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Paediatric ENT Disorders

Paediatric ENT is the medical specialty that looks after ear nose and throat problems in children. Dr McGuinness has over 20 years of experience in the management of paediatric ENT problems but has a special interest in the management of neck lumps in children.

The common problems we see in paediatric ENT surgery include:

  • Adenoid and Tonsil Problems
  • Snoring and Sleep Apnoea
  • Glue Ear and Hearing Loss
  • Problems with breathing which are by no means common. They are however extremely important.
  • Paediatric Neck Lumps- again not common but very important

Adenoid and Tonsil Problems in Children

Enlarged Adenoids

Background

The adenoids are located right at the back of the nose and are comprised of lymphoid tissue. In childhood they are part of the immune system that fights infections. They have a tendency to increase in size during childhood, in response to routine childhood nose and throat infections. After childhood they get smaller but may still be present in young adults.

Symptoms and Signs

Children between the ages of 2 and 6 years are those most commonly affected by enlarged adenoids. Enlarged adenoids may block the back of the child’s nose leading to blockage, green discharge, snoring and sometimes obstructive sleep apnoea (OSA see later). Enlarged and infected adenoids may also lead to glue ear. Long term enlargement and blockage may lead to mouth breathing which can cause the bones of the face to grow abnormally to produce a long face with a small lower jaw, doctors call this the "adenoidal facies". Sometimes the first person to notice an adenoid problem maybe your dentist or orthodontist who spots a problem with the teeth and jaw alignment.

Diagnosis

Often it is even possible to look at the adenoids in small children with a flexible camera or nasoendoscope passed through the nose. If this is not possible, XRays of the back of the nose may show enlarged adenoids but are usually not needed to make a diagnosis.

Treatment

Enlarged adenoids in childhood are normal and for most children, with minimal symptoms, no treatment is required other than reassurance that they are likely to grow out of the problem.

If enlarged adenoids cause problems they can be treated in the following ways:

  • Medical. In children, a trial of a steroid nose spray may be appropriate before proceeding with surgery. This is especially the case if the child has known allergies especially to pollens or house dust mites.
  • Surgery. Adenoidectomy may be performed under general anaesthetic.

The following are some of the more common reasons for removal of the adenoids or Adenoidectomy:

  • Severe nose blockage or dischrage that does not respond to medical treatment
  • Child with Obstructive Sleep Apnoea (usually along with a tonsillectomy)
  • As a treatment of Glue Ear (with grommet insertion)
  • To rule out more serious problems, adenoid biopsy (mainly adults)

Adenoidectomy

This is the operation to remove the adenoids. It is a common operation in children. It is performed under general anaesthetic and is usually a day case procedure. Children having their adenoids (but not their tonsils) removed can return to school the next day. A pillow is placed beneath the shoulders and the neck extended. A catheter is placed through the nose to hold the soft palate out of the way and the back of the nose examined via the mouth using a mirror. Enlarged adenoids are then removed using an electrical suction-diathermy or a Coblation wand . These devices cauterise then suck away the adenoids. Complications are unusual but may include bleeding and minor scarring. The adenoids may occasionally grow back some years later especially in children with allergies.

The Tonsils

These small organs on the sides of the throat can cause problems out of all proportion to their size. Like the adenoids, they are part of the immune system and are partly responsible for the body’s response to infection. Childhood infection is common but unlike infection of the adenoids it is frequently painful.

Tonsillitis

In childhood the immune system is still developing and tonsillitis is extremely common. These infections are caused by common upper respiratory tract viruses and bacteria. It is unclear if bacterial infection follows initial viral infection. In teenagers a virus called Epstein Barr Virus (EBV) can cause glandular fever with repeated sore throats.

Symptoms and Signs

The child is generally unwell with a high temperature and lethargy. Both sides of the throat are sore and swallowing is often difficult. Tender lymph glands are often felt in the neck. Examination of the tonsils may show generalised redness or pus arising from the tonsils. The illness is generally self-limiting and gets better within a week. Plenty of fluids and painkillers such as paracetomol and ibuprofen are useful. Antibiotics are generally not required and should be reserved for cases that don’t get better after 72 hours.

Glandular fever is a variable illness. Tiredness, headache and muscle pain are usually worse than in straightforward tonsillitis. Enlarged lymph glands in the neck are common and large. Up to 10% of patients will develop jaundice.

Diagnosis

The diagnosis is usually made on the basis of a careful history. Throat swabs are not useful. During the acute episode and especially in adolescent patients a blood test looking for Glandular fever may be performed.

Treatment

Management of the severe, acute attack (i.e. a child who cannot swallow fluids and hence medication) is with anti-inflammatory medications, intravenous fluids and antibiotics. Penicillin will be effective in most cases but some bacteria are now resistant so Augmentin is also commonly used. It is important to avoid amoxycillin in glandular fever as it commonly produces a rash which may be mistaken for allergy.

Surgery:

Tonsillectomy is reserved for those children with significant recurrent tonsillitis. The usual rules for considering tonsillectomy are more than five episodes of significant tonsillitis (requiring time off school) per year or three episodes per year for two years.

Complications of acute tonsillitis

These may be divided into local and general complications. General complications are rare but include scarlet fever, rheumatic fever and glomerulonephritis (inflammation of the kidneys). Local complications are much more common, in smaller children especially. If there is a background of obstructive sleep apnoea, the swelling associated with tonsillitis may worsen snoring and breathing obstruction.

Peri-tonsillar abscess (Quinsy)

Infection can spread outside the tonsil where it forms a painful abscess. It is usually seen as a complication of tonsillitis in young adults.

Symptoms and Signs

The patient usually gives a history of a sore throat on both sides, but as it gets worse becomes more severe and one sided. They usually feel extremely unwell and have severe one sided throat pain which is commonly felt in the ear (referred otalgia). Examination reveals a sick looking patient who has a high temperature. They may be dehydrated. The voice has a "hot potato" quality due to throat obstruction by the swollen tonsil. The patient is often drooling and unable to swallow their saliva; the breath usually smells foul. Examination of the throat is always difficult as difficulty opening the mouth is nearly always present.

Diagnosis

It is the general condition of the patient that gives away the diagnosis of quinsy. They feel, look, sound and smell unwell! A CT scan is sometimes performed if the quinsy does not rapidly respond to treatment.

Treatment

The infection will usually only settle down once the abscess is drained. This is done by inserting a needle into the abscess under a local anaesthetic.

The patient is generally admitted to hospital for intravenous fluids, anti inflammatories and antibiotics . The risk of a second subsequent quinsy is in the region of 20%. Most surgeons would suggest tonsillectomy following a second quinsy. This is performed once the acute infection has settled.

Unilateral Tonsillar Enlargement

Background

It is entirely normal for there to be a difference in size between the two tonsils. However painless, one sided tonsil enlargement cannot be ignored as it may represent more serious problems.

Causes of unilateral tonsillar enlargement include:

  • Normal variant
  • Recurrent tonsillitis
  • Quinsy (painful)
  • Lymphoma
  • Squamous Cell Carcinoma (SCC)

Symptoms and Signs

Unilateral tonsil swelling is usually painless and may be noticed by chance. Except in the case of a quinsy, which is obviously quite different, it may be difficult to exclude serious disease without removing the tonsil and performing a biopsy.

Diagnosis

CT scanning may be helpful in diagnosing the cause of the swelling; it may also show associated lymph node swelling. Tonsillectomy and biopsy is however often required.

Tonsillectomy

The surgical removal of the tonsils is one of the most commonly performed surgical operations. In the past the most common reason for removing the tonsils was recurrent tonsillitis, it is now increasingly common to remove the tonsils as a treatment for obstructive sleep apnoea in a child. The main reasons for tonsillectomy are listed below.

  • Recurrent acute tonsillitis- > 5 significant episodes in a year
  • Recurrent peri-tonsillar abscess- usually after second episode
  • Treatment of Obstructive Sleep Apnoea / snoring
    • Children- Adenotonsillectomy
    • Adults- usually with soft palate surgery (see sleep disorders)
  • Exclusion of malignancy
    • Obvious tumour of tonsil
    • Unilateral tonsillar enlargement

The operation

Tonsillectomy is performed in a hospital under general anaesthetic. The shoulders are supported and the neck extended . The mouth is opened with a special device called a "mouth gag". The tonsil is grasped by forceps and the tonsil dissected from the surrounding tissue using an electrical scalpel that cuts and seals blood vessels at the same time. Local anaesthetic is injected into the tonsillar area to prevent post operative pain. The operation takes around 30-45 minutes and the patient usually spends one night in hospital.

Complications of tonsillectomy

Tonsillectomy is very safe, but as with all operations complications can occur. These include:

  • Pain – Pain is usual, may be severe and lasts around one week. A combination of Ibuprofen and Paracetomol is usually prescribed and should be taken regularly for the first 5 days.
  • Bleeding- Bleeding can occur immediately after the operation (primary or reactionary haemorrhage) this is very rare due to the use of electrical scalpels and cautery instruments. If it happens the patient most often requires a return to the operating theatre where the bleeding point may be identified and treated.
  • Secondary haemorrhage is more common. It occurs up to 6-8 days after tonsillectomy and is often preceded by an increase in pain and temperature. It is speculated that secondary haemorrhage is the result of post-operative infection of the tonsil wound. Giving antibiotics at the time of surgery or for 10 days after, does not however seem to prevent its occurrence. It is important that post tonsillectomy bleeding is taken seriously and that medical help is obtained. Most often the patient is admitted to hospital and given intravenous antibiotics, anti-inflammatories and in older children peroxide mouth washes. Rarely, if these measures are not successful, a return to the operating theatre is required.

Childhood Ear Infections (Acute Suppurative Otitis Media)

Background

This bacterial infection of the middle ear is very common in childhood. Few children will escape an episode. Bacteria can reach the middle ear space via its normal drainage tube, the Eustachian tube, via a hole in the eardrum or rarely by the bloodstream. Bacterial infection may be a primary event or may follow initial viral infection. The result is the formation of pus in the middle ear. It is a self -limiting condition in the vast majority of cases; for the unfortunate few middle ear infections can progress to major and life-threatening complications.

Clinical Presentation

The patient is most often a child. There is often a cold or flu like illness leading up to the ear infection. Infection of the middle ear results in severe earache, a loss of hearing and a child who feels unwell and has a high temperature. In very young children who cannot describe what is happening, ear infections may cause crying and screaming along with ear pulling and generalised restlessness.

Examination of the eardrum shows a red inflamed appearance which eventually progresses to a bulging yellow ear-drum (the yellow is the pus in the middle ear) and finally if untreated, to a perforation of the ear –drum and a wet, runny ear. Once the eardrum perforates and the ear discharges the pain, temperature and hearing loss begin to get better. Sometimes this natural resolution doesn’t happen and complications may occur. (See below)

Investigation

Clinical examination- reveals a red or bulging drum. At a later stage there is obvious ear discharge and a hole in the eardrum.

No other investigations are usually required. In some cases an ear swab will be taken to guide antibiotic treatment.

Management

Most cases are seen and managed in general practice.

  • Pain killers- Paracetomol and Ibuprofen are useful
  • Antibiotics- recently there has been a great deal of debate whether antibiotics are effective in this common and often self-limiting disease. They tend to be used in children less than two in whom complications are more common, in severe infections and in infections that are not settling spontaneously after 48-72 hours. If amoxycillin is used, it is as effective as more expensive drugs as a first line therapy. Failure to respond indicates possible drug resistance and the need for second line antibiotics such as Augmentin or a cephalosporin.
  • Some children develop recurrent bouts of ear infection requiring frequent medical attention. For some of these children, surgical insertion of drainage tubes into the ear-drum (grommets) to ventilate the middle ear can alleviate the pain associated with frequent infection and reduce the number of infections.

Complications of Suppurative Ear Infections

Complications within the ear

  • Glue Ear - in 10% of children following the ear infection there is persistent mucus formation in the middle ear. This can lead to a hearing loss and sometimes delayed speech development.
  • Hearing loss. As well as glue ear, ear infections can have direct toxic effects on the organ of hearing (the cochlea) producing a sensori-neural hearing loss, this is generally not reversible. Hearing loss can also be the result of damage to the delicate bones in the middle ear or due to a large perforation of the eardrum.
  • Dizziness- acute infection may spread to the balance organ resulting in dizziness.
  • Facial nerve weakness- in around 4 % of the population the nerve that supplies movement to the face travels through the middle ear cavity without its normal covering of bone. These patients are at risk of facial nerve paralysis during a bout of ear infection. This would normally return to normal once the ear infection has settled.
  • Mastoiditis – infection can spread to the bone behind the ear, the mastoid. Mastoiditis usually shows up as an ear infection that progresses to swelling and/or an abscess over the mastoid. This requires surgical drainage and often a mastoidectomy operation to clear the infection.

Complications outside the ear

These conditions are rarely seen following acute ear infections.

  • Neck abscess. Pus tracks from mastoiditis down into the neck where it causes a painful swelling.
  • Intra-cranial complications. These are the much feared complications of suppurative ear disease and thankfully these days they are rare. The brain is very close to the ear and separated from it by only a flimsy bony barrier called the tegmen tympani, the roof of the middle ear. Especially in young children in whom the bone is not yet fully developed, infection can spread from the middle ear to the brain. All of these complications, unless they are treated by aggressive surgery and antibiotic therapy may be fatal.

Glue Ear or Otitis Media with Effusion (OME)

Background

Glue ear or otitis media with effusion (OME), is an extremely common problem in children. It is estimated that it will affect around 4 out of 5 children before their 4th birthday. The number of these children in whom glue ear is present over a longer period is much lower.

There is a build up of thick sticky mucus or "glue" beneath the ear drum and this often follows an ear infection, acute otitis media. The glue prevents the eardrum from vibrating properly and passing sounds to the inner ear, causing a conductive hearing loss. It is thought to be common in young children as they have a relatively inefficient Eustachian tube, the natural ventilation tube for the ear. Certainly it is seen even more frequently in children in whom Eustachian function is compromised further, for example those with a cleft palate. Large adenoids are thought to act as a source of infection and therefore continued inflammation may make glue ear worse.

Clinical presentation

Glue ear often doesn’t cause many symptoms. Most often it causes nothing other than a mild to moderate hearing loss. You can get an idea of the sort of hearing loss most sufferers have by sticking your fingers in your ears!

The effect of this hearing loss may however be profound. Due to the young age of the population it affects, the presence of glue ear is often not noticed until the child fails a school hearing test or has a delay in their speech. Glue ear is the commonest cause of significant speech delay in toddlers.

The lack of hearing and speech may cause other problems in young children some of whom have difficulty concentrating and poor behaviour, there is also some evidence that some children with glue ear have poorer balance and may be regarded as "clumsy".

Occasional episodes of mild, short lived ear pain are not uncommon but are not associated with the severe pain and fevers seen with acute ear infections. Children may get severe ear pain when flying.

Examination of the ears with a special torch, an otoscope, shows dull grey looking eardrums which may look sucked in or retracted. They do not move with changes in air pressure. The nose may be blocked if large adenoids are present.

Investigation

Most often a hearing test (audiogram) and a pressure test (tympanogram) are performed to confirm the diagnosis. No other tests are required.

Treatment

Intervention is usually recommended for children with glue in both ears and hearing loss of 20 decibels or more for longer than three months. Treatment may also be recommended if the child suffers from repeated ear pain or ear infections. Usually a period of waiting (for three months) is recommended initially. This is because in many children the glue ear will get better by itself if given time.

If the glue ear continues to cause problems then surgery may be recommended. This is done under a short general anaesthetic. Using an operating microscope, small cuts are made in the child’s eardrum and the fluid sucked out. Small plastic drainage tubes, called grommets, are then inserted into the eardrums allowing the glue out and letting air back under the eardrum. The child can usually be discharged home a few hours later. This usually results in a speedy return of normal hearing and often dramatic improvements in speech and overall behaviour.

Grommets last roughly 6 to 18 months and are expelled naturally by the eardrum. Some children require multiple sets of grommets whilst normal Eustachian function is awaited. This can take until the early teens. Taking out the adenoids, adenoidectomy, has been shown to reduce rates of recurrent glue ear and the need for subsequent grommets; it is normally recommended for children requiring a second set of grommets.

After Surgery

Most children who have grommets inserted and their adenoids removed can go home the same day. Usually simple painkillers such as panadol are all that is required. There may be small amounts of bloodstained fluid coming out of the ears but this usually settles within 48 hours. If there is discharge after 48 hours this may be the result of an infection and specialist advice should be sought. The child’s ears should be kept dry when bathing or showering and they should not swim until they are reviewed usually after 3 weeks.

It is advisable that you protect your child’s ears when they are swimming if they have grommets. An easy way to do this is to put a big ball of cotton wool into the ear canal and cover this with a neoprene headband (http://www.littlegrommets.com/swimming-earbands.html).

Children with grommets are usually seen for review every 6 months and regular hearing tests are performed. The grommets drop out by themselves and hardly ever do they have to be removed.

Further Information

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