Kids E.N.T. Health
Children and Facial Trauma
Foreign Bodies in the Airway
Foreign Bodies - Ear/Nose
LPR in Children
Pediatric GERD
Pediatric Obesity and ENT
Glossary for Good Ear Health
How Allergies Affect Your Child's Health
Day Care and E.N.T. Problems
Tonsils and Tonsillectomy for a kids
point of view
Laryngopharyngeal Reflux and Children
Pediatric Obstructive Sleep Apnea
Pediatric Sinusitis
T & A PostOp
Tonsillectomy Procedures
Tonsillitis
Why Do Children Have Earaches?
Children and Facial Trauma
What is facial trauma?
The term facial trauma means any injury to the
face or upper jaw bone. Facial traumas include injuries to the
skin covering, underlying skeleton, neck, nasal (sinuses), orbital
socket, or oral lining, as well as the teeth and dental structures.
Sometimes these types of injuries are called maxillofacial injury.
Facial trauma is often recognized by lacerations (breaks in
the skin); bruising around the eyes, widening of the distance
between the eyes (which may indicate injury to the bones between
the eye sockets); movement of the upper jaw when the head is
stabilized (which may indicate a fracture in this area); and
abnormal sensations on the cheek.
In the U.S., about three million people are
treated in emergency departments for facial trauma injuries
each year. Of the pediatric patients, five percent have suffered
facial fractures. In children less than three years old, the
primary cause of these fractures is falls. In children more
than five years old the primary cause for facial trauma is motor
vehicle accidents.
Our fast paced world of ultra sports and increasing
violence puts children at risk for facial injury. But, children’s
facial injuries require special attention. A child’s future
growth plays a big role in treatment for facial trauma. So,
one of the most important issues as a care giver is to follow
a physician’s treatment plan as closely as you can until your
child is fully recovered.
Why is facial trauma different in children
than adults?
Facial trauma can range between minor injury
to disfigurement that lasts a lifetime. The face is critical
in communicating with others, so it is important to get the
best treatment possible. Pediatric facial trauma differs from
adult injury because the face is not fully formed and future
growth will be a factor in how the child heals and recovers.
Certain types of trauma may cause a delay in the growth or further
complicate recovery. Difficult cases require physicians with
great skill to make a repair that will grow with your child.
Types of facial trauma
New technology, such as CT scans, have improved
physicians ability to evaluate and manage facial trauma. In
some cases, immediate surgery is needed to realign fractures
before they heal incorrectly. Other injuries will have better
outcomes if repairs are done after cuts and swelling have improved.
A new study has shown that even when injury does not require
surgery, it is important to a child’s health and welfare to
continue to follow up with a physicians care.
Soft tissue injuries
Injuries such as cuts (lacerations) may occur
on the soft tissue of the face. In combination with suturing
the wound, the provider should take care to inspect and treat
any injures to the facial nerves, glands, or ducts.
Bone injuries
When a fracture of the bones in the face occurs,
the treatment process is similar to that of a fracture in other
parts of the body. Factors that affect how the fracture should
be dealt with are the location of the fracture, the severity
of the fracture, and the age and general health of the patient.
It is important during treatment of facial fractures to be careful
that the patient's facial appearance is minimally affected.
Injuries to the teeth and surrounding
dental structures style
Isolated injuries to teeth are quite common
and may require the expertise of various dental specialists.
Because of the specific needs of the dental structures, certain
actions and precautions should be taken if a child has received
an injury to his or her teeth or surrounding dental structures.
If a tooth is "knocked out", it should
be placed in salt water or milk. The sooner the tooth is re-inserted
into the dental socket, the better chance it will survive. Therefore,
the patient should see a dentist or oral surgeon as soon as
possible.
Never attempt to "wipe the tooth off" since remnants
of the ligament which hold the tooth in the jaw are attached
and are vital to the success of replanting the tooth.
References:
Stewart MG, Chen AY. Factors predictive of poor
compliance with follow-up after Facial trauma: A prospective
study. Otolaryn Head and Neck Surg 1997: 117:72-75
Kim MK, Buchman R, Szeremeta. Penetratin neck
trauma in children: an urban hospital’s experience. Otolaryn
Head and Neck Surg 2000: 123: 439-43
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Foreign Bodies in the Airway
Children put many things in their mouths (including food) that
can cause trouble. When you know that a child has ingested a
foreign object, consider this a medical emergency and seek immediate
attention. If your child is choking – cannot breathe, is gasping,
cannot talk, or is turning blue – call 911 or an ambulance immediately.
Parents should be alert for these commonly
ingested items:
Pop corn seeds
Small jewlery
Pebbles
Nuts
Hot dogs
Toy parts
Grapes
Buttons
Seeds
Marbles
Small button-shaped
batteries
Coins (especially
newer pennies)
Aside from choking, trouble may happen if the object becomes
lodged in the "airway" tube (trachea) instead of the
"eating" tube (esophagus), which may make the child’s
distress harder to see. Children may experience symptoms differently;
some children can even have vague symptoms that do not immediately
suggest ingestion. While most swallowed foreign objects pass
harmlessly through the esophagus, the stomach, and intestines,
a foreign body may also cause harm if it has associated toxicity
or becomes lodged in the gastrointestinal tract.
Parents should suspect their child might have
swallowed a foreign object if breathing or swallowing difficulties
persist longer than two weeks despite medical treatment. For
example, continuing asthma or upper respiratory treatment without
seeing improvement.
If you know that your child has swallowed
a foreign object look for these symptoms of choking first, and
then look next for signs of obstruction:
Not breathing, unconscious;
Choking or gagging
when the object is first inhaled;
Inability to
speak;
Blueness around
the lips.
Signs of airway obstruction:
Stridor (a high pitched sound usually heard when the child breathes);
Cough that gets
worse;
Inability to
speak;
Pain in the
throat area or chest;
Hoarse voice;
Blueness around
the lips;
Not breathing,
unconscious;
Unexplained
fever.
Signs of gastrointestinal (GI) blockage:
If you are fairly sure that a foreign body has
been swallowed and your child is not experiencing an airway
obstruction, continue to watch for the following:
Vomiting;
Blood in the
stool;
Unexplained
fever
Abdominal distention/pain
Toxicity is another consequence of ingestion
that may cause problems. Coins (for instance newer copper-coated
zinc pennies) and batteries may cause system-wide reactions
because some metals are extremely toxic and may cause inflammation.
Treatment for foreign bodies in the
airway
Treatment of the problem varies with the degree
of airway blockage. If the object is completely blocking the
airway, the child will be unable to breath or talk and his/her
lips will become blue. This is
a medical emergency and you should seek emergency medical care.
Sometimes, surgery is necessary to remove the
object. Children that are still talking and breathing but show
other symptoms also need to be evaluated by a physician immediately.
Follow these
steps if your child is unconscious:
Call 911 or an ambulance.
Lay the child
on the floor on his/her back.
Place one hand
on the child's abdomen and cover it with your other hand, then
press on the abdomen four times. (This should release the object
that is obstructing the airway.)
Repeat this life saving procedure until the ambulance arrives.
Make sure you tell the medical team immediately what caused
the child to choke or what obstructs the breathing so that proper
treatment can be administered.
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Foreign Bodies - Ear/Nose
It is a well-known fact among parents that children sometimes
put things such as dried beans, small toys, or beads in their
ears, nose, or mouth. Such inappropriate objects may cause harm
if immediate medical attention is not provided. Often, caregivers
are unaware that a child has taken in such an object and this
makes getting the right treatment more difficult.
The symptoms caused by these objects range from
discomfort and pain, to decreased hearing, changes or noises
from breathing, difficulty swallowing or choking and sometimes
drainage especially from objects in the ear or nose. If there
is difficulty breathing, the object could cause serious problems
and immediate action should be taken.
Doctors call these objects foreign bodies. A
recent medical studyhas shown that with some people it is hard
to see certain types of foreign bodies with the naked eye. It
recommends that “these cases should be referred directly to
otolaryngologists for otomicroscopic removal or removal with
special light scopes.” In other words, an ear, nose, and throat
specialist physician should remove such objects to avoid further
harm.
Facts about foreign bodies in the ear,
nose, and airway
Children under age five are the most likely to ingest foreign
bodies in the ear, nose, or airway. But teenagers and irresponsible
adults have been known to engage in such activities as well,
though these are often accidental happenings.
Foreign bodies
in the ear canal are found most often in children between the
ages of two and four.
Airway obstruction
from foreign bodies may cause suffocation and death. This accounts
for nearly nine percent of accidental deaths in the home, especially
among children under the age of five years.
About five percent
of all children swallow coins, and a coin-swallower’s average
age is three.
Foreign bodies in the ear
Children usually place things in their ear canal
because they are bored, curious, or copying other children.
Sometimes one child may put an object in another child's ear
during play. It is important for parents to be aware that children
may cause themselves or other children great harm by placing
objects in the ear. There may also be a link between chronic
outer ear infections and children who tend to place things in
their ears. Insects may also fly into the ear canal, causing
potential harm. Any child with a chronically draining ear should
be evaluated for a foreign body.
Some of the items that are commonly found in
the ear (usually the canal) of young children include the following:
food, insects, toys, buttons, pieces of crayon, and small button-shaped
batteries. Teenagers sometimes have objects imbedded in the
ear lobe due to an infection from a pierced ear or a poorly
healed piecing.
Treatment
The treatment for foreign bodies in the ear is prompt removal
of the object by your child's physician. The following are some
of the techniques that may be used by your child's physician
to remove the object from the ear canal:
instruments may be inserted in the ear;
magnets are
sometimes used if the object is metal;
cleaning the
ear canal with water;
filling the
ear with mineral oil to suffocate an insect; and
use of a suction
machine to help pull the object out.
After removal of the object, your child's physician will re-examine
the ear to determine if there has been any injury to the ear
canal. Antibiotic drops for the ear may be prescribed to treat
any possible infections.
Foreign bodies in the nose
Objects that are put into the child's nose are
usually, but not always, soft things like tissue, clay, and
pieces of toys or erasers. Harder objects, much like those commonly
put in the ear, may also be put into the nose. From time to
time, a foreign body may enter the nose while the child is trying
to smell the object.
Symptoms
The most common symptom of a foreign body in the nose is nasal
drainage. The drainage often has a bad odor. Parents should
suspect a foreign body and not a “cold” when drainage is from
only one nostril. In some cases, the child may alsohave a bloody
nose.
Treatment
Foreign objects in your child’s nose should be removed promptly.
Sedating the child is sometimes necessary in order to remove
the object successfully. This may necessitate a trip to the
hospital, depending on the extent of the problem and the cooperation
of the child. Some of the techniques that your child's physician
may use to remove the object from the nose include suction machines
with tubes attached or instruments such as small tweezers called
forceps.
After removal of the object, your child's physician
may re-examine the nose with a special fiberoptic light looking
for another foreign body or may prescribe nose drops or antibiotic
ointments to treat any possible infections.
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LPR in Children
What is laryngopharyngeal reflux (LPR)?
Food or liquids that are swallowed travel through
the esophagus and into the stomach where acids help digestion.
Each end of the esophagus has a sphincter, a ring of muscle,
that helps keep the acidic contents of the stomach in the stomach
or out of the throat. When these rings of muscle do not work
properly, you may get heartburn or gastroesophageal reflux (GER).
Chronic GER is often diagnosed as gastroesophageal reflux disease
or GERD.
Sometimes, acidic stomach contents will reflux
all the way up to the esophagus, past the ring of muscle at
the top (upper esophageal sphincter or UES), and into the throat.
When this happens, acidic material contacts the sensitive tissue
at back of the throat and even the back of the nasal airway.
This is known as laryngopharyngeal reflux or LPR.
During the first year, infants frequently spit
up. This is essentially LPR because the stomach contents are
refluxing into the back of the throat. However, in most infants,
it is a normal occurrence caused by the immaturity of both the
upper and lower esophageal sphincters, the shorter distance
from the stomach to the throat, and the greater amount of time
infants spend in the horizontal position. Only infants who have
associated airway (breathing) or feeding problems require evaluation
by a specialist. This is most critical when breathing-related
symptoms are present.
What are symptoms of LPR?
There are various symptoms of LPR. Adults may
be able to identify LPR as a bitter taste in the back of the
throat, more commonly in the morning upon awakening, and the
sensation of a “lump” or something “stuck” in the throat, which
does not go away despite multiple swallowing attempts to clear
the “lump.” Some adults may also experience a burning sensation
in the throat. A more uncommon symptom is difficulty breathing,
which occurs because the acidic, refluxed material comes in
contact with the voice box (larynx) and causes the vocal cords
to close to prevent aspiration of the material into the windpipe
(trachea). This event is known as “laryngospasm.”
Infants and children are unable to describe
sensations like adults can. Therefore, LPR is only successfully
diagnosed if parents are suspicious and the child undergoes
a full evaluation by a specialist such as an otolaryngologist.
Airway or breathing-related problems are the most commonly seen
symptoms of LPR in infants and children and can be serious.
If your infant or child experiences any of the following symptoms,
timely evaluation is critical.
Chronic cough
Hoarseness
Noisy breathing
(stridor)
Croup
Reactive airway
disease (asthma)
Sleep disordered
breathing (SDB)
Frank spit up
Feeding difficulty
Turning blue
(cyanosis)
Aspiration
Pauses in breathing
(apnea)
Apparent life
threatening event (ALTE)
Failure to thrive
(a severe deficiency in growth such that an infant or child
is less than five percentile compared to the expected norm)
What are the complications of LPR?
In infants and children, chronic exposure of
the laryngeal structures to acidic contents may cause long term
airway problems such as a narrowing of the area below the vocal
cords (subglottic stenosis), hoarseness, and possibly eustachian
tube dysfunction causing recurrent ear infections, or persistent
middle ear fluid, and even symptoms of “sinusitis.” The direct
relationship between LPR and the latter mentioned problems are
currently under research investigation.
How is LPR diagnosed?
Currently, there is no good standardized test
to identify LPR. If parents notice any symptoms of LPR in their
child, they may wish to discuss with their pediatrician a referral
to see an otolaryngologist for evaluation. An otolaryngologist
may perform a flexible fiberoptic nasopharyngoscopy/laryngoscopy,
which involves sliding a 2 mm scope through the infant or child’s
nostril, to look directly at the voice box and related structures
or a 24 hour pH monitoring of the esophagus. He or she may also
decide to perform further evaluation of the child under general
anesthesia. This would include looking directly at the voice
box and related structures (direct laryngoscopy), a full endoscopic
look at the trachea and bronchi (bronchoscopy), and an endoscopic
look at the esophagus (esophagoscopy) with a possible biopsy
of the esophagus to determine if esophagitis is present. LPR
in infants and children remains a diagnosis of clinical judgment
based on history given by the parents, the physical exam, and
endoscopic evaluations.
How is LPR treated?
Since LPR is an extension of GER, successful
treatment of LPR is based on successful treatment of GER. In
infants and children, basic recommendations may include smaller
and more frequent feedings and keeping an infant in a vertical
position after feeding for at least 30 minutes. A trial of medications
including H2 blockers or proton pump inhibitors may be necessary.
Similar to adults, those who fail medical treatment, or have
diagnostic evaluations demonstrating anatomical abnormalities
may require surgical intervention such as a fundoplication.
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Pediatric GERD
Pediatric GERD (Gastro-Esophageal Reflux
Disease) and Your Otolaryngologist
Everyone has gastroesophageal reflux (GER), the backward movement
(reflux) of gastric contents into the esophagus. Extraesophageal
Reflux (EER) is the reflux of gastric contents from the stomach
into the esophagus with further extension into the throat and
other upper aerodigestive regions. In infants, more than 50
percent of children three months or younger have at least one
episode of regurgitation a day. This rate peaks at 67 percent
at age four months. But an infant’s improved neuromuscular control
and the ability to sit up will lead to a spontaneous resolute
ion of significant GER in more than half of infants by age ten
months and four out of five at age 18 months.
Researchers have found that 10 percent of infants
(younger than 12 months) with GER develop significant complications.
The diseases associated with reflux are known collectively as
Gastro-Esophageal Reflux Disease (GERD). Physically, GERD occurs
when a muscular valve at the lower end of the esophagus malfunctions.
Normally, this muscle closes to keep acid in the stomach and
out of the esophagus. The continuous entry of acid or refluxed
materials into areas outside the stomach can result in significant
injury to those areas. It is estimated that some five to eight
percent of adolescent children have GERD.
What symptoms are displayed by a child
with GERD?
GER and EER in children often cause relatively
few symptoms until a problem exists (GERD). The most common
initial symptom of GERD is heartburn. Heartburn is more common
in adults, whereas children have a harder time describing this
sensation. They usually will complain of a stomach ache or chest
discomfort, particularly after meals.
More frequent or severe GER and EER can cause
other problems in the stomach, esophagus, pharynx, larynx, lungs,
sinuses, ears and even the teeth. Consequently, other typical
symptoms could include crying/irritability, poor appetite/feeding
and swallowing difficulties, failure to thrive/weight loss,
regurgitation (“wet burps” or outright vomiting), stomach aches
(dyspepsia), abdominal/chest pain (heartburn), sore throat,
hoarseness, apnea, laryngeal and tracheal stenoses, asthma/wheezing,
chronic sinusitis, ear infections/fluid, and dental caries.
Effortless regurgitation is very suggestive of GER. However
recurrent vomiting (which is not the same) does not necessarily
mean a child has GER.
Unlike infants, the adolescent child will not
necessarily resolve GERD on his or her own. Accordingly, if
your child displays the typical symptoms of GERD, a visit to
a pediatrician is warranted. However, in some circumstances,
the disorder may cause significant ear, nose, and throat disorders.
When this occurs, an evaluation by an otolaryngologist is recommended.
How is GERD diagnosed?
Most of the time, the physician can make a diagnosis
by interviewing the caregiver and examining the child. There
are occasions when testing is recommended. The tests that are
most commonly used to diagnose gastroesophageal reflux include:
pH probe: A small wire with an acid sensor
is placed through the nose down to the bottom of the esophagus.
The sensor can detect when acid from the stomach is "refluxed"
into the esophagus. This information is generally recorded on
a computer. Usually, the sensor is left in place between 12
and 24 hours. At the conclusion of the test, the results will
indicate how often the child "refluxes" acid into
his or her esophagus and whether he or she has any symptoms
when that occurs.
Barium
swallow or upper GI series: The child is fed barium,
a white, chalky, liquid. A video x-ray machine follows the barium
through the upper intestinal tract and lets doctors see if there
are any abnormal twists, kinks or narrowings of the upper intestinal
tract.
Technetium
gastric emptying study: The child is fed milk mixed
with technetium, a very weakly radioactive chemical, and then
the technetium is followed through the intestinal tract using
a special camera. This test is helpful in determining whether
some of the milk/technetium ends up in the lungs (aspiration).
It may also be helpful in determining how long milk sits in
the stomach.
Endoscopy
with biopsies: This most comprehensive test involves
the passing down of a flexible endoscope with lights and lenses
through the mouth into the esophagus, stomach, and duodenum.
This allows the doctor to get a directly look at the esophagus,
stomach, and duodenum and see if there is any irritation or
inflammation present. In some children with gastroesophageal
reflux, repeated exposure of the esophagus to stomach acid causes
some inflammation (esophagitis). Endoscopy in children usually
requires a general anesthetic.
Fiberoptic
Laryngoscopy: A small lighted scope is placed in the
nose and the pharynx to evaluate for inflammation.
What treatments for GERD are available?
Treatment of reflux in infants is intended to
lessen symptoms, not to relieve the underlying problem, as this
will often resolve on its own with time. A useful simple treatment
is to thicken a baby's milk or formula with rice cereal, making
it less likely to be refluxed.
Several steps can be taken to assist
the older child with GERD:
Lifestyle changes: Raise the head of the child’s bed about 30
degrees while they sleep and have the child eat smaller, more
frequent meals instead of large amounts of food at one sitting.
Avoid having the child eat right before they go to bed or lie
down; instead, let two or three hours pass. Try a walk or warm
bath or even a few minutes on the toilet. Some researchers believe
that certain lifestyle changes such as losing weight or dressing
in loose clothing my assist in alleviating GERD. Even chewing
sugarless gum may help.
Dietary changes:
Avoid chocolate, carbonated drinks, caffeine, tomato products,
peppermint, and other acidic foods as citrus juices. Fried foods
and spicy foods are also known to aggravate symptoms. Pay attention
to what your child eats and be alert for individual problems.
Medical Treatment:
Most of the medications prescribed to treat GERD either break
down or lessen intestinal gas, decrease or neutralize stomach
acid, or improve intestinal coordination. Your physician will
prescribe the most appropriate medication for your child.
Surgical Treatment:
It is rare for children with GERD to require surgery. For the
few children who do require surgery, the most commonly performed
operation is called Nissen fundoplication. With this procedure,
the top part of the stomach (the fundus) is wrapped around the
bottom of the esophagus to create a collar. After the operation,
every time the stomach contracts, the collar around the esophagus
contracts preventing reflux.
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Pediatric Obesity and ENT
Pediatric Obesity and Ear, Nose, and Throat Disorders
Today in the United States, studies estimate
that 34 percent of U.S. adults are overweight and an additional
31 percent (approximately 60 million) are obese. Combined, approximately
127 million Americans are overweight or obese. Some 42 years
ago, 13 percent of Americans were obese, and in 1980 15 percent
were considered obese.
Alarmingly, the number of children who are overweight
or obese has doubled in the last two decades as well. Currently,
more than 15 percent of 6- to 11-year-olds and more than 15
percent of 12- to 19-year-olds are considered overweight or
obese.
What is the difference between designated
“obese” versus “overweight?”
Unfortunately, the words overweight and obese
are often interchanged. There is a difference:
Overweight: Anyone with a body mass index (BMI) (a
ratio between your height and weight) of 25 or above (e.g.,
someone who is 5-foot-4 and 145 pounds) is considered overweight.
Obesity:
Anyone with a BMI of 30 or above (e.g., someone who is 5-foot-4
and 175 pounds) is considered obese.
Morbid
obesity: Anyone with a BMI of 40 or above (e.g., someone
who is 5-foot-4 and 233 pounds) is considered morbidly obese.
"Morbid" is a medical term indicating that the risk
of obesity related illness is increased dramatically at this
degree of obesity.
Obesity can present significant health risks to the young child.
Diseases are being seen in obese children that were once thought
to be adult diseases. Many experts in the study of children’s
health suggest that a dysfunctional metabolism, or failure of
the body to change food calories to energy, precedes the onset
of disease. Consequently, these children are at risk for Type
II Diabetes, fatty liver, elevated cholesterol, SCFE (a major
hip disorder), menstrual irregularities, sleep apnea, and irregular
metabolism. Additionally, there are psychological consequences;
obese children are subject to depression, loss of self-esteem,
and isolation from their peers.
Pediatric obesity and otolaryngic problems
Otolaryngologists, or ear, nose, and throat
specialists, diagnose and treat some of the most common children’s
disorders. They also treat ear, nose, and throat conditions
that are common in obese children, such as:
Sleep apnea: Children with sleep apnea literally stop
breathing repeatedly during their sleep, often for a minute
or longer, usually ten to 60 times during a single night. Sleep
apnea can be caused by either complete obstruction of the airway
(obstructive apnea) or partial obstruction (obstructive hypopnea—hypopnea
is slow, shallow breathing), both of which can wake one up.
There are three types of sleep apnea—obstructive, central, and
mixed. Of these, obstructive sleep apnea (OSA) is the most common.
Otolaryngologists have pioneered the treatment for sleep apnea;
research shows that one to three percent of children have this
disorder, often between the age of two-to-five years old.
Enlarged tonsils, which block the airway, are
usually the key factor leading to this condition. Extra weight
in obese children and adults can also interfere with the ability
of the chest and abdomen to fully expand during breathing, hindering
the intake of air and increasing the risk of sleep apnea.
The American Academy of Pediatrics has identified obstructive
sleep apnea syndrome (OSAS) as a “common condition in childhood
that results in severe complications if left untreated."
Among the potential consequences of untreated pediatric sleep
apnea are growth failure; learning, attention, and behavior
problems; and cardio-vascular complications. Because sleep apnea
is rarely diagnosed, pediatricians now recommend that all children
be regularly screened for snoring.
Middle
ear infections: Acute otitis media (AOM) and chronic
ear infections account for 15 to 30 million visits to the doctor
each year in the U.S. In fact, ear infections are the most common
reason why an American child sees a doctor. Furthermore, the
incidence of AOM has been rising over the past decades. Although
there is no proven medical link between middle ear infections
and pediatric obesity there may be a behavioral association
between the two conditions. Some studies have found that when
a child is rubbing or massaging the infected ear the parent
often responds by offering the child food or snacks for comfort.
When a child does have an ear infection the
first line of treatment is often a regimen of antibiotics. When
antibiotics are not effective, the ear, nose and throat specialist
might recommend a bilateral myringotomy with pressure equalizing
tube placement (BMT), a minor surgical procedure. This surgery
involves the placement of small tubes in the eardrum of both
ears. The benefit is to drain the fluid buildup behind the eardrum
and to keep the pressure in the ear the same as it is in the
exterior of the ear. This will reduce the chances of any new
infections and may correct any hearing loss caused by the fluid
buildup.
Postoperative vomiting (POV) is a common problem
after bilateral myringotomy surgery. The overall incidence is
35 percent, and usually occurs on the first postoperative day,
but can occur up to seven days later. Several factors are known
to affect the incidence of POV, including age, type of surgery,
postoperative care, medications, co-existing diseases, past
history of POV, and anesthetic management. Obesity, gastroparesis,
female gender, motion sickness, pre-op anxiety, opiod analgesics,
and the duration of anesthetic all increase the incidence of
POV. POV interferes with oral medication and intake, delays
return to normal activity, and increases length of hospital
stay. It remains one of the most common causes of unplanned
postoperative hospital admissions.
Tonsillectomies:
A child’s tonsils are removed because they are either chronically
infected or, as in most cases, enlarged, leading to obstructive
sleep apnea. There are several surgical procedures utilized
by ear, nose, and throat specialists to remove the tonsils,
ranging from use of a scalpel to a wand that emits energy that
shrinks the tonsils.
Research conducted by otolaryngologists found that:
Morbid obesity was a contributing factor for
requiring an overnight hospital admission for a child undergoing
removal of enlarged tonsils. Most children who were diagnosed
as obese with sleep apnea required a next-day physician follow-up.
A study from the University of Texas found that
morbidly obese patients have a significant increase of additional
medical disorders following tonsillectomy and adenoidectomy
for obstructive sleep apnea or sleep-disordered breathing when
compared to moderately obese or overweight patients undergoing
this procedure for the same diagnosis. On average they have
longer hospital stays, a greater need for intensive care, and
a higher incidence of the need for apnea treatment of continuous
positive airway pressure upon discharge from the hospital. The
study found that although the morbidly obese group had a greater
degree of sleep apnea, they did benefit from the procedure in
regards to snoring, apneic spells, and daytime somnolence.
What you can do
If your child has a weight problem, contract
your pediatrician or family physician to discuss the weight’s
effect on your child’s health, especially prior to treatment
decisions. Second, ask your physician about lifestyle and diet
changes that will reduce your child’s weight to a healthy standard.
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Glossary for Good Ear Health
Your child has an earache. After your first visit to a physician
you may hear some of the following terms related to the diagnosis
and treatment of this common childhood disorder.
Acute otitis media - the medical term for the
common ear infection. Otitis refers to an ear inflammation,
and media means middle. Acute otitis media is an infection of
the middle ear, which is located behind the eardrum. This diagnosis
includes fluid effusion trapped in the middle ear.
Adenoidectomy
– removal of the adenoids, also called pharyngeal tonsils. Some
believe their removal helps prevent ear infections.
Amoxicillin
- a semi-synthetic penicillin antibiotic often used as the first-line
medical treatment for acute otitis media or otitis media with
effusion. A higher dosage may be recommended for a second treatment.
Analgesia –
immediate pain relief. For an earache, it may be provided by
acetaminophen, ibuprofen, and auralgan.
Antibiotic -
a soluble substance derived from a mold or bacterium that inhibits
the growth of other bacterial micro-organisms.
Antibiotic resistance
– a condition where micro-organisms continue to multiply although
exposed to antibiotic agents, often because the bacteria has
become immune to the medication. Overuse or inappropriate use
of antibiotics leads to antibiotic resistance.
Audiometer -
an electronic device used in measuring hearing for pure tones
of frequencies, generally varying from 125–8000 Hz, and speech
(recorded in terms of decibels).
Azithromyacin
– an antibiotic prescribed for acute otitis media due to Haemophilus
influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis.
Also known by its brand name, Zithromax®.
Bacteria – organisms
responsible for about 70 percent of otitis media cases. The
most common bacterial offenders are Streptococcus pneumoniae,
Haemophilus influenzae and Moraxella catarrhalis.
Chronic otitis
media – when infection of the middle ear persists, leading to
possible ongoing damage to the middle ear and eardrum.
Decibel – one
tenth of a bel, the unit of measure expressing the relative
intensity of a sound. The results of a hearing test are often
expressed in decibels.
Effusion – a
collection of fluid generally containing a bacterial culture.
First-line agent
– The first treatment of antibiotics prescribed for an ear infection,
often amoxicillin.
Myringotomy
– an incision made into the ear drum.
Otitis media
without effusion - an inflammation of the eardrum without fluid
in the middle ear.
Otitis media
with effusion - the presence of fluid in the middle ear without
signs or symptoms of ear infection. It is sometimes called serous
otitis media. This condition does not usually require antibiotic
treatment.
Otitis media
with perforation - a spontaneous rupture or tear in the eardrum
as a result of infection. The hole in the ear drum usually repairs
itself within several weeks.
OtoLAMä – a
myringotomy performed with computer-driven laser technology
(rather than manual incision with a conventional scalpel).
Pneumatic otoscopy
- a test administered for the middle ear consisting of an inspection
of the ear with a device capable of varying air pressure against
the eardrum. If the tympanic membrane moves during the test,
normal middle ear function is indicated. A lack of movement
indicates either increased impedance, as with fluid in the middle
ear, or perforation of the tympanic membrane.
Recurrent otitis
media – when the patient incurs three infections in three months,
four in six months, or six in 12 months. This is often an indicator
that a tympanostomy with tubes might be recommended.
Second line
treatment – antibiotics prescribed when the first line of treatment
fails to resolve symptoms after 48 hours.
Trimethoprim
Sulfamethoxazole – an alternative first line treatment for children
allergic to amoxicillin.
Tympanostomy
tubes – small tubes inserted in the eardrum to allow drainage
of infection.
Do not hesitate to seek clarification from your physician
if he or she uses a term that you do not fully understand.
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How Allergies Affect Your Child's Health
Your child has been diagnosed with allergic rhinitis, a physiological
response to specific allergens such as pet dander or ragweed.
The symptoms are fairly simple -- a runny nose (rhinitis), watery
eyes, and some periodic sneezing. The best solution is to administer
over-the-counter antihistamine, and the problem will resolve
on its own ….right?
Not really – the interrelated structures of
the ears, nose, and throat can cause certain medical problems
which trigger additional disorders – all with the possibility
of serious consequences.
Simple hay fever can lead to long term problems
in swallowing, sleeping, hearing, and breathing. Let’s see what
else can happen to a child with a case of hay fever.
Ear
infections: One of children’s most common medical problems
is otitis media, or middle ear infection. These infections are
especially common in early childhood. They are even more common
when children suffer from allergic rhinitis (hay fever) as well.
Allergic inflammation can cause swelling in the nose and around
the opening of the Eustachian tube (ear canal). This swelling
has the potential to interfere with drainage of the middle ear.
When bacteria laden discharge clogs the tube, infection is more
likely.
Sore
throats: The hay fever allergens may lead to the formation
of too much mucus which can make the nose run or drip down the
back of the throat, leading to "post-nasal drip."
It can lead to cough, sore throats, and husky voice. Although
more common in older people and in dry inland climates, thick,
dry mucus can also irritate the throat and be hard to clear.
Air conditioning, winter heating, and dehydration can aggravate
the condition. Paradoxically, antihistamines will do so as well.
Some newer antihistamines do not produce dryness.
Snoring:
Chronic nasal obstruction is a frequent symptom of seasonal
allergic rhinitis (hay fever) and perennial (year-round) allergic
rhinitis. This allergic condition may have a debilitating effect
on the nasal turbinates, the small, shelf-like, bony structures
covered by mucous membranes (mucosa). The turbinates protrude
into the nasal airway and help to warm, humidify, and cleanse
air before it reaches the lungs. When exposed to allergens,
the mucosa can become inflamed. The blood vessels inside the
membrane swell and expand, causing the turbinates to become
enlarged and obstruct the flow of air through the nose. This
inflammation, or rhinitis, can cause chronic nasal obstruction
that affects individuals during the day and night.
Enlarged turbinates and nasal congestion can
also contribute to headaches and sleep disorders such as snoring
and obstructive sleep apnea, because the nasal airway is the
normal breathing route during sleep. Once turbinate enlargement
becomes chronic, it is irreversible except with surgical intervention.
Pediatric
sinusitis: Allergic rhinitis can cause enough inflammation
to obstruct the openings to the sinuses. Consequently, a bacterial
sinus infection occurs. The disease is similar for children
and adults. Children may or may not complain of pain. However,
in acute sinusitis, they will often have pain and typically
have fever and a purulent nasal discharge. In chronic sinusitis,
pain and fever are not evident. Some children may have mood
or behavior changes. Most will have a purulent, runny nose and
nasal congestion even to the point where they must mouth breathe.
The infected sinus drains around the Eustachian tube, and therefore
many of the children will also have a middle ear infection.
Seasonal allergic rhinitis may resolve after a short period.
Administration of the proper over-the-counter antihistamines
may alleviate the symptoms. However, if your child suffers from
perennial (year round) allergic rhinitis, an examination by
specialist will assist in preventing other ear, nose, and throat
problems from occurring.
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Day Care and E.N.T. Problems
Who is in day care?
The 2000 census reported that of among the nation's 19.6 million
preschoolers, grandparents took care of 21 percent, 17 percent
were cared for by their father (while their mother was employed
or in school); 12 percent were in day care centers; nine percent
were cared for by other relatives; seven percent were cared
for by a family day care provider in their home; and six percent
received care in nursery schools or preschools. More than one-third
of preschoolers (7.2 million) had no regular child-care arrangement
and presumably were under maternal care.
Day care establishments are defined as those
primarily engaged in care of infants or children, or in providing
pre-kindergarten education, where medical care and/or behavioral
correction are not a primary function or major element. Some
may or may not have substantial educational programs, and some
may care for older children when they are not in school.
What are your child’s risks of being
exposed to a contagious illness at a day care center?
Medline, a service of the National Library of
Medicine and the National Institutes of Health, reports that
day care centers do pose some degree of an increased health
risk for children, because of the exposure to other children
who may be sick.
When your child is in a day care center, the
risk is greatest for viral upper respiratory infection (affecting
the nose, throat, mouth, voice box) and the common cold, ear
infections, and diarrhea. Some studies have tried to link asthma
to day care. Other studies suggest that being exposed to all
the germs in day care actually IMPROVES your child's immune
system.
Studies suggest that the average child will
get eight to ten colds per year, lasting ten - 14 days each,
and occurring occurring primarily in the winter months. This
means that if a child gets two colds from March to September,
and eight colds from September to March, each lasting two weeks,
the child will be sick more than over half of the winter.
At the same time, children in a day care environment,
exposed to the exchange of upper respiratory tract viruses every
day, are expected to have three to ten episodes of otitis media
annually. This is four times the incidence of children staying
at home.
When should your child remain at home
instead of day care or school?
Simply put, children become sick after being
exposed to other sick children. Some guidelines to follow are:
When your child has a temperature higher than 100 degrees, keep
him/her at home. A fever is a sign of potentially contagious
infection, even if the child feels fine. Schools often advise
keeping the child at home until a fever-free period has existed
for 24 hours.
When other children in the day care facility have a known contagious
infection, such as chicken pox, strep throat or conjunctivitis,
keep your child at home.
Children taking antibiotics should be kept at home until they
have taken the medicine for one or two days.
If your child is vomiting or has diarrhea, the young patient
should not be around other children. Other signs of illness
are an inability to take fluids, weakness or lethargy, sunken
eyes, a depressed soft spot on top of infant’s head, crying
without tears, and dry mouth.
Can you prevent your child from becoming
sick at a day care center?
The short answer is no. Exposure to other sick
children will increase the likelihood that your child may “catch”
the same illness, particularly with the common cold. The primary
rule is to keep your own children at home if they are sick.
However, you can:
Teach
your child to wash his or her hands before eating and after
using the toilet. Infection is spread the most by children putting
dirty toys and hands in their mouths, so check your day care's
hygiene cleaning practices.
Have
your child examined by a physician before enrollment in a day
care center or school. During the examination, the physician
will:
Look for otitis (inflammation) in the ear. This is an indicator
of future ear infections.
Review with
you any allergies your child may have. This will assist in determining
if the diet offered at the day care center may be harmful to
your child.
Examine the
child’s tonsils for infection and size. Enlarged tonsils could
indicate that your child may not be getting a healthy sleep
at night, resulting in a tired condition during the day.
Alert
the day care center manager when your child is ill, and include
the nature of the illness.
Day care has become a necessity for millions
of families. Monitoring the health of your own child is key
to preventing unneccessary sickness. If a serious illness occurs,
do not hesitate to have your child examined by a physician.
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Tonsils and Tonsillectomy
for a kids point of view
What are tonsils?
Tonsils are the two pink lumps of tissue found
on each side of the back of your throat. (Open your mouth wide
and say ‘ahhhh’ in front of a mirror to see them.) Each grape-size
lump fights off the bad bacteria or germs living in your body.
What is tonsillitis?
Bacteria (bad germs) are tiny living things
that can cause sickness and infection. Too many bad germs on
your tonsils can make you sick. This is what your doctor calls
tonsillitis (ton-sil-lie-tis), or an infection in one or both
of your tonsils.
Do you think you have tonsillitis? A symptom
is a signal that something is wrong with your body. Talk with
Mom and Dad if you see or feel:
Bright red tonsils
White or yellow
goo covering your tonsils
A sore throat
Pain when you
swallow
Pain or swelling
in your neck
A hot forehead
Stinky breath
even after you’ve brushed your teeth
Will I have to visit
the doctor?
If you have tonsillitis symptoms, your parents
will probably take you to see a doctor usually a pediatrician,
or doctor for children. During your visit, the doctor will:
Ask questions about your symptoms and how long
you’ve had them
Look at and feel your head, neck, and throat with a tongue depressor,
small mirror, or lighted instrument
Look in your ears
Perform a few tests, like x-rays, blood tests, or throat cultures,
to find out exactly what’s making you sick
Once your doctor examines the results, he or she will decide
if you have tonsillitis.
What
happens after the doctor says I have tonsillitis?
If your doctor decides you have tonsillitis,
he will probably give you an antibiotic, a medicine that gets
rid of bad bacteria. If you have tonsillitis a lot, your doctor
will contact an otolaryngologist (oh-toe-lair-in-goll-oh-gist),
a doctor who specializes in taking care of the ears, nose, and
throat. This doctor might tell you to take some more antibiotics
but if your throat continues to hurt, you might be told you
need a tonsillectomy.
What is a tonsillectomy?
A tonsillectomy (ton-seh-leck-teh-me) is an
operation where your tonsils are taken out of your throat. If
you have tonsillitis a lot, or if your tonsils get really big
and you have trouble breathing, your doctor and parents may
decide they need to be removed.
What happens when I
have a tonsillectomy?
After dinner the night before your tonsillectomy,
you won’t be allowed to eat or drink anything -- even water!
When you arrive at the hospital, you’ll put
on a special bracelet with your name on it and hospital clothes.
Then you will meet the doctors and nurses that will be helping
you. When the doctor is ready, you’ll be given a special medicine
that makes you fall asleep. Then, the doctor and nurses will
use special tools to remove your tonsils. It doesn’t take very
long – just about 20 minutes!
When you wake up, you will be with your Mom
or Dad and the operation will be all over. Your throat will
hurt but the nurses and doctors will keep an eye on you to make
sure you’re okay. In a few hours you will be ready to go home.
Your throat will be sore for a few weeks, but your tonsils won’t
bother you ever again!
What happens after I
get home?
When you get home, be sure to drink a lot and
get lots of rest. It will help to keep your throat moist and
your body energized. You can eat non-dairy popsicles and other
cold treats or soft food that makes your throat feel better,
but save ice cream for the next day. Ice cream and other milk
products can make your throat worse right after the operation.
Within two weeks, you’ll be back to school and better than ever!
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Laryngopharyngeal Reflux and Children
What is laryngopharyngeal reflux (LPR)?
Food or liquids that are swallowed travel through
the esophagus and into the stomach where acids help digestion.
Each end of the esophagus has a sphincter, a ring of muscle,
that helps keep the acidic contents of the stomach in the stomach
or out of the throat. When these rings of muscle do not work
properly, you may get heartburn or gastroesophageal reflux (GER).
Chronic GER is often diagnosed as gastroesophageal reflux disease
or GERD.
Sometimes, acidic stomach contents will reflux
all the way up to the esophagus, past the ring of muscle at
the top (upper esophageal sphincter or UES), and into the throat.
When this happens, acidic material contacts the sensitive tissue
at back of the throat and even the back of the nasal airway.
This is known as laryngopharyngeal reflux or LPR.
During the first year, infants frequently spit
up. This is essentially LPR because the stomach contents are
refluxing into the back of the throat. However, in most infants,
it is a normal occurrence caused by the immaturity of both the
upper and lower esophageal sphincters, the shorter distance
from the stomach to the throat, and the greater amount of time
infants spend in the horizontal position. Only infants who have
associated airway (breathing) or feeding problems require evaluation
by a specialist. This is most critical when breathing-related
symptoms are present.
What are symptoms of LPR?
There are various symptoms of LPR. Adults may
be able to identify LPR as a bitter taste in the back of the
throat, more commonly in the morning upon awakening, and the
sensation of a “lump” or something “stuck” in the throat, which
does not go away despite multiple swallowing attempts to clear
the “lump.” Some adults may also experience a burning sensation
in the throat. A more uncommon symptom is difficulty breathing,
which occurs because the acidic, refluxed material comes in
contact with the voice box (larynx) and causes the vocal cords
to close to prevent aspiration of the material into the windpipe
(trachea). This event is known as “laryngospasm.”
Infants and children are unable to describe
sensations like adults can. Therefore, LPR is only successfully
diagnosed if parents are suspicious and the child undergoes
a full evaluation by a specialist such as an otolaryngologist.
Airway or breathing-related problems are the most commonly seen
symptoms of LPR in infants and children and can be serious.
If your infant or child experiences any of the following symptoms,
timely evaluation is critical.
Chronic cough
Hoarseness
Noisy breathing
(stridor)
Croup
Reactive airway
disease (asthma)
Sleep disordered
breathing (SDB)
Frank spit up
Feeding difficulty
Turning blue
(cyanosis)
Aspiration
Pauses in breathing
(apnea)
Apparent life
threatening event (ALTE)
Failure to thrive
(a severe deficiency in growth such that an infant or child
is less than five percentile compared to the expected norm)
What are the complications of LPR?
In infants and children, chronic exposure of
the laryngeal structures to acidic contents may cause long term
airway problems such as a narrowing of the area below the vocal
cords (subglottic stenosis), hoarseness, and possibly eustachian
tube dysfunction causing recurrent ear infections, or persistent
middle ear fluid, and even symptoms of “sinusitis.” The direct
relationship between LPR and the latter mentioned problems are
currently under research investigation.
How is LPR diagnosed?
Currently, there is no good standardized test
to identify LPR. If parents notice any symptoms of LPR in their
child, they may wish to discuss with their pediatrician a referral
to see an otolaryngologist for evaluation. An otolaryngologist
may perform a flexible fiberoptic nasopharyngoscopy/laryngoscopy,
which involves sliding a 2 mm scope through the infant or child’s
nostril, to look directly at the voice box and related structures
or a 24 hour pH monitoring of the esophagus. He or she may also
decide to perform further evaluation of the child under general
anesthesia. This would include looking directly at the voice
box and related structures (direct laryngoscopy), a full endoscopic
look at the trachea and bronchi (bronchoscopy), and an endoscopic
look at the esophagus (esophagoscopy) with a possible biopsy
of the esophagus to determine if esophagitis is present. LPR
in infants and children remains a diagnosis of clinical judgment
based on history given by the parents, the physical exam, and
endoscopic evaluations.
How is LPR treated?
Since LPR is an extension of GER, successful
treatment of LPR is based on successful treatment of GER. In
infants and children, basic recommendations may include smaller
and more frequent feedings and keeping an infant in a vertical
position after feeding for at least 30 minutes. A trial of medications
including H2 blockers or proton pump inhibitors may be necessary.
Similar to adults, those who fail medical treatment, or have
diagnostic evaluations demonstrating anatomical abnormalities
may require surgical intervention such as a fundoplication.
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Pediatric Obstructive Sleep Apnea
Sleep disordered breathing (SDB) is a common
problem for adults leading to hypertension, heart attack, stroke,
and early death. Other consequences are bedroom disharmony,
excessive daytime sleepiness, weight gain, poor performance
at work, failing personal relationships, and increased risk
for accidents, including motor vehicle accidents.
Sleep disordered breathing in children, from
infancy through puberty, is in some ways a similar condition
but has different causes, consequences, and treatments. A child
with SDB does not necessarily have this condition as an adult.
Pediatric obstructive sleep apnea
The premiere symptom of sleep disordered breathing
is snoring that is loud, present every night regardless of sleep
position, and is ultimately interrupted by complete obstruction
of breathing with gasping and snorting noises. Approximately
10 percent of children are reported to snore. Ten percent of
these children (one percent of the total pediatric population)
have obstructive sleep apnea.
When an individual, young or old, obstructs
breathing during sleep, the body perceives this as a choking
phenomenon. The heart rate slows, the sympathetic nervous system
is stimulated, blood pressure rises, the brain is aroused, and
sleep is disrupted. In most cases a child’s vascular system
can tolerate the changes in blood pressure and heart rate. However,
a child’s brain does not tolerate the repeated interruptions
to sleep, leading to a child that is sleep deprived, cranky,
and ill behaved.
Consequences of untreated pediatric
sleep disordered breathing
Snoring: A problem if a child shares a room with a
sibling and during sleepovers.
Sleep
deprivation: The child may become moody, inattentive,
and disruptive both at home and at school. Classroom and athletic
performance may decrease along with overall happiness. The child
will lack energy, often preferring to sit in front of the television
rather than participate in school and other activities. This
may contribute to obesity.
Abnormal
urine production: SDB also causes increased nighttime
urine production, and in children, this may lead to bedwetting.
Growth:
Growth hormone is secreted at night. Those with SDB may suffer
interruptions in hormone secretion, resulting in slow growth
or development.
Attention
deficit disorder (ADD) / attention deficit hyperactivity disorder
(ADHD): There are research findings that identify sleep
disordered breathing as a contributing factor to attention deficit
disorders.
Diagnosis of sleep disordered breathing
The first diagnosis of sleep disordered breathing
in children is made by the parent’s observation of snoring.
Other observations may include obstructions to breathing, gasping,
snorting, and thrashing in bed as well as unexplained bedwetting.
Social symptoms are difficult to diagnose but include alteration
in mood, misbehavior, and poor school performance. (Note: Every
child who has sub par academic and social skills may not have
SDB, but if a child is a serious snorer and is experiencing
mood, behavior, and performance problems, sleep disordered breathing
should be considered.)
A child with suspected SDB should be evaluated
by an otolaryngologist – head and neck surgeon. If the symptoms
are significant and the tonsils are enlarged, the child is strongly
recommended for T&A, or tonsillectomy and adenoidectomy
(removal of the tonsils and adenoids). Conversely, if the symptoms
are mild, academic performance remains excellent, the tonsils
are small, and puberty is eminent (tonsils and adenoids shrink
at puberty), it may be recommended that SDB be treated only
if matters worsen. The majority of cases fall somewhere in between,
and physicians must evaluate each child on a case-by-case basis.
There are other pediatric sleep disorder diagnoses.
Sudden infant death syndrome (SIDS) and apparent life threatening
episode (ALTE) are considered forms of sleep disordered breathing.
Children with these conditions warrant thorough evaluation by
a pediatric sleep specialist. Children with craniofacial abnormalities,
primarily abnormalities of the jaw bones, tongue, and associated
structures, often have sleep disordered breathing. This must
be managed and the deformities treated as the child grows.
The sleep test is the standard diagnostic test
for sleep disordered breathing. This test can be performed in
a sleep laboratory or at home. Sleep tests can produce inaccurate
results, especially in children. Borderline or normal sleep
test results may still result in a diagnosis of SDB based on
parental observation and clinical evaluation.
Treatment for sleep disordered breathing
Enlarged tonsils are the most common cause for
SDB, thus tonsillectomy/adenoidectomy is the most effective
treatment for pediatric sleep disordered breathing. T&A
achieves a 90 percent success rate for childhood SDB. Of the
nearly 400,000 T&As performed in the U.S. each year, 75
percent are performed to treat sleep disordered breathing.
Not every child with snoring should undergo
T&A. The procedure does have risks and possible complications.
Aside from the mental anguish experienced by the parent and
child, potential problems include: anesthesia risks,
bleeding, and infection.
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Pediatric Sinusitis
Your child’s sinuses are not fully developed until age 20. Although
small, the maxillary (behind the cheek) and ethmoid (between
the eyes) sinuses are present at birth. Unlike in adults, pediatric
sinusitis is difficult to diagnose because symptoms can be subtle
and the causes complex.
How do I know when my child has sinusitis?
The following symptoms may indicate
a sinus infection in your child:
a “cold” lasting
more than 10 to 14 days, sometimes with a low-grade fever thick,
yellow-green
nasal drainage
post-nasal drip,
sometimes leading to or exhibited as sore throat, cough, bad
breath, nausea, and/or vomiting
headache, usually
in children age six or older
irritability
or fatigue
swelling around
the eyes
Young children have immature immune systems
and are more prone to infections of the nose, sinus, and ears,
especially in the first several years of life. These are most
frequently caused by viral infections (colds), and they may
be aggravated by allergies. However, when your child remains
ill beyond the usual week to ten days, a serious sinus infection
is likely.
You can reduce the risk of sinus infections
for your child by reducing exposure to known allergens and pollutants
such as tobacco smoke, reducing his/her time at day care, and
treating stomach acid reflux disease.
How will the doctor treat sinusitis?
Acute sinusitis: Most children
respond very well to antibiotic therapy. Nasal decongestants
or topical nasal sprays may also be prescribed for short-term
relief of stuffiness. Nasal saline (saltwater) drops or gentle
spray can be helpful in thinning secretions and improving mucous
membrane function.
If your child has acute sinusitis, symptoms
should improve within the first few days. Even if your child
improves dramatically within the first week of treatment, it
is important that you continue therapy until all the antibiotics
have been taken. Your doctor may decide to treat your child
with additional medicines if he/she has allergies or other conditions
that make the sinus infection worse.
Chronic sinusitis: If your child suffers from
one or more symptoms of sinusitis for at least 12 weeks, he
or she may have chronic sinusitis. Chronic sinusitis or recurrent
episodes of acute sinusitis numbering more than four to six
per year are indications that you should seek consultation with
an ear, nose, and throat (ENT) specialist. The ENT may recommend
medical or surgical treatment of the sinuses.
Diagnosis of sinusitis: If your child sees
an ENT specialist, the doctor will examine his/her ears, nose,
and throat. A thorough history and examination usually leads
to the correct diagnosis. Occasionally, special instruments
will be used to look into the nose during the office visit.
An x-ray called a CT scan may help to determine how your child's
sinuses are formed, where the blockage has occurred, and the
reliability of a sinusitis diagnosis.
When is surgery necessary?
Only a small percentage of children with severe
or persistent sinusitis require surgery to relieve symptoms
that do not respond to medical therapy. Using an instrument
called an endoscope, the ENT surgeon opens the natural drainage
pathways of your child's sinuses and makes the narrow passages
wider. This also allows for culturing so that antibiotics can
be directed specifically against your child's sinus infection.
Opening up the sinuses and allowing air to circulate usually
results in a reduction in the number and severity of sinus infections.
Your doctor may advise removing adenoid tissue
from behind the nose as part of the treatment for sinusitis.
Although the adenoid tissue does not directly block the sinuses,
infection of the adenoid tissue, called adenoiditis, or obstruction
of the back of the nose, can cause many of the symptoms that
are similar to sinusitis, namely, runny nose, stuffy nose, post-nasal
drip, bad breath, cough, and headache.
Sinusitis in children is different than sinusitis in adults.
Children more often demonstrate a cough, bad breath, crankiness,
low energy, and swelling around the eyes along with a thick
yellow-green nasal or post-nasal drip. Once the diagnosis of
sinusitis has been made, children are successfully treated with
antibiotic therapy in most cases. If medical therapy fails,
surgical therapy can be used as a safe and effective method
of treating sinus disease in children.
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T & A PostOp
The tonsils are two pads of tissue located on
both sides of the back of the throat. Adenoids sit high on each
side of the throat behind the nose and the roof of the mouth.
Tonsils and adenoids are often removed when they become enlarged
and block the upper airway, leading to breathing difficulty.
They are also removed when recurrence of tonsil infections or
strep throat cannot be successfully treated by antibiotics.
The procedure to remove the tonsils is called
a tonsillectomy; excision of the adenoids is an adenoidectomy.
Both are usually performed concurrently; hence the procedure
is known as a tonsillectomy and adenoidectomy or T&A.
T&A is an outpatient surgical procedure
lasting between 30 and 45 minutes and performed under general
anesthesia. Normally, the young patient will remain at the hospital
or clinic for about four hours after surgery for observation.
An overnight stay may be required if there are complications
such as excessive bleeding or poor intake of fluids.
When the tonsillectomy patient comes
home
Most children require seven to ten days to recover
from the surgery. Some may recover more quickly; others can
take up to two weeks for a full recovery. The following guidelines
are recommended:
Drinking: The most important requirement for recovery
is for the patient to drink plenty of fluids. Milk products
should be avoided in the first 24 hours after surgery. Offer
juice, soft drinks, popsicles, and Jell-O (pudding, yogurt,
and ice-cream after 24 hours). Some patients experience nausea
and vomiting after the surgery caused by the general anesthetic.
This usually occurs within the first 24 hours and resolves on
its own. Contact your physician if there are signs of dehydration
(urination less than 2-3 times a day or crying without tears).
Eating:
Generally, there are no food restrictions (other than milk products)
after surgery. The sooner the child eats and chews, the quicker
the recovery. Tonsillectomy patients may be reluctant to eat
because of sore throat pain; consequently, some weight loss
may occur, which is gained back after a normal diet is resumed.
Fever: A low-grade fever may be observed several days
after surgery. Contact your physician if the fever is greater
than 102º.
Activity: Bed rest is recommended for several days
after surgery. Activity may be increased slowly, with a return
to school after normal eating and drinking resumes, pain medication
ceases, and the child sleeps through the night. Travel away
from home is not recommended for two weeks following surgery.
Breathing: The parent may notice abnormal snoring and
mouth breathing due to swelling in the throat. Breathing should
return to normal when swelling subsides, 10-14 days after surgery.
Scabs: A scab will form where the tonsils and adenoids
were removed. These scabs are thick, white, and cause bad breath.
This is not unexpected. Most scabs fall off in small pieces
five to ten days after surgery and are swallowed.
Bleeding: With the exception of small specks of blood
from the nose or in the saliva, bright red blood should not
be seen. If such bleeding occurs, contact your physician immediately
or take your child to the emergency room. Bleeding is an indication
that the scabs have fallen off too early, and medical attention
is required.
Pain: Nearly all children undergoing a tonsillectomy/adenoidectomy
will have mild to severe pain in the throat after surgery. Some
may complain of an earache (because stimulation of the same
nerve that goes to throat also travels to the ear), and a few
may incur pain in the jaw and neck (due to positioning of the
patient in the operating room).
Pain control: Your physician will prescribe appropriate
pain medications for the young patient such as codeine, hydrocodone,
Tylenol with codeine liquid, or Lortab (hydrocodone with Tylenol).
Generally, an acetaminophen (Tylenol, Tempra, Panadol) teaspoon
solution is recommended for regular administration to the patient
for three or four days after surgery.
If you are troubled about any phase of your
child’s recovery, contact your physician immediately.
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Tonsillectomy Procedures
Unfortunately, there may be a time when medical
therapy (antibiotics) fails to resolve the chronic tonsillar
infections that affect your child. In other cases, your child
may have enlarged tonsils, causing loud snoring, upper airway
obstruction, and other sleep disorders. The best recourse for
both these conditions may be removal or reduction of the tonsils
and adenoids. The American Academy of Otolaryngology—Head and
Neck Surgery recommends that children who have three or more
tonsillar infections a year undergo a tonsillectomy; the young
patient with a sleep disorder should be a candidate for removal
or reduction of the enlarged tonsils.
The tonsillectomy today
The first report of tonsillectomy was made by
the Roman surgeon Celsus in 30 AD. He described scraping the
tonsils and tearing them out or picking them up with a hook
and excising them with a scalpel. Today, the scalpel is still
the preferred surgical instrument of many ear, nose, and throat
specialists. However, there are other procedures available –
the choice may be dictated by the extent of the procedure (complete
tonsil removal versus partial tonsillectomy) and other considerations
such as pain and post-operative bleeding. A quick review of
each procedure follows:
Cold knife (steel) dissection: Removal of the
tonsils by use of a scalpel is the most common method practiced
by otolaryngologists today. The procedure requires the young
patient to undergo general anesthesia; the tonsils are completely
removed with minimal post-operative bleeding.
Electrocautery: Electrocautery burns the tonsillar tissue and
assists in reducing blood loss through cauterization. Research
has shown that the heat of electrocautery (400 degrees Celsius)
results in thermal injury to surrounding tissue. This may result
in more discomfort during the postoperative period.
Harmonic scalpel: This medical device uses ultrasonic energy
to vibrate its blade at 55,000 cycles per second. Invisible
to the naked eye, the vibration transfers energy to the tissue,
providing simultaneous cutting and coagulation. The temperature
of the surrounding tissue reaches 80 degrees Celsius. Proponents
of this procedure assert that the end result is precise cutting
with minimal thermal damage.
Radiofrequency ablation (Somnoplasty):Monopolar radiofrequency
thermal ablation transfers radiofrequency energy to the tonsil
tissue through probes inserted in the tonsil. The procedure
can be performed in an office setting under light sedation or
local anesthesia. After the treatment is performed, scarring
occurs within the tonsil causing it to decrease in size over
a period of several weeks. The treatment can be performed several
times. The advantages of this technique are minimal discomfort,
ease of operations, and immediate return to work or school.
Tonsillar tissue remains after the procedure but is less prominent.
This procedure is recommended for treating enlarged tonsils
and not chronic or recurrent tonsillitis.
Carbon dioxide laser: Laser tonsil ablation (LTA) finds the
otolaryngologist employing a hand-held CO2 or KTP laser to vaporize
and remove tonsil tissue. This technique reduces tonsil volume
and eliminates recesses in the tonsils that collect chronic
and recurrent infections. This procedure is recommended for
chronic recurrent tonsillitis, chronic sore throats, severe
halitosis, or airway obstruction caused by enlarged tonsils.
The LTA is performed in 15 to 20 minutes in
an office setting under local anesthesia. The patient leaves
the office with minimal discomfort and returns to school or
work the next day. Post-tonsillectomy bleeding may occur in
two to five percent of patients. Previous research studies state
that laser technology provides significantly less pain during
the post-operative recovery of children, resulting in less sleep
disturbance, decreased morbidity, and less need for medications.
On the other hand, some believe that children are adverse to
outpatient procedures without sedation.
Microdebrider: What is a “microdebrider?” The microdebrider
is a powered rotary shaving device with continuous suction often
used during sinus surgery. It is made up of a cannula or tube,
connected to a hand piece, which in turn is connected to a motor
with foot control and a suction device.
The endoscopic microdebrider is used in performing
a partial tonsillectomy, by partially shaving the tonsils. This
procedure entails eliminating the obstructive portion of the
tonsil while preserving the tonsillar capsule. A natural biologic
dressing is left in place over the pharyngeal muscles, preventing
injury, inflammation, and infection. The procedure results in
less post-operative pain, a more rapid recovery, and perhaps
fewer delayed complications. However, the partial tonsillectomy
is suggested for enlarged tonsils – not those that incur repeated
infections.
Bipolar Radiofrequency Ablation (Coblation): This procedure
produces an ionized saline layer that disrupts molecular bonds
without using heat. As the energy is transferred to the tissue,
ionic dissociation occurs. This mechanism can be used to remove
all or only part of the tonsil. It is done under general anesthesia
in the operating room and can be used for enlarged tonsils and
chronic or recurrent infections. This causes removal of tissue
with a thermal effect of 45-85 C°. The advantages of this technique
are less pain, faster healing, and less post operative care.
Consult with our office regarding the optimum
procedure to remove or reduce your child’s tonsils and adenoids.
972-492-6990
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Tonsillitis
What is tonsillitis? Tonsillitis refers to inflammation of the
pharyngeal tonsils. The inflammation may involve other areas
of the back of the throat including the adenoids and the lingual
tonsils (areas of tonsil tissue at the back of the tongue).
There are several variations of tonsillitis: acute, recurrent,
and chronic tonsillitis and peritonsillar abscess.
Viral or bacterial infections and immunologic
