ENT Guides

Ear infections (otitis media)

Acute otitis media (AOM) is one of the most common reasons children visit a pediatrician. By age 3, roughly five out of six children will have had at least one ear infection. They occur when fluid behind the eardrum becomes infected — usually after a cold, when the eustachian tube (which drains the middle ear) becomes congested.

Common symptoms:

• Ear pain (older children describe it; infants tug or pull at the ear, cry inconsolably, or sleep poorly)
• Fever, often 101–104°F
• Fussiness or irritability disproportionate to the cold
• Difficulty sleeping or lying flat
• Fluid draining from the ear (usually means the eardrum has perforated — most heal on their own)
• Trouble hearing or responding to sounds
• Loss of appetite

Watch-and-wait vs. antibiotics:

• Observation (48–72 hours) may be appropriate for children ≥2 years with mild symptoms and unilateral infection. About two-thirds of cases improve without antibiotics.
• Antibiotics are recommended for children under 2 years (unilateral or bilateral), all children under 6 months, severe symptoms (fever ≥102.2°F, moderate-to-severe ear pain, or symptoms ≥48 hours), and any child with drainage from the ear.
• First-line antibiotic: amoxicillin (45 mg/kg/dose twice daily). Use augmentin if the child has been on amoxicillin in the past 30 days, has concurrent conjunctivitis, or has not improved on amoxicillin within 48–72 hours.
• For children with true penicillin allergy: cefdinir, cefpodoxime, or azithromycin are alternatives.

Pain management:

• Acetaminophen or ibuprofen for pain and fever (see our weight-based OTC dosage calculator).
• Warm compress on the affected ear.
• Keep the child upright when possible — gravity helps drain the eustachian tube.
• Topical anesthetic ear drops are no longer routinely recommended for AOM.

When to see a specialist (ENT):

• 3+ ear infections in 6 months, or 4+ in 12 months (consider ear tubes)
• Persistent middle-ear fluid for 3+ months
• Hearing loss associated with ear infections
• Infections not responding to first- and second-line antibiotics
• Speech delay associated with recurrent infections

Tonsillitis & strep throat

The tonsils are part of the immune system and help filter germs entering through the mouth and nose. Tonsillitis is inflammation of the tonsils, which can be caused by viruses (most common), bacteria (like Group A Streptococcus, the cause of strep throat), or — rarely — by fungal or parasitic infections.

Symptoms of tonsillitis:

• Sore throat, especially with swallowing
• Red, swollen tonsils, sometimes with white patches or pus
• Fever
• Swollen lymph nodes in the neck
• Bad breath
• Headache or stomachache (more common with strep)
• Hoarse or muffled voice

When to test for strep:

• Sudden onset sore throat without cough or runny nose
• Fever combined with sore throat
• Tiny red spots on the roof of the mouth (palatal petechiae)
• Sandpaper-like rash (scarlet fever)
• Known exposure to someone with confirmed strep
• A rapid strep test or throat culture is required for diagnosis — strep cannot be reliably diagnosed by symptoms alone, and viral infections cause similar findings.

Treatment:

• Viral tonsillitis: rest, fluids, pain relievers (acetaminophen/ibuprofen), warm or cold liquids, and throat lozenges for older children. Antibiotics do not help.
• Strep and other bacterial tonsillitis: antibiotics (typically amoxicillin or penicillin for 10 days, or one IM dose of penicillin G benzathine). Complete the full course even if symptoms improve.
• For penicillin allergy: cephalexin (if no severe reaction), clindamycin, or azithromycin.

When tonsillectomy is considered:

• Recurrent severe infections — a common framework is 7+ in 1 year, 5+/year for 2 years, or 3+/year for 3 years (the "Paradise criteria"), but quality-of-life impact, school absences, antibiotic burden, and severity of episodes are also weighed.
• Obstructive sleep apnea caused by enlarged tonsils — the most common indication today.
• Peritonsillar abscess (more than one episode).
• Difficulty breathing or swallowing due to tonsil size.
• Tonsils affecting voice quality (muffled or hyponasal speech) or causing chronic bad breath that doesn't respond to dental hygiene.

Croup

Croup is a common illness caused by ordinary respiratory viruses that inflame and swell the upper airway — especially around the voice box (larynx) and windpipe (trachea). It most often affects children between 6 months and 6 years old, although it is not uncommon for older children to get it as well. While most respiratory illnesses last several days to a couple of weeks, croup symptoms often resolve faster.

Typical symptoms:

• A barking cough that sounds like a seal
• A hoarse voice
• Stridor — a harsh, high-pitched sound when breathing in, breathing out, or both
• Runny nose and mild fever often preceding the cough
• Symptoms that usually start at night

What causes it? Most cases are caused by viruses, particularly:

• Parainfluenza virus (most common)
• Respiratory syncytial virus (RSV)
• Coronaviruses, including COVID-19
• Influenza and other respiratory viruses

Severity:

Mild croup

• Barking cough
• No stridor at rest, but may have some when active or breathing harder
• Child is comfortable between coughing spells

Moderate croup

• Stridor at rest
• Increased work of breathing
• Chest retractions above the sternum or under the ribs

Severe croup

• Significant breathing difficulty
• Marked retractions
• Agitation or lethargy
• Bluish lips or skin (cyanosis)

Treatment — mild cases:

• Keep the child calm — crying, talking, yelling, and activity can worsen cough, stridor, and airway swelling.
• Encourage fluids.
• Fever reducers (acetaminophen or ibuprofen) if needed — see our OTC dosage calculator.
• Try cold air (step outside, or a brief look in the freezer) and humid air (humidifier, nebulizer, or sit in a steamy bathroom with the shower running).

Treatment — moderate to severe cases:

• A single dose of the steroid dexamethasone is commonly used and is highly effective. It is usually given in urgent care or the emergency department, and is sometimes prescribed to take at home. Doses can be repeated when needed.
• In emergency settings, nebulized epinephrine may be given for significant stridor or respiratory distress. It works quickly but wears off in 1–2 hours, so children who receive it usually need to be observed.

When to seek urgent medical care: a child should be evaluated promptly if they have any of the following:

• Stridor while resting
• Difficulty breathing
• Retractions (skin pulling between the ribs, under the ribs, or at the lower neck)
• Drooling or difficulty swallowing
• Blue or grey lips
• Significant lethargy or decreased responsiveness

What is the usual course? Croup is generally self-limited:

• Symptoms often peak on nights 2–3.
• Most children improve within 3–5 days.
• The barking cough may linger for up to several weeks.

ENT emergencies

Foreign body in the nose:

• Most common in children ages 2–5
• Signs: one-sided nasal discharge (often foul-smelling), difficulty breathing through one nostril, recurrent nosebleeds from one side
• What to do: have the child blow their nose gently. Try the "parent's kiss" — cover the unaffected nostril, place your mouth over the child's mouth, and give a short puff of air to push the object out.
• What NOT to do: do not use tweezers, cotton swabs, or other tools — you may push the object deeper or damage the nasal lining. Do not repeatedly probe the nose.
• Seek medical care if the object can't be easily removed, or if you suspect a button battery or magnet (these are emergencies).

Foreign body in the ear:

• Signs: ear pain, decreased hearing, drainage from the ear, sensation of something moving (insects)
• What to do: if you can clearly see the object and it's reachable, gently try to remove it. For insects, tilt the head and pour warm (not hot) mineral oil to float the insect out before going in.
• What NOT to do: do not insert cotton swabs, bobby pins, or other objects. Do not use water if you suspect a button battery, the eardrum may be perforated, or the child has ear tubes.
• Seek immediate care for any suspected button battery in the ear — they can cause chemical burns within hours.

Peritonsillar abscess (quinsy):

• Severe sore throat, usually worse on one side
• Fever, difficulty swallowing, drooling
• Muffled "hot potato" voice
• Trismus — difficulty opening the mouth
• Visible bulge of one tonsil with the uvula deviated to the opposite side
• Seek emergency care immediately — usually requires drainage in the emergency department or operating room, plus IV antibiotics.

Sudden hearing loss:

• Rapid loss of hearing, usually in one ear, over 72 hours or less
• May be accompanied by dizziness, ear fullness, or tinnitus (ringing)
• Seek ENT evaluation within 24–48 hours — early treatment with oral or intratympanic steroids substantially improves the chance of recovery.

Epiglottitis:

• Sudden high fever, severe sore throat, drooling, and stridor (high-pitched noisy breathing)
• Child often sits forward in a "tripod" position to keep the airway open
• Call 911. Do not attempt to look in the throat. Now rare thanks to Hib vaccination, but still a true airway emergency.

Ear tubes (tympanostomy tubes)

What are ear tubes?

• Tiny cylinders (about 1 mm wide) placed through the eardrum to ventilate the middle ear and allow trapped fluid to drain.
• One of the most common childhood surgeries — about 600,000 are placed each year in the United States.
• The procedure typically takes 10–15 minutes under brief general anesthesia. Most children go home within an hour of the procedure.

When are ear tubes recommended?

• 3+ acute ear infections in 6 months, or 4+ in 12 months
• Persistent middle-ear fluid for 3+ months with hearing loss
• Recurrent infections not responding to antibiotics
• Eustachian tube dysfunction causing persistent negative pressure or retraction of the eardrum
• Speech delay or learning difficulty associated with chronic middle-ear fluid

What to expect on the day of surgery:

• Outpatient procedure — children go home the same day, typically within an hour or two of arrival.
• Most children return to normal activity within 24 hours.
• Hearing improvement is often noticed immediately, sometimes the same day.
• Antibiotic ear drops may be prescribed for several days after surgery.
• Mild irritability or imbalance is common for 24 hours after anesthesia.

Post-op care:

• Most children do not need to keep ears dry during routine bathing, showering, or swimming in clean pools less than 3 feet deep — but follow your surgeon's specific instructions, which may differ for swimming in lakes, oceans, or pools deeper than 3 feet, or if your child has frequent drainage.
• If drainage occurs from the ear, use prescribed ear drops. This is common and usually not an emergency — the tube is doing its job by allowing fluid to escape.
• Follow up with ENT as scheduled (typically every 6–12 months) to confirm the tubes are open and check hearing.
• Tubes typically fall out on their own in 6–18 months. The eardrum heals after the tube extrudes; rarely, a small persistent perforation requires later patching.