helps us hear, but also keeps us steady on our feet.

Kids need to hear well to develop and use their speech, social, and listening skills. Even mild or partial hearing loss can affect their ability to speak and understand language, while problems with balance can influence how they’re able to move and how well they feel.

How the Ear Works

To understand ear injuries, it’s helpful to review the ins and outs of the ears. Basically, the ear is made up of three parts — the outer ear, middle ear, and inner ear.

Hearing begins when sound waves that travel through the air reach the outer ear, or pinna (the visible part of the ear). The outer ear captures the sound vibration and sends it through the ear canal to the middle ear, which contains the eardrum (a thin layer of tissue) and three tiny bones (called ossicles). The sound causes the eardrum to vibrate. The ossicles amplify these vibrations and carry them to the inner ear.

The inner ear is made up of a snail-shaped chamber (the cochlea), which is filled with fluid and lined with four rows of tiny hair cells. When the vibrations move through this fluid, the outer hair cells contract back and forth and amplify the sound.

When the vibrations are big enough, the inner hair cells translate them into electrical nerve impulses in the vestibulocochlear nerve (also called the auditory nerve, acoustic nerve, or eighth cranial nerve), which sends signals to the brain to be interpreted as sound. The vestibulocochlear nerve also helps with balance.

Types of Ear Injuries

Hearing loss and balance problems can happen when there’s damage to key parts of the ear, like the eardrum, ear canal, ossicles, cochlea, or the vestibular nerve.

Here’s a look at the most common causes of ear injuries and how they can affect kids:

Cuts, scrapes, burns, or frostbite. When there’s an injury (even minor) to the outer ear or ear canal, bleeding and infection can affect other parts of the ear.

Inserting something into the ear. Things like a cotton swab, fingernail, or pencil can scratch the ear canal or cause a tear or hole in the eardrum (called a ruptured eardrum).

Direct blows to the ear or head. Falls, car accidents, sports injuries, or fights may tear the eardrum, dislocate the ossicles, or damage the inner ear. Wrestlers, boxers, and other athletes who endure repeated forceful hits to the outer ear can develop severe bruising or blood clots that block blood flow to the cartilage of the outer ear and damage its shape and structure (known as cauliflower ear).

Loud noise. Kids can have significant or permanent hearing loss when they’re exposed to really loud noises daily or over a long period of time. This is called acoustic trauma or noise-induced hearing loss.

When this happens, the tiny hairs in the cochlea become damaged. Loud sounds (like a gunshot, firecracker, or explosion) can cause it, as can noises that are repeated over time (like lawn mowers, power tools, farm equipment, noise from sporting events, band or shop classes, motorbikes, even movie theaters). But for kids and teens, listening to loud music (at concerts, in the car, through headphones) is one of the chief causes of this type of preventable hearing loss.

Sudden, significant change in air pressure. When we fly or scuba dive, air pressure decreases as we go higher and increases as we go lower. If the pressure isn’t equalized, the higher air pressure pushes on one side of the eardrum and causes pain and sometimes partial hearing loss, called barotrauma.

Normally, the eustachian tube (a passageway that leads from the middle ear to the back of the throat behind the nose) equalizes the air pressure in the middle ear to the outside air pressure by opening and letting air reach the middle ear. When your ears “pop” while yawning or swallowing, your eustachian tubes are adjusting the air pressure in your middle ears.

But in kids, the relatively narrow eustachian tubes may not work as well, especially if they’re clogged by inflammation and mucus from an ear infection or cold, or blocked by enlarged or swollen adenoids. Any pain or hearing problems are usually minor and temporary, though — they usually go away within minutes and don’t cause any lasting damage. In some cases, a child can have pain for several hours if the ears don’t “pop.” Occasionally, extreme pressure changes can fill the middle ear with fluid or blood or cause the eardrum to burst.

Signs of Hearing Loss or Balance Problems

Ear injuries can affect kids differently. Some may have partial hearing loss, with symptoms like:

• trouble hearing when there’s background noise
• difficulty hearing high-pitched sounds or music notes
• hearing only certain or muffled sounds
• ringing in the ears or other strange sounds like hissing, buzzing, humming, or roaring
• turning up the TV
• difficulty paying attention or keeping up in school
• complaining that the ears feel “full”
• trouble talking (with poor, limited, or no speech)
• talking loudly
• failing to turn toward loud noises or respond to conversation-level speech
• answering inappropriately

In other cases, kids may have complete hearing loss or deafness (when they can’t hear anything at all).

Depending on whether they hurt one or both ears, kids with ear injuries that affect balance may have symptoms like:

• falling or stumbling a lot (clumsiness)
• vertigo (a sudden feeling of spinning or whirling that feels like moving while sitting or standing)
• feeling unsteady, “woozy,” or disoriented
• dizziness or lightheadedness
• vision problems (like bouncing eyesight or blurriness, called oscillopsia)
• trouble going up stairs or standing up without falling
• problems walking (inability to walk without staggering, walking with legs too far apart, or trouble walking in the dark or over uneven areas)
• nausea or vomiting
• headaches
• major fatigue

Preventing Ear Injuries

You can’t protect children from getting hurt all the time — accidents and injuries are par for the course with raising kids. But you can keep prevent some ear injuries by encouraging kids to:

• Never stick anything in their ears — not even cotton swabs or their fingers. Regular bathing should be enough to keep earwax at normal levels. If your child complains of ear discomfort and you see earwax in the ear, it’s OK to wipe the outside of the ear with a washcloth. If earwax interferes with hearing or causes pain or discomfort, talk to your doctor about having the earwax removed in the office.
• Steer clear of uncomfortable, potentially damaging noise. If you or your kids have to shout to be heard from 3 feet away, that’s far too loud.
• Turn down the volume when listening to music, especially while wearing headphones or riding in the car. Also look for portable media or music players with “volume limiters” (they may come with the device or it can be bought separately).
• Wear ear protection at concerts, especially when sitting near the stage or speakers (they’ll still be able to hear with earplugs — it just won’t be as deafening), mowing the lawn or using machinery (like in metal or wood shop at school), or playing a loud instrument (like the drums).
• Always put on a snug-fitting helmet whenever they ride bikes or scooters, skateboard, or inline skate.
• Don the right kind of protective equipment every time they practice or play sports — helmets for baseball, softball, hockey, and football; headgear or ear guards for wrestling, rugby, and boxing.

Seeking Treatment

How long hearing or balance problems last and how they’re treated will depend on what part of the ear was hurt, what caused the injury, and how severe it is. While minor injuries usually cause temporary problems, serious injuries may cause permanent hearing loss or balance problems.

Vestibular therapy may help kids with balance problems. And some with significant hearing loss may need a hearing aid, an FM system or auditory trainer (specialized devices that block out background noise), or a cochlear implant (a surgically implanted device that helps overcome problems in the inner ear, or cochlea). They also might need listening therapy with an audiologist (hearing specialist).

Make sure to call your doctor if your child has:

• had any type of ear or head injury, even if it seems minor
• any signs of problems with balance or hearing
• severe ear pain
• blood or fluid draining from the ear (that doesn’t look like earwax)

If there’s a concern, your doctor can refer you to an ear, nose, and throat specialist and possibly an audiologist to figure out the next step to take.

A ruptured or perforated eardrum is exactly what you might imagine: a tear or hole in the eardrum — the part of the ear that vibrates in response to sound waves. Eardrum injuries can be extremely painful and, in the worst cases, might lead to infections and hearing loss.

Fortunately, though, most eardrum injuries heal within a few weeks with no problems. When an eardrum won’t heal on its own, surgery may be needed to repair it and restore normal hearing.

How the Ear Works

The eardrum, also called the tympanic membrane, is the thin, cone-shaped piece of tissue that separates the outer ear from the middle ear. It’s found at the end of the ear canal (the part that gets waxy).

The hearing process begins when the pinna (the part of the ear that’s visible) funnels sound waves into the ear canal, where they hit the eardrum and make it vibrate. In the inner ear, these vibrations are converted into nerve impulses by the snail-shaped cochlea. These impulses then travel to the brain along the cochlear nerve, also known as the auditory nerve. The brain’s auditory cortex receives these signals and interprets them as different sounds.

If the eardrum is perforated, it can hurt the eardrum’s ability to vibrate correctly, leading to muffled or diminished hearing. Hearing loss is usually temporary and can vary in intensity based on the size and location of the injury.

Sometimes bacteria and other materials enter the middle ear through this opening and can cause an infection. Fortunately, this rarely leads to permanent hearing damage.

Causes

Many people don’t know that cleaning their ears with cotton swabs is a major cause of eardrum injuries. That’s because poking around in the ear canal too harshly can easily injure the eardrum’s fragile tissue, especially in young children, who have very narrow ear canals. (Tip: To clean wax build-up in the ears, opt for a wet washcloth and gently wipe outside the ear canal.)

But eardrums can be injured in lots of other ways, including:

• Ear infections. An infection of the middle ear or inner ear (such as otitis media) can lead to pus or fluid buildup behind the eardrum, which can cause it to burst. This is a common cause of ruptured eardrums in children.
• High or low altitudes (barotrauma). Usually, the air pressure in the middle ear and the pressure in the environment are in balance. A sudden change in barometric pressure (such as during air travel, driving on a mountain road, or scuba diving) can be enough to rupture an eardrum.
• Loud noises (acoustic trauma). Although uncommon, loud noises (like an explosion) can sometimes produce sound waves that are strong enough to damage the eardrum. Any loud noise also can cause temporary or permanent hearing damage to the cochlea and lead to hearing loss.
• Foreign objects. Besides cotton swabs, hairpins and other small objects that kids can fit in the ear canal can cause injuries.
• Head trauma. A direct blow to the ear can cause a skull fracture or pressure that might tear the eardrum.

Symptoms

When a child injures an eardrum, the first symptom is usually ear pain, which can range from mild to severe and might increase for a time before suddenly decreasing.

Other symptoms of an injured eardrum include:

• drainage from the ear that can be clear, pus-filled, or bloody
• hearing loss that may be mild to severe
• ringing or buzzing in the ear (tinnitus)
• dizziness or vertigo that can cause nausea or vomiting

Diagnosis

If your child has symptoms of a ruptured or perforated eardrum, call a doctor right away. Most injuries will heal on their own, but you should ensure that any hearing loss is only temporary.

Also seek medical care right away if your child has severe symptoms, such as bloody discharge from the ear, extreme pain, total hearing loss in one ear, or dizziness that causes vomiting.

To check for ruptured or perforated eardrum, the doctor will examine your child’s ear canal with a lighted tool called an otoscope. Sometimes the doctor will be able to see the tear in the eardrum, but other times fluid in the ear will block the view.

The doctor might order other tests to check for hearing loss, such as:

• audiology exams that measure how well someone hears sounds at different pitches and volumes
• tympanometry to measure the response of the eardrum to slight changes in air pressure

If there is fluid leaking from the ear, the doctor might send a sample for testing to see if there is an infection of the middle ear or inner ear.

Treatment

Usually, eardrum injuries heal on their own within a few weeks without any treatment. While the eardrum is healing, over-the-counter pain relievers can help ease any pain. Ask your doctor about which pain relievers are best for your child.

To help prevent infections or treat an existing infection, the doctor may prescribe antibiotics. These may be liquid or pills to be swallowed or ear drops. Never give your child over-the-counter ear drops unless your doctor recommends it. Some drops are not meant to be used if there is a hole in the eardrum because they can cause problems with the middle ear or cochlea.

To protect the eardrum while it heals, your doctor may advise keeping your child’s ear dry. Tell your child to keep his or her head above water while swimming, and gently place a waterproof earplug or cotton ball coated with petroleum jelly in the ear when your child showers or bathes. Children also should not forcefully blow their noses until the eardrum is completely healed.

If a ruptured or perforated eardrum doesn’t heal on its own within about 4 weeks, a child might need to see a pediatric otolaryngologist or ENT (ear, nose, and throat doctor). After an exam and hearing testing, the otolaryngologist or ENT may recommend an eardrum patch. During this procedure, a chemical is applied to the edges of the rupture to stimulate growth and healing, then a paper patch is placed over the area to protect it. This might have to be done a few times before the eardrum is fully healed.

If all other treatments fail, a specialist might perform a surgery known as a tympanoplasty. In this procedure, a small patch of a child’s own tissue is grafted onto the affected eardrum to close the tear. This is a relatively simple surgery, and kids usually can leave the hospital the same day.

Prevention

In some cases, such as an accidental blow to the ear, it’s impossible to prevent an eardrum injury. But other cases of eardrum perforation are entirely preventable.

Here are some ways you and your kids can reduce the odds of an injury:

• Get immediate medical treatment for your child as soon as you notice any signs of an ear infection.
• Never stick anything in your child’s ears — like cotton swabs — and teach kids to do the same. Regular bathing should be enough to keep earwax at normal levels. If your child complains of ear discomfort and you see earwax in the ear, it’s OK to wipe the outside of the ear with a washcloth.

  If earwax is causing pain, discomfort, or a problem with hearing, talk to your doctor about having the earwax removed in the office. If your child does get something stuck in the ear, have a health care provider remove it to avoid further damage to the ear.

• Kids with colds or sinus infections should avoid airplane travel if possible. When kids do fly, give them some gum to chew during takeoff and landing or make sure they know how to equalize the pressure in their ears by yawning or swallowing. Babies should be breastfed or given a bottle or sippy cup to drink during these times.
• Anyone who will be scuba diving should be properly certified and know how to equalize the pressure in the ears.

Listen. Whatever you’re hearing — the hum of a computer, your kids playing, a car going by — is thanks to your ears.

Hearing is their main job, but it’s not all our ears do. These delicate organs also need care and protection, so let’s take a look at how they work and what conditions and problems can affect them.

All About Ears

There’s a lot more to an ear than what you see on the side of your head. The ear is made up of three different sections that work together to collect sounds and relay them to the brain: the outer ear, the middle ear, and the inner ear.

The outer ear, the part that is visible on the side of your head, is called the pinna or auricle. It’s made of tough cartilage covered by skin. The pinna’s main job is to gather sounds and funnel them to the ear canal, which leads to the middle ear. The pinna, which includes the earlobe, is the part that people pierce to wear earrings.

The ear canal, the hollow passage that leads to the eardrum, is also part of the outer ear. Glands in the skin lining the ear canal produce earwax, which protects the canal by cleaning out dirt and helping to prevent infections.

The middle ear is an air-filled cavity about the size of a pea. It turns sound waves into vibrations and delivers them to the inner ear. The middle ear is separated from the outer ear by the eardrum, or tympanic membrane, a thin, cone-shaped piece of tissue stretched tight across the ear canal.

To hear properly, the pressure on both sides of your eardrum must be equal. When you go up or down in elevation, the air pressure changes and you may feel a popping sensation as your ears adjust. Ears are able to adjust thanks to the narrow Eustachian tube that connects the middle ear to the back of the nose and acts as a sort of pressure valve, opening to keep the pressure equalized on both sides of the eardrum.

The middle ear also includes the three smallest bones in the body, located just past the eardrum and collectively known as the ossicles. The ossicles consist of:

1. the malleus (“hammer”), which is attached to the eardrum
2. the incus (“anvil”), which is attached to the malleus
3. the stapes (“stirrup”), which is attached to the incus and is the smallest bone in the body

The inner ear consists of two tiny organs called the cochlea and the semicircular canals. The snail-shaped cochlea act as a sort of microphone, converting the vibrations from the middle ear into nerve impulses that travel to the brain along the cochlear nerve, also known as the auditory nerve.

The semicircular canals look like three tiny, interconnected tubes sticking out in loops from the top of the cochlea. It’s their job to help you balance. The canals are filled with fluid and lined with tiny hairs. When your head moves, the fluid in the canals sloshes around, moving the hairs. The hairs send this position information as impulses through the vestibular nerve to your brain. The brain interprets these impulses and sends messages to the muscles that help keep you balanced.

When you spin around and stop, the reason you feel dizzy is because the fluid in your semicircular canals continues to slosh around for awhile, giving your brain the idea that you’re still spinning even when you aren’t. When the fluid stops moving, the dizziness goes away.

The cochlear nerve, which is attached to the cochlea and relays sound information to the brain, and the vestibular nerve, which carries balance information from the semicircular canals to the brain, are collectively known as the vestibulocochlear nerve, or 8th cranial nerve.

How We Hear

What’s a Sound?

When something vibrates, it makes a sound. Most of the sounds we hear and interpret are vibrations in air (but they can happen in other gases, and in liquids or solids).

When an object or thing vibrates, it flexes in and out. Flexing out pushes the object against the air molecules around it. These molecules in turn push against the molecules next to them. The vibration created travels outward in this manner, much like a ripple or wave. This is a process called compression.

Flexing in while vibrating creates a drop in air pressure that pulls nearby air molecules toward an object. This, in turn, creates another drop in pressure that pulls in the surrounding air molecules, and so on. This process is called rarefaction.

These waves of change in air pressure — compression and rarefaction — are what we hear as sounds.

Detecting Where Sounds Come From

When a sound wave reaches the ear, it’s corralled by the pinna and directed into the ear canal. The pinna, through its distinctive shape and curves, helps us determine the direction a sound is coming from. Sounds coming from different places bounce off the pinna differently. The brain can recognize the difference and decide if the sound is coming from in front or behind.

The two pinnae (plural of pinna) of the left and right ears work together to determine if a sound is coming from the right or left. A sound that’s coming from the right reaches the right eardrum sooner than the left. It also sounds slightly louder in the right ear. The brain compares the input from both ears and uses this to decide which side the sound came from.

Once inside the ear canal, sound waves vibrate the eardrum, which is very sensitive. The tensor tympani muscle that’s attached to the eardrum keeps it taut. So the entire eardrum vibrates no matter where it is hit by a sound wave. This allows the eardrum to detect even the slightest fluctuations in air pressure.

As the eardrum is moved back and forth by the compressions and rarefactions of sound waves, the ossicles move, too. The movement of these tiny bones transmits and amplifies sound waves into the cochlea.

The Ear ‘Talks’ to the Brain

The cochlea is filled with fluid and contains thousands of tiny fibers that detect sound waves. These fibers are short and stiff in some areas and longer and more flexible in others, which helps each hair detect certain frequencies (pitches).

When sound waves travel into the cochlea, they reach the fibers and give off a burst of energy. This burst of energy is detected by the organ of Corti, a structure that lines the cochlea and contains thousands of tiny hair cells. When energy is released, it’s strong enough to move these hairs.

The organ of Corti sends an electrical impulse to the brain telling it which hairs (and how many) were moved. This information helps the brain’s cerebral cortex determine the pitch and volume of a sound. So, for example, when a person hears a loud sound, it’s because a stronger burst of energy affected more of the hairs in the organ of Corti.

Things That Can Go Wrong With the Ears

Given the outer ear’s exposure to the elements and the middle ear’s connection to the nose via the Eustachian tube, more than a few things can affect the ear and lead to hearing loss. Fortunately, most of these conditions can be treated effectively when detected early.

Some of the more common ear problems include:

• Noise-induced hearing loss (NIHL). NIHL is hearing loss from overexposure to loud noises, which can damage the hair cells in the cochlea. A common cause of this in kids is the use of portable music players. Loud video games, TVs, movie theaters, traffic, power tools, and even some appliances also can be culprits. Hearing loss can even be caused by a single exposure to a very loud sound, such as an explosion or thunderclap. NIHL is almost 100% preventable if parents help kids protect their ears.
• Otitis media. This middle ear infection is the most common cause of hearing loss in kids and can affect one or both ears. It happens when pus and mucus build up behind the eardrum when the Eustachian tube is blocked due to allergies, a cold, or upper respiratory infection. Untreated otitis media can lead to a ruptured eardrum, hearing loss, and an infection of the mastoid bone behind the ear.
• Swimmer’s ear. Also known as otitis externa, this infection of the outer ear happens when water and bacteria get trapped in the ear canal. The bacteria can multiply in this warm, moist environment, leading to irritation and infection of the skin lining the ear canal. This is a common problem for swimmers, but can affect anyone after bathing or taking a shower.
• Tinnitus. A ringing, humming, buzzing, roaring, or clicking in the ears is known as tinnitus. It’s the result of damage to nerve endings in the inner ear, which can happen naturally as someone ages or, in young people, by exposure to loud noises. Medical treatments or hearing devices often can help people who have tinnitus.
• Cerumen impaction. Earwax, also known as cerumen, traps dirt and dust before they reach the eardrum. Usually, earwax dries and falls out of the ear or is washed away. But sometimes it can build up and plug the inside of the ear canal (known as “impaction”) and cause hearing loss. Fortunately, doctors and nurse practitioners usually can treat this kind of hearing loss simply by washing away the wax. Because earwax can get impacted, doctors recommend never using cotton swabs in the ear canal because doing so can push wax deeper into the ear canal and make it harder to get out.
• Ruptured (or perforated) eardrum. A puncture or rupture of the tympanic membrane can cause pain, discharge from the ear, and decreased hearing. Ruptured eardrums often heal on their own, but sometimes surgery is needed to repair the rupture. If your child has a ruptured eardrum, talk to a doctor about how to protect it from water and bacteria while it heals.
• Cholesteatoma. Someone can be born with this type of skin cyst that affects the middle ear, but most happen as a complication of chronic otitis media (swimmer’s ear). If the Eustachian tube isn’t working correctly, it can build pressure in the middle ear, pulling the eardrum into the middle ear and creating a cyst or pocket. This pocket can fill with dead skin cells and other waste material and become infected. Surgery is needed to remove the cyst. Left untreated, the infection can spread to the brain, with extremely serious complications, including facial paralysis, deafness in the affected ear, and meningitis.
• Meniere’s disease. Meniere’s disease causes problems with balance and hearing. It happens when a part of the semicircular canals (the endolymphatic sac) becomes swollen, which affects the movement of the fluid in the canal and sends an incorrect signal to the brain about body position and balance. Episodes of Meniere’s disease, which can cause severe dizziness, can happen without warning and take place daily or as rarely as once a year. The exact causes of Meniere’s disease are not known, but some treatments and lifestyle changes can help to relieve symptoms.
• Injuries, burns, and frostbite. Exposed as they are, ears are subject to all kinds of minor injuries. Usually it’s no big deal, but an injury to the outer ear or ear canal can lead to bleeding and infection that can affect other parts of the ear. A direct blow to the ear, such as from a car accident or sports injury, may tear the eardrum, dislocate the ossicles, or damage the inner ear. Repeated hits to the outer ear can cause bruising and blood clots that disrupt blood flow to the cartilage of the pinna and damage its shape and structure. This condition is called cauliflower ear.

  When kids are out in the sun for an extended period of time, put sunscreen on their ears to protect them from getting burned. Likewise, if kids will be outside in the cold for a long time, make sure they bring along warm hats that cover the ears to protect against frostbite.

• Piercing problems. If kids or teens get their ears pierced, this should be done by reputable, trained practitioners in clean, sanitary surroundings. Earrings should be made of surgical-grade stainless steel or 18- or 24-karat gold. Because piercing breaks the skin, there’s always a risk of infection. Carefully clean the pierced areas of the ear daily and rotate the earrings at least twice a day to keep the holes open while they heal. Pierced earlobes usually take about 6 to 8 weeks to heal. Pierced ear cartilage takes 4 months to a year to heal completely.

Protecting Your Child’s Ears

There’s an old saying about how you should never stick anything in your ear except your elbow. It’s meant to be funny, but there’s a kernel of truth to it. Sticking things like cotton swabs and fingernails into ears can scratch the ear canal, push earwax deeper into the ear, and even rupture the eardrum. If you find yourself having trouble removing earwax from your child’s ear canal, seek a doctor’s help.

Protecting kids’ hearing is mostly a matter of common sense. You can start by convincing your kids to turn down the volume on the stereo and TV and, especially, on portable music players. If you know that they will be exposed to loud noises (at a concert, car race, construction site, etc.), make sure they bring protection for their ears (like earplugs or protective earmuffs/headphones).

If your child has any hearing loss or hearing problems, contact your doctor right away. Depending on the cause, hearing loss can be irreversible. But when treated early, hearing damage often can be minimized.

Enlarged Adenoids

Adenoids are a patch of tissue that sits at the very back of the nasal passage. Like tonsils, adenoids help keep the body healthy by trapping harmful bacteria and viruses that you breathe in or swallow. Although you can see the tonsils at the back of the throat, adenoids aren’t directly visible.

Adenoids do important work as infection fighters for babies and young children. But they become less important once a child gets older and the body develops other ways to fight germs. In kids, adenoids usually begin to shrink after about 5 years of age and often practically disappear by the teen years.

Because adenoids trap germs that enter the body, adenoid tissue sometimes temporarily swells (becomes enlarged) as it tries to fight off an infection. The swelling sometimes gets better, but sometimes adenoids can get infected. If the adenoids get infected a lot, a doctor might recommend they be removed. Often, tonsils and adenoids are surgically removed at the same time.

Symptoms of Enlarged Adenoids

These symptoms are often associated with enlarged adenoids:

• difficulty breathing through the nose
• breathing through the mouth
• talking as if the nostrils are pinched
• noisy breathing
• snoring
• stopped breathing for a few seconds during sleep (obstructive sleep apnea)
• frequent “sinus” symptoms
• ongoing middle ear infections or middle ear fluid in a school-aged child

If enlarged adenoids are suspected, the doctor may ask about and then check your child’s ears, nose, and throat, and feel the neck along the jaw. To get a really close look, the doctor might order X-rays or look into the nasal passage with a tiny telescope. For a suspected infection, the doctor may prescribe different types of medicine like pills or liquids. Nasal steroids (a liquid that is sprayed into the nose) might also be prescribed to help reduce swelling in the adenoids.

When Is Surgery Necessary?

If enlarged or infected adenoids keep bothering your child and are not controlled by medication, the doctor may recommend surgically removing them with an adenoidectomy. This may be recommended if your child has one or more of the following:

• difficulty breathing
• obstructive sleep apnea
• repeated infections
• frequent sinus infections
• ear infections, middle ear fluid, and hearing loss requiring a second or third set of ear tubes

Having your child’s adenoids removed is especially important if repeated infections lead to sinus and ear infections. Badly swollen adenoids can interfere with the ability of the middle ear space to stay ventilated. This can sometimes lead to infections or middle ear fluid causing a temporary hearing loss. So kids whose infected adenoids cause frequent earaches and fluid buildup might also need an adenoidectomy at the time of their ear tube surgery.

And although adenoids can be taken out without the tonsils, if your child is having tonsil problems, they may be removed at the same time. A tonsillectomy with an adenoidectomy is a common pediatric operation.

What Happens During Surgery

Surgery, no matter how common or simple the procedure, can be frightening for both kids and parents. You can help prepare your child for surgery by talking about what to expect. During the adenoidectomy:

• Your child will receive general anesthesia. This means the surgery will be performed in an operating room so that an anesthesiologist can monitor your child.
• Your child will be asleep for about 20 minutes.
• The surgeon can get to the tonsils and/or the adenoids through your child’s open mouth — there’s no need to cut through skin.
• The surgeon removes the adenoids and then controls any bleeding.

Your child will wake up in the recovery area. In most cases, a child can go home the same day as the procedure. Some children may need to stay overnight for observation.

The typical recovery after an adenoidectomy often involves several days of moderate pain and discomfort, which may include sore throat, runny nose, and bad breath.

In less than a week after surgery, everything should return to normal and the problems caused by the adenoids should be gone. There are no stitches to worry about, and the adenoid area will heal naturally.

At just three months old, a blue-eyed boy named Sam was diagnosed with profound hearing loss. His parents, Chris and Teresa, found comfort and hope as they learned that a cochlear implant could one day help Sam to hear.

Cochlear implants are devices that can restore the ability to sense sound by taking it from the environment to the hearing nerve and directly to the brain, bypassing the damaged parts of the ear. The implant must be inserted surgically, and the surgery can be done no earlier than a child’s first birthday.

For Chris and Teresa, the cochlear implant offered hope that Sam would have a chance to hear them sing him a lullaby or read him a story, listen to the laughter of older brother Jack, and reach for all his dreams in life.

Through articles, photographs, and videos you can learn about this family’s journey to help Sam hear.

Chapter One: The Diagnosis
Chris and Teresa learn that their son Sam has been born with a profound hearing loss.

Chapter Two: Finding the Way
Chris and Teresa learn all that they can about Sam’s condition and the options for coping with his hearing loss.

Chapter Three: Surgery
The big day finally arrives — Sam undergoes cochlear implant surgery.

Chapter Four: Breaking the Silence
The implant is activated, marking a new beginning for Sam.

Chapter Five: New Beginnings
Almost 3 years old, Sam speaks and understands language spoken to him.