Sleep Apnea May Be a Cause of Recurrent Middle Ear Infections in Children
Does Your Child Have Frequent Middle Ear Infections?
Obstructive sleep apnea may promote recurrent middle ear infections in children. Studies indicate that the prevalence of recurrent middle ear infections is greater among children who have obstructive sleep apnea than among children who do not.
What Is a Middle Ear Infection?
A middle ear infection occurs when microorganisms enter the middle ear and cause inflammation, resulting in swelling of tissues and an excessive production of fluid in the middle ear. The pressure from excess fluid in the middle ear can cause pain; a sense of fullness in the ear; popping, crackling, or clicking sounds on swallowing; hearing an echo when speaking; or experiencing a sense of top heaviness. In severe cases, it is possible for the excess fluid to rupture and damage the eardrum. Frequent middle ear infections can cause thickening and scarring of the eardrum (thereby restricting movement of the eardrum) or can contribute to the development of a cholesteatoma (a fatty cyst containing cholesterol, white blood cells, and other material) that gradually destroys middle ear structures such as the eardrum. These effects can permanently impair a child's hearing. Middle ear infections are considered recurrent if a child has three episodes within a six month period or if a child has four or more episodes within one year.
Scientists believe that the primary cause of recurrent middle ear infections is a narrow or blocked Eustachian tube, which is an air-filled tubular structure extending from the middle ear to the nasopharynx (i.e., the upper throat area). When a child has an upper respiratory tract infection, infectious microorganisms (e.g., bacteria or viruses) travel from the nasopharynx through the Eustachian tube into the middle ear, inducing inflammation along the way. The inflamed tissue swells and produces excess fluid. These inflammatory reactions narrow the Eustachian tube and prevent fluid from easily draining out of the middle ear. The microorganisms grow in the stagnant fluid, creating further inflammation and fluid build-up in the middle ear.
To relieve excessive fluid pressure in the middle ear, a physician may perform a myringotomy (pronounced "MEER-ing-GOT-oh-mee")---a procedure that creates a small hole in the eardrum. The infected fluide is withdrawn through the hole. After a myringotomy, the eardrum normally takes about two weeks to heal. In some children, however, two weeks is insufficient to allow an infection to fully resolve. Therefore, a physician may place a small cylindrical tube (i.e., tympanostomy tube), commonly called an "ear tube," through the eardrum to maintain the hole for weeks, months, or years. Recurrent middle ear infections often cease while a tympanostomy tube is in place.
What Is Obstructive Sleep Apnea?
Children who have recurrent middle ear infections often have enlarged tonsils and adenoids. Enlarged tonsils and adenoids have also been frequently noted in children who have obstructive sleep apnea (OSA). Enlarged tonsils and adenoids are apparently a primary cause of OSA in children since removing these tissues often eliminates or greatly reduces OSA symptoms.
In a child with OSA, the upper airway muscles relax excessively during sleep, allowing upper airway tissues (e.g., tonsils and adenoids) to collapse into the airway during sleep. This blocks airflow, resulting in the cessation of breathing (i.e., apnea) and causing the blood oxygen level to fall. When the blood oxygen level falls to a certain point, the child arouses for a few seconds to take some deep breaths, which restores the blood oxygen level. Once the oxygen level is restored the child resumes sleep. However, the upper airway muscles again relax, setting the stage for another episode of apnea.
What Is the Connection between Sleep Apnea and MIddle Ear Infections?
Some research indicates that treating OSA may improve or resolve recurrent middle ear infections in children. For example, in a study at the University of Southern California (Los Angeles, CA), researchers found that recurrent middle ear infections resolved or were greatly reduced in nearly ninety percent of the children who had been treated for OSA by tonsillectomy (i.e., removal of tonsils), adenoidectomy (i.e., removal of adenoids), or adenotonsillectomy (i.e., removal of tonsils and adenoids).1
However, it often takes several years before a physician or parents will have a child with recurrent middle ear infections evaluated for OSA. The delay typically occurs because (1) the physician or parents believe that the child will "outgrow" having recurrent middle ear infections; (2) the physician believes the recurrent middle ear infections result from a sinus infection or allergy; (3) the child does not meet the criteria to undergo a tonsillectomy or adenoidectomy; or (4) the physician or parents do not recognize or disregard a child's OSA symptoms (e.g., snoring).
Parents of a child who has recurrent ear infections should consider having the child assessed for OSA. If your child does have OSA, then treating it may lower or eliminate recurrent middle ear infections. Some common symptoms of OSA in children are listed below.
1. The study was performed in 2000 by Warren Richards and Ronald Ferdman at the University of Southern Caiifornia in Los Angeles, CA. They reported their results in the medical journal Clinical Pediatrics. The original article can be found at:
Richards W, Ferdman RM. Prolonged morbidity due to delays in the diagnosis and treatment of obstructive sleep apnea in children. Clinical Pediatrics (Phila). Feb 2000;39(2):103-108.
What Are the Signs that My Child May Have Obstructive Sleep Apnea?
LOUD SNORING OR GASPING
Snoring and gasping for air occurs during the few seconds a child arouses to take some deep breaths after an apnea episode.
MOUTH BREATHING DURING SLEEP AND/OR DURING WAKE
Mouth opening as a child struggles to breathe during an apnea episode is the body's attempt to open the airway to draw in as much air in as possible. For the same reason, a child with OSA who also has enlarged tonsils or adenoids may continue to breathe through the mouth when awake during the daytime.
EXCESSIVE DAYTIME SLEEPINESS
Apnea-related arousals from sleep prevent a child from having solid sleep at night. As a result of poor sleep, a child with OSA may struggle with daytime sleepiness (e.g., falling asleep in school).
POOR SCHOOL PERFORMANCE, BEHAVIORAL PROBLEMS, HYPERACTIVITY, IRRITABILITY
Sleepiness in children often manifests as inattention, hyperactivity, behavioral problems, or irritability. These effects can negatively impact a child's school performance.
For reasons scientists still can not explain, many children with OSA are also bedwetters (i.e., enuresis [pronounced "EN-you-REE-sis"]).
YOU WITNESS YOUR CHILD NOT BREATHING OR STRUGGLING TO BREATHE WHILE SLEEPING
A child having an apnea episode has little to no airflow but continues making respiratory movements; the child is silent during the apnea. Then suddenly the child begins gasping or snoring loudly while taking deep breaths. Not all children with apnea snore. However, your child may have OSA if you note your child struggling to breathe while sleeping or if your child has alternating periods of snoring and quiet.
Some children with OSA report nightmares that have themes of being choked or suffocated.
Did you know ...?
Obstructive sleep apnea in children has been linked to attention deficit/hyperactivity disorder (ADHD).
Some studies suggest that obstructive sleep apnea may run in families.
Attempting to have a child "overtired" before bedtime so that the child will sleep all night may defeat a parent's goal of having that child sleep well. Once a parent puts an overly tired child to bed, the child may have more difficulty settling down and going to sleep.
Scientists believe that obstructive sleep apnea affects up to 13% of children three to six years old and 2% to 3% of middle school children.
Some research indicates that obstructive sleep apnea may be two to four times more likely in children who were born prematurely than in children born at term.