All About Ear Tubes- Episode 13 with Dr. Hadassah Kupfer
Welcome back to the All About Audiology podcast. I’m your host Dr. Lilach Saperstein and this is a very special episode; it’s going to be our first interview episode. I’d like to introduce more voices and bring in more professionals who are in the field or who are related to audiology in some way. And also to hear some of your stories like we did in the last All About You episode. It’s really important for me that your voice is heard and for you to know that what you’re going through is helpful for other people for what they’re going through and this way we can all connect and help each other.
So I have a few things to tell you before we jump into the interview. If you haven’t gotten it already or heard about the free checklist that I created for you guys, be sure to check it out. It’s a morning and evening routine checklist for caring for a hearing aid. It’s available for free! All you have to do is go to the podcast show notes or check on my Instagram @allaboutaudiology podcast or go to allaboutaudiology.com, or any way that you would reach me, you can get to this PDF file. It has information about caring for hearing aids and how to clean them. And also I made it that if you put it into a plastic sleeve or have it laminated, you can use a dry erase marker to check off what you’ve done. Hang it near the bed or have it in the bathroom, wherever you get ready in the morning with your hearing aids.
So right before we jump into the interview, let me tell you about Dr. Hadassah Kupfer, a private practice audiologist in the Mill Basin area in Brooklyn, New York. Dr. Kupfer and I went to school together; she was a few years ahead of me in school. I knew her when I was doing my undergraduate degree at Brooklyn College and we both attended the CUNY graduate center in New York for the audiology doctoral program. We had an excellent conversation that I’m going to play for you now all about ear infections, tubes, etc. The reason I reached out to my friend and colleague was because I know that she did a research capstone, kind of like a dissertation in the doctoral program, on this topic of childhood ear infections and fluid in the ears and has a lot of information and guidance for parents of young children dealing with this issue.
Dr. Kupfer has a patient-first approach and her passion for audiology and for her patients comes through in our interview. We’ll have Dr. Hadassa Kupfer’s information and links in the show notes and in the post at allaboutaudiolgy.com and if you want to visit her website, it’s www.doctorkupfer.com.
So before we start, I’m just going to make an apology. The sound quality is good but I wish it can be better. This is my first time doing an online interview like this and even though it can be better, and I’m going to improve as I make more online interviews, I really didn’t want to miss out on this amazing interview and be able to share all of the information that she shared with us and so without further ado we are going to jump right in, let’s welcome Dr. Kupfer.
Dr. Lilach Saperstein: “Dr. Kupfer, welcome to the all about audiology podcast. I’d like to start out by asking you to tell us about yourself and your journey to becoming an audiologist and a private practice owner.”
Dr. Hadassah Kupfer: “Thank you so much for having me and hello from Brooklyn, NY, your home town. I’m an audiologist now, my practice focuses on adults and older adults mostly but we also see children. A lot of my training involved seeing children so I have a fond place in my heart for this. I myself am a mother of three young children so I think a lot about these topics. As an audiologist my journey here came from my parents both being doctors so I always knew I wanted to do something in healthcare. And looking into the different specialties I came across audiology and it was just really fascinating between the aspects of communication and psychology and biology of the human ear and how it all came together. That’s what got me started down this path.
LS: “I think that we have in common this idea that there’s this magic in audiology. Like all the intersections, is it neuroscience or like talking about music and art, or how to pick up on the cues of someone’s speech, it all comes together. It’s really fun.”
HK: “Yeah, absolutely!”
LS: “I think also that’s one of the reasons that this podcast has such a wide range of listeners because audiology itself can cover so many different topics. So today’s topic is all about ear infections, fluid in the ears and this thing about ear tubes, they call them grommets. What is all of this about and I wanted to have you on here because I know you’ve done a lot of research and have experience with this. So you are our expert today.”
HK: “Thank you so much. So we’ll try to cover a little bit of this. Basically ear infections, as a mother/parent, we have all heard about this. We take the child to the doctor and they look inside the child’s ear and they will either say, it’s an ear infection, take medication or they will say they have fluid in the ear and not explain much more than that. Sometimes you’ll walk out of there with a referral to an ENT or an audiologist, but the parents aren’t really explained much in the cross-hairs. That was one of the reasons why I actually did my capstone, which is kind of like a dissertation on this topic because audiologists often end up interacting with parents in this situation and I discovered that parents were really poorly informed about what’s going on or what their options are. And I wanted to educate myself properly on the actual evidence and the science, just letting people know about what was actually happening to their child and what the proper thing to do is and what their options are. Now what’s tricky is that even in the literature, in the evidence, there isn’t so much agreement about some things which is why there’s this confusion. It’s not as straight forward like a broken leg, we treat it this way. It’s much more murky than that. That’s why it’s so important to have a good team between your pediatrician, your audiologist if any and the ENT .
So lets’ step back and talk about something called otitis media. This refers to inflammation in the middle ear. The middle ear is something that’s inside the body; it’s behind the ear drum. So when you stick your finger into your ear, your finger will only go so far and you’ll never touch your ear drum but this is an area that’s inside the body. So that’s one big misunderstanding that parents have. When they think about infections or fluid they think it has something to do with their kids going into the bathtub or the pool and that typically doesn’t have any relation to this. This is something inside the body and comes from something inside the body and should be treated as something inside the body. So there’s this general concept that this area behind the ear drum, the middle ear, can get inflamed. Sometimes it gets inflamed and an infection sets in. When it gets infected, antibiotics are usually what the doctor will recommend to clear up the infection. Sometimes though, that area just becomes inflamed and then there’s a fluid that builds up. Just like our nose can get congested and get a little phlegm, the ear can also get a bit congested in its own way and there can be fluid that builds up.
Just to back up a little bit, let me explain why is all this happening? Why is it only happening to kids? Why is it happening to my child, etc. Most of the scientists out there agree that the origin of the problem starts with the area called the Eustachian tube. This is a tube, some sort of muscle that connects the middle ear to the back of the throat and to the nose. In children this area isn’t as developed as it is for adults. Usually the Eustachian tube has a well defined opening and closing mechanism. When it’s closed, everything that’s in the ear stays in the ear. Everything that’s in the back of the throat will stay in the throat. Its job is actually to open at certain times to kind of equalize the pressure in the middle ear, to let out pressure and let out fluid into the back of the throat and to drain. Other times its job is to close and keep it closed and keep it protected. In children this is not so defined. It’s at a different angle and things can easily pass between the back of the throat and the ear. So what we often see is that when a child gets a cold, it escalates into some sort of ear infection or fluid in the ears because this tube at the back of the throat is enabling that cold to go from the nose and the throat into the ear and then the symptoms go on.
LS: “Would you say that’s a little bit similar to what happens with reflux?Something’s supposed to stay where it is but it backs up back and then it’s in the wrong place.”
HK: “Yes, absolutely. There have actually been studies looking at the content of middle ear fluids and they have seen contents of reflux in that so, yes it can back up into the middle ear space as well.”
LS: “That can’t be comfortable. Wow!”
HK: “No, not at all.
So a lot of the treatments that are involved for children have to do with dealing with the symptoms of the fact that for the time being during childhood, a child’s Eustachian tube is causing secretions to go back and forth. Now most children do grow out of this condition by around the age of seven. The goal of a lot of these treatments are just to get the child by this childhood period. Whether it’s discomfort or whether it’s affecting their behavior or speech, treatments are just to get them by in this critical period. But in general most kids grow out of it. In general, there’s a very favorable, natural outcome for fluid and ear infections just resolving on their own. The question is though do we have time to wait? And that’s where your doctor, your pediatrician together with your audiologist and your ENT help piece that all together. Based on you, based on how long you have been waiting already and based on your other medical history, does this look like something that will naturally clear up on its own, and if so there’s one way of handling it. Or does it look like this is really here to stay and waiting will not do you much good and in this case there’s no reason to wait any longer and let’s just take care of it right away.”
LS: “Wonderful. So that was a very good overview of what’s going on of why this happens. How common is it in kids?”
HK: “By the age of three, 80% of children have had one ear infection. So ear infections like we said are an actual infection and are very common especially between the ages of 6 months to 24 months. Between the ages of 3 and 7, it’s also very common. I don’t have the specific percentage off hand but I will say that this counts for a major cause of childhood hearing loss. Childhood hearing loss in this case is of course temporary because it’s just being caused by this blockage of fluid, which means that when sound goes into the ear, it’s getting reduced in volume as it travels through the fluid and the child is hearing everything as if they are under water and everything just sounds very muffled. So in this age group it’s pretty common. They say at any one point in a classroom during this age group, there’s about 15% of the class that has some sort of hearing loss related to fluid. So it is pretty common and the challenges are not symptomatic the way that an ear infection is. An ear infection child will have fever, will be complaining that their ear hurts and they will tug on their ear. With fluid in the ears, it’s not an infection that the doctor will just prescribe medication right away. They’ll kind of leave it very vague and say that there is fluid without really saying much more but even though there are no acute symptoms of it, there are other issues that are a lot more subtle that will come up.
So for example, a child may not be speaking so well or they may not be speaking at all because they are just hearing everything muffled and therefore they are not being exposed to sounds around them in order to learn how to say those sounds. Or they might be speaking unclear because the way that they hear sounds is distorted by the fluid, they aren’t hearing clearly and therefore they are imitating those sounds. Or they might have behavioral issues, they might be fussy or just not paying attention in school or when you call their name they aren’t really answering you. All those things are products of hearing loss that the fluid is causing. There are no medical symptoms that will be caught by a doctor. The thing is as parents, these are things that we can catch onto and bring to our doctor’s attention to be able to investigate further.”
LS: “Also it is fluctuating so you can be like this for one week and then when you go to see your doctor, it’s an off week and everything is fine. And then the week after that it’s back. It goes up and down like that.”
HK: “Yes, absolutely. We see that very often. One thing I would say is just to pay attention when your children have colds, stuffiness or heavy breathing. That’s usually when you know you will see these symptoms popping up more and that’s when you want to just keep an eye and you’ll notice it more then. See if it lingers or if it passes within a week or two.”
LS: “Okay, so if someone has this, what should they do? If their doctor is just kind of waving it off and saying, ‘Let’s see what happens’ but maybe they are more worried and they want to know how to fix this or is there a way to avoid it?”
HK: “Yeah, that’s a great question. Like I said the good news is that there is a very favorable natural history. Even if someone doesn’t do anything, most cases this will go away on its own. The question is just if the child is going to have delays in the meantime based on the fact that for a time being, even 3 or 6 months in a child’s life span is a significant amount of time for them not to be hearing well, not engaged, not being exposed to the language. You don’t want to set up your child like that. When a child is so young it’s a very critical period where they are exposed to everything around them. First thing’s first, if it is ear infections that your child has, a few infections here and there are very common, listen to the doctor and take antibiotics as needed. Typically that’s all that’s needed. If someone has more than three ear infections in the span of six months or if they have four or more infections over the course of a year, if their doctor hasn’t recommended to see an ENT, they should probably try to get an ENT consultation on their own just to check and be sure. Because when children are having a lot of infections and are on antibiotics repeatedly, this isn’t good for the child’s antibiotics resistance and it’s not good for their appetite. Children who take a lot of medicine like that, some can be very fussy and if there’s a way to treat this medically, it may be worth looking into.
The other thing is with the fluid. If the doctor sees the fluid in the ear, one time is fine. The next time you come back again, and that keeps going on, you may want to ask if it’s time to see an audiologist or an ENT. Most of the time, a lot of cases of fluid go away on its own like I said before. Usually it goes away within three months. If it lasts longer than that, and fluid is still there, chances are it needs more help, especially if the child is experiencing hearing loss in both of the ears. How do you know that there is hearing loss? You’ll go to the audiologist at that point to see if there’s fluid and how much hearing loss is the fluid creating. They’ll check if there is a little blockage, a lot of blockage, is the fluid very thin or is it very thick like glue. If it’s lasting more than 3 months and hearing loss is in both of the ears, this isn’t usually good for the child’s development, especially if the child is more at risk for language delays. If you already see that they are delayed or if there are other medical conditions putting them at risk for delay, there is no time to waste. Go see the ENT right away and they will probably recommend tubes.
When we say “tubes”, it’s not an actual tube coming out of the ear like I used to think it was before I went to school and learned better. It’s actually just a little cut that they make in the ear drum, no one can see it deep in the ear, and they put in like a tiny little straw in the eardrum so instead of the fluid building up behind the ear drum and causing pain or hearing loss etc., it can drain through that tube. So when the Eustachian tube is in the body and is immature and not opening and closing correctly, at least this tube we know is open, a little plastic thing, letting the fluid drain out through the ear canal, sidestepping the natural way the fluid would normally drain. This procedure is done and is extremely common among children. It’s one of the most common surgeries among children. Recovery time is very brief. It doesn’t require general anesthesia in most cases, which is something parents are afraid of most of the time. It’s extremely common, and very quick.”
LS: “It does or it does not (require anesthesia)?”
HK: “Yes it does. In cases where the child can’t tolerate general anesthesia I’ve heard of doctors doing it without. For example, children with down syndrome, sometimes it’s hard to put them under, because they aren’t sure of what’s going on. Or children with heart conditions, they basically will strap the child down and it’s a little scary in the moment but it’s such a quick procedure that they are able to do it while the child is awake and they will put local anesthesia on the ear drum.
When are the times that it’s possible theoretically to wait on a surgery like this? First of all if hearing loss is only affecting one ear, then the child has another good ear, I guess, to rely on. If there are no academic concerns or speech concerns and the parent is monitoring it very closely then sometimes we would wait up to six months. In those cases we’ll see if the child is growing out of it. The whole idea is that we’re just trying to allow the time to pass with the least consequences for the child knowing that the child will eventually grow out of it. The tubes by the way do naturally come out of the ear as the ear drum heals. In most cases the tube stays in for about six to nine months, then the ear drum heals and by then hopefully they have bought themselves some time and hopefully at that point they are a little bit older and the Eustachian tube is holding up better naturally. For this reason doctors will usually do this procedure closer to the winter which is when more children get colds and suffer from ear infections from fluid. Less likely to do it in the spring when children are a little bit better because the whole idea is that we need them to be in place for the winter time, the more difficult months.
As far as who is at a higher risk, the risk is definitely higher with younger children. We see it in family patterns, if there is a family history that the mother had history with fluid and tubes, we will suspect it more with the children that they won’t grow out of it and that they will need some assistance to take care of it. We see it with children who drink their bottles lying down. This isn’t good because it helps those secretions go to the back of the nose and the throat, all the bacteria that kind of just stays there, bringing it into the back of the ear causing it to brew in there. That’s not a good idea. That’s something that parents can often control and should be aware of. We see ear infections more often in smoking homes. So try to be aware of that. It’s just another benefit of not smoking. There’s also actually a protective affect of breastfeeding for children on ear infections and number of ear infections. By the way this holds true whether or not they drink the breast-milk from the breast or from a bottle. The actual breast-milk has this protective affect. There was actually a study on children who were born with cleft palate, it’s where part of their palate on the inside is missing and they can’t latch for normal breastfeeding. So they were fed through a special contraption with the breast milk and they still noticed the same protective affect against ear infections as the children who drank regularly from bottles or from the breast so I thought that was fascinating.”
LS: “Wow, that’s a long list.”
HK: “Yeah, exactly.”
LS: “What can people do if they want to avoid it in addition to everything you just mentioned? Let’s say they already have fluid and don’t want to have the surgery. Can they change their diet, are there exercises…What can they do?”
HK: “So yeah this is a hot topic because a lot of people do want to avoid surgery. So again it’s very important to keep the timeline in mind. If this is something that’s going on for more than 3-6 months chances are it’s not going away on its own and you will probably need medical or surgical intervention there. Things to keep in mind other than that are just the other things like risk factors. By the way another risk factor is having other children in the home because they’re around other colds and being in a playgroup also getting colds more often. That being said there is something called the auto inflation device. It’s called the ear popper. Basically it’s trying to strengthen the Eustachian tube which is the root cause of all of these childhood ear problems. It forces air up through the nose to the back through the throat and into the ear forcing the Eustachian tube to open up and strengthen and as it opens up it drains out some of the fluid. Depending on what the reason is that the tube is not able to open and close, sometimes this device can help. It’s natural and not too expensive, maybe $120 or $150. You could buy it on amazon. I know because I did buy it for my son.
I’ll tell you a story. Recently with my son who is 3 years old, I noticed he was speaking loudly, his speech was not clear, and he was having a lot of colds, just always very stuffy, Finally we did see the ENT to see what was going on. He had a mild/moderate hearing loss which means everything we hear normally he was hearing it as a whisper or barely hearing it. I was doing the ear popper with him hoping that we can avoid surgery if possible, not that I’m against it, but if we can avoid it, why not. It turned out when the ENT examined him, his root issue was with his adenoid. He had a very inflamed adenoid and he needed antibiotics for the adenoid. Doing this ear popper alone would have never helped with that because the adenoid is totally separate from the Eustachian tube and that is what needed to be treated.
So my take away from this is that even if you want to take the natural approach to things or you don’t want to do surgery, at least have the consultation just to see what’s going on and to see if you are on the right track because it’s easy to get misguided with these things. The way that the ENT knew this was the case was because he did a nasal endoscopy, where you take a little camera and snake it down the nose and he actually saw where the origin was, where it was coming from. That was pretty powerful to me.”
LS: “Yeah. And I think also some children have hearing loss that’s permanent, sensorineural hearing loss that might have developed in the first 3 years of life, and you say ‘oh it might just be the fluid or it might just be this.’ Meanwhile it has nothing to do with that.”
LS: “I agree.”
HK: “That is so true Dr. Saperstein. We have seen cases like that where they thought the child would grow out of it and they didn’t take it really seriously at first and didn’t have it formally evaluated and they missed a critical period. So hearing tests can definitely show which part of the ear the trouble is coming from. Whether it’s coming from the middle ear which usually is treatable or if it’s coming from the inner ear, the cochlea, that is something that is permanent and should be taken very seriously. The hearing test can distinguish between the two of those things.
The other thing is that often times the child will have a lot of ear wax in their ears. On its own there is nothing wrong with it however a lot of pediatricians unfortunately will look in the ear and see a lot of ear wax and don’t get a good view of what’s happening in the ear drum and beyond and they will just let the child out the door without really saying fluid, ear infection, etc. There is a lot of misdiagnosis going around. So if you have a hunch that something is going on, just recognize it but not distrusting your doctor. It is very easy to miss and there is a lot of misinformation and lack of agreement even among medical guidelines of what the correct thing is to do, so it’s worth asking, worth getting a second opinion and it’s always worth going to a specialist, after all that is the one and only thing that they look at so they are really good at getting to the root of the issue.”
LS: “Excellent. We have so much information. I’ve heard people ask about what if I take my child off of dairy and do a dairy free diet or what if I take them to the chiropractor that will give them an alignment, and all these other options. Have you heard of anyone using them and are they successful?”
HK: “Unfortunately, the medical evidence is reviewed by experts and people with medical degrees, reviewed by peers and not just something that can go in a magazine and just get looked over by the editor. Things that are rigorously reviewed for their true evidence and ethicacy and experiments, none of this supports the chiropractic remedies or the diets. Usually what’s happening is the natural course of the ear just playing out and whether or not you did that the ear would have healed on its own. I hate to say it because I know people get very invested in these things. Think about the fact that most children do clear up within 3 months or even 6 months and you are doing all these things and chances are it would just clear up on its own.
I’m not a fan of subjecting a child to a chiropractor. The diets, I mean again, if the reason why a child is congested is because they anyway had an allergy then yes this plays into the whole concept that inflammation and swelling of the Eustachian tube is not allowing things to drain properly and therefore it’s backing up. If you are generally concerned about that then have the allergy checked and this is something that the ENT will often do. ENT and allergists often work together for this reason. They will often do an allergy test and if the child truly has an allergy then they will often make a recommendation and chances are it will improve. Just to randomly take your child off of food groups is not advisable. I don’t think that should be done without specific physician guidance.”
LS: “I agree. Yeah, I think that what you’re saying about really monitoring and being on top of the progression of it is really smart. We would see patients that come in initially and come back only eight months later. What happened in the last eight months? No idea. We haven’t had another hearing test, we haven’t had another tympanogram…
LS: “and the status of the ear drum moves around and we don’t know. So even if you are taking this wait and see approach which can resolve on its own, at least come back to your follow up in six weeks.”
HK: “Yes come back after six weeks. Exactly. That is usually the timeline that we recommend. Anytime we see something unusual about this part of the ear, something that could be coming and going, getting better or getting worse, we usually recommend coming back within four to six weeks just to get an idea of where it’s heading. Maybe it’s getting better. Maybe it’s getting worse. Either way we want to know so we can guide you further. It doesn’t automatically mean that your child needs surgery and in fact by doing these things you can actually probably prevent them from getting surgery because as we see it getting better we know what to do and as we see it getting worse we know what to do. So monitoring is very key here.”
LS: “Yeah. And you mentioned the ramifications for speech development but it can also have ramifications medically where if there is untreated ear infections over and over again, that can affect the middle ear, making something temporary into something more permanent.”
HK: “Yeah, it’s true.”
LS: “It’s really unfortunate because at that point it’s kind of preventable.”
HK: “For sure, definitely.”
LS: “So to rap up I would like to ask you where you have all of our parents listening here today; What is one thing you would tell them about their child, whether or not they have hearing loss or whether or not they have gone through the ear infections, the recommended tubes or not? But everyone who is listening to this has children or has children in their life, what would you say to them?”
HK: “Yeah, yeah sure. Hearing is one of those things that can be a silent disability and children don’t often speak up and tell you, ‘Mommy I’m not hearing so well’. So I would say as parents, it’s our job to keep an eye on our kids and look out for those signs that something is not going right so that you could step in earlier on when it’s usually preventable if it’s something temporary or to take action before longer term consequences come in. The ears, people don’t realize play such a huge role on child development, their learning, their ability to read, their ability to make inferences, their ability for their personality to develop because when we hear we are really interacting with the world around us and it’s keeping the brain stimulated.
By the way this is something that can be said for children and it’s something that can be said for adults often. Sometimes it’s not the person themselves who is experiencing that and can speak up for themselves and say what’s happening because they don’t know what’s missing. These changes happen slowly and they don’t even realize it’s the people around them that will notice that something is not right. Either asking to repeat something or speak louder in order for them to hear. Or a child can be acting out in class. They’re not really catching what I’m telling them, I’m giving them a few instructions and they are only catching the first one. They are more tired than usual at the end of the day possibly because they are straining all day to listen. They are acting out because it’s too difficult to strain and listen.”
LS: “And yeah socially, missing jokes and not really knowing what’s going on.”
HK: “Yeah absolutely. And of course the speech is super important and that’s usually the reason why parents get drawn into this. That’s the thing they notice that their child is speech delayed and then they don’t know what’s going on. And the thing is that if we can, we would prevent your child from being delayed or limit their delays by recognizing the issue right away, getting the proper treatment, getting their therapy started. Obviously to treat someone who is younger treating somebody at age two or three than someone at the age of five or six. That is a major difference in a young child’s lifespan and the outcomes are very different. So definitely when you notice something it can’t hurt to mention it to your doctor and just to see.
It doesn’t mean that they automatically are going to get surgery. Just to see where your child falls and realizing that this is a very common, normal thing. Like I said my son had it too. If anyone should be able to prevent these things I would have thought it would have been me, but my son got it anyway. It happens and it’s not your fault. It’s usually not something you can prevent from happening, even with those mild things you can sway it back and forth a little bit but usually it’s out of your control. It happens and if you take care of it properly your child will be just fine.”
LS: “Thank you so much. I think we all feel a little bit better…
HK: [laughs] “I hope so.”
LS: “and a lot more informed. Thanks for coming on the show.”
So there you have our first all about audiology interview with my friend and colleague, Dr. Hadassa Kupfer. I hope that you were able to gain a lot of insight about fluid in the ears, the tube surgery and the difference between ear infection and fluid accumulation. I really appreciate her insightful and concise way of explaining things and so now I’m going to ask you what did you think of our episode? What did you think of the interview format? And if you can share with us your experience with tube surgery, with ear infections, with fluid in the ears, I’d really like to hear about you and get more of your voices on the show. You can record a quick voice memo and email it to me through the contact form on my website or through Instagram or through Facebook all about audiology. Also don’t forget if you’d like to download that free PDF checklist you can get that on my website as well.
On the next episode I have another exciting interview lined up with an amazing speech language pathologist and we are going to be talking about the deaf community, american sign language and language deprivation that unfortunately is all too common in the deaf and hard of hearing population. It’s a topic that I’m very passionate about and I’m really looking forward to that interview. I can’t wait to hear your comments and your voice memos and I can’t tell you enough how much I appreciate you listening and supporting the podcast.
I’m Dr. Lilach Saperstein and this is the All About Audiology podcast.