When to consult an ENT Doctor for my child?

“Your child’s Pediatrician is the primary care provider and incharge of your child’s health.”

Parents should consult a Pediatric ENT only if the child’s Pediatrician has suggested them to do so.

Pediatric otolaryngologists are concerned with treatment of medical and surgical ENT disorders in children. They have been trained to take care of children from newborn period to teenage years.

Children are not just small adults.The disease presentations and management can differ from adults.Right from the clinical approach for diagnosis differs in children.It needs specialised training and experience in working with children to keep them comfortable while examining them.

A child will not always be cooperative and will not be able to answer medical questions or express their problems. Sometimes they have their own ways of expressing concerns. I cannot forget a 3 year old telling me her ears are “singing” and we did go ahead and found a cause.

If we learn to interact with kids, they are also capable of giving information.They may not answer direct questions or get overwhelmed with questioning.

Interaction with the child is a must for a pediatric otolaryngologists as they are the ones who needs attention.This is especially useful in diagnosing social and communication disabilities.Many times parents are in denial or do not know age appropriate behaviours,in these situations direct interaction with the child is a must.

All of the above requires experience,skill and judgement with the team including the primary treating pediatrician.

Finally be a child with the child….

Tongue Tie in babies and children

Tongue-tie (ankyloglossia) is where the strip of skin connecting the baby’s tongue to the floor of their mouth is shorter than usual.

Some babies who have tongue-tie don’t seem to be bothered by it.

In others, it can restrict the tongue’s movement, making it harder to breastfeed.
Other potential problems could be difficulty in sticking tongue out and sticking it side to side.
 
Treatment of choice depends on the infant’s ability to feed.

Division with scissors in outpatients is the optimum treatment up until the age of 12 weeks after which, without general anaesthetic, it is not feasible

There is anxiety among parents that child will not learn speech and language due to tongue:this is not true. Learning speech and language is a higher skill.

Drooling in Children

Drooling is unintentional salivary flow from the mouth.It is common or physiological in children below 4 years of age.

Saliva is mainly produced by three pairs of salivary glands.

Saliva has following functions:

  • Protects dentition and gingiva
  • Lubricates oral mucosa and helps swallowing and speech
  • Antibacterial
  • Digestion

Drooling can also occur with teething due to stimulation of salivary reflex and hypersalivation.

After 4 years of age, drooling is considered abnormal. However, children with neurologic impairment may be slow in their oral neuromuscular control development, and may continue to improve this control until 6 years of age.

Drooling beyond toddlers should be shown to a doctor.Most of the time it can be due to neurological impairments.After assessment of severity and cause, treatment is planned.Many times conservative approaches like head and neck positioning as well as exercises to improve jaw/tongue movements and mouth closure help.

In severe cases medical and surgical intervention are offered by specialists

Steam Inhalations

Being an ENT Surgeon,I often keep telling patients to do steam inhalations.Next comes a query- how to do steam inhalations?

The simple way is sitting with your head over a bowl of hot water. Place a towel over your head, close your eyes and breathe deeply. Avoid getting the hot steam in your eyes.Adding menthol, eucalyptus, camphor, thymol or pine oil to the water may help,however plain water also does the job of loosening the mucus.

Steam inhalation in children as described above should be avoided due to the risk of scalding in babies & younger children. Instead, a child may benefit from sitting in a hot, steamy bathroom.

There are now steamers available in the market which prevent the risks of accidental burns & scalding.However get a good product as my personal experience with a local made product has been mould in the equipment if left unused for some days!

Vapour rubs are also traditionally used.However it is not advisable to put them in steam/hot water.Apply the rub to your chest and back. Don’t apply it to their nostrils because this could cause pain and breathing difficulties

Children with Special Abilities

“It was ability that mattered, not disability, which is a word I’m not crazy about using.” – Marlee Matlin

Could not agree more ……Every child’s needs attention and so do children with special abilities.

As an ENT Surgeon working with hearing impaired children, I come across children with various speech and language disorders as well.

Also I get involved in multidisciplinary teams who take care of children with drooling and swallowing problems as well.

Regular hearing and vision check ups are necessary in children.If a child cannot express his/her needs ,we need to be more responsible in taking care of the sensory issues.This will help them in undergoing other therapies in full potential.

A small procedure as removing impacted wax gives the child the joy of hearing normally again and prevents water retention and ear infection.

As an ENT surgeon, working with special children & their parents.The role of an ENT will be in assessing,diagnosing ear, nose,throat problems & helping in habilitation alongside the therapists.

Ear:

Often hearing disability or impairment goes undiagnosed as it is not as explicit or obvious as physical impairment or blindness.Ear wax & middle ear effusions should be regularly attended to as in any other child.

Reduced hearing acuity during infancy and early childhood interferes with the development of speech and language skills, because it is likely that the child will not receive adequate auditory, linguistic, and social stimulation required for speech and language learning, social and emotional development, and that family functioning will suffer accordingly (NIH, 1993).It can be argued that these effects are even larger in a population with an intellectual disability.

There are also communication disorders which can be of several types including expressive language disorder & mixed receptive-expressive language 

Nose:
Commonly we come across nasal allergy,infection,muscular tone /nasopharyngeal narrowing due to structural abnormality or adenoids.

Throat:

Specific problems in differently abled children are drooling & swallowing or feeding difficulties.

It is considered abnormal for a child older than four years to exhibit persistent drooling and this problem is most commonly seen in special children.The management is tailored case basis.It can be conservative-speech therapy & oral stimulation therapy to use of Appliances –Dental.We also sometimes use anticholinergic drugs.Injection of botox in the salivary gland & Surgery is reserved for severe cases.

In conclusion,there is so much to do & help our special kids.Its all about strengthening their abilities…as a team.

Adenoids and Tonsils in Children

Removal of Adenoids and Tonsils/Adenotonsillectomy is commonly indicated in the following conditions:

  1. Recurrent infections:more than 3-4/years for 2 consecutive years
  2. Upper airway obstruction due to enlarged tonsils and adenoids
  3. Peritonsillar Abscess
  4. Asymmetrical Size of Tonsils
  5. Adenoidectomy especially if recurrent middle ear infections or sinusitis in children

Surgical Removal of adenoids and Tonsils can be done through following techniques:

in the order of older to newer techniques as they evolved.We shall discuss how we decide which technique to be used at the end of the article.

  • Cold knife (steel) dissection:Gold old method using surgical dissection of tissues with bleeding controlled with taking ties.
  • ElectrocauteryThermal Dissection
  • Harmonic scalpelThis medical device uses ultrasonic energy to vibrate its blade at 55,000 cycles per second.
  • Radiofrequency ablationMonopolar radiofrequency thermal ablation transfers radiofrequency energy to the tonsil tissue through probes inserted in the tonsil. This procedure is recommended for treating enlarged tonsils and not chronic or recurrent tonsillitis. However, tonsils may re-grow after this procedure.
  • Carbon dioxide laserHand-held CO2 or KTP laser to vaporize and remove tonsil tissue.
  • MicrodebriderThe microdebrider is a powered rotary shaving device with continuous suction often used during sinus surgery.
  • 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.

I have personally been trained and used all above techniques.Harmonic Scalpel and Coblation while training in the U.K.I also learned Bipolar Tonsillectomy which if used carefully gives good outcomes.

As a Surgeon,my decision to use any particular technique depends on following factors :

  • I have to first be familiar and learn each technique.
  • Then go through medical literature about randomised controlled trails and their results about each technique.
  • Availability of equipment in my setting
  • One technique or combination of technique
  • What has worked for my patients so far in terms of less bleeding and less pain
  • Lastly..Do No Harm.

Tonsils can be examined in the opd on oral examination.

I must make a special mention about Adenoids here.Anatomically the adenoids sit at the back of the nose,behind and above soft palate.Here is a picture of nasoendoscopy done in the opd (picture 1) to look for the size of adenoid(picture 2)

The approach to adenoid has improved with endoscopes through the nose.There is a risk of incomplete removal of adenoids with traditional method.Newer techniques like Microdebrider and Coblater will ensure complete removal and avoid regrowth.

I am very comfortable to use dissection Technique for tonsillectomy with minimal bipolar for hemostasis with excellent outcomes in the last 9 years.For Adenoidectomy,I use Microdebridor or Coblator.

What medical literature says..these are articles from Medline Database

Laryngoscope. 2009 Jan;119(1):162-70. doi: 10.1002/lary.20024.

Comparison of three common tonsillectomy techniques: a prospective randomized, double-blinded clinical study.

Wilson YL1, Merer DM, Moscatello AL

Otolaryngol Head Neck Surg. 2003 Oct;129(4):360-4.

Hot versus cold tonsillectomy: a systematic review of the literature.

Leinbach RF1, Markwell SJ, Colliver JA, Lin SY

Cochrane Database Syst Rev. 2007 Jul 18;(3):CD004619.

Coblation versus other surgical techniques for tonsillectomy.

Burton MJ1, Doree C

Nasal polyps in children

Nasal Polyps are common nasal swellings or masses seen in children.

The paranasal sinuses (“the sinuses”) are air-filled cavities located within the bones of the face and around the nasal cavity and eyes.

Each sinus is named for the bone in which it is located:

Maxillary sinus– one sinus located within the bone of each cheek

Ethmoid sinus– located under the bone of the inside corner of each eye, although this is often shown as a single sinus in diagrams   this is really a honeycomb-like structure of 6-12 small sinuses that is better appreciated on CT scan images through the face

Frontal– one sinus per side, located within the bone of the forehead above the level of the eyes and nasal bridge

Sphenoid– one sinus per side, located behind the ethmoid sinuses; the sphenoid is not seen in a head-on view but is better appreciated looking at a side view

However in children sinuses are still developing and when we refer to sinuses in children;it is mainly maxillary and ethmoids.

Nasal polyps in children can be inflamatory (bacterial),allergic or associated with cystic fibrosis. 

The nasal polyps are of two kinds mainly : Antrochoanal or Sinonasal.

Antrochoanal are ususally single polyps aising from the maxillay antrum and going towards the choana (posterior opening of nostrils).They are usually one sided.

Sinonasal usually arise from the sinus lining of both sides of sinuses.

The common symptoms of polyps are 

nasal block

obstructive sleep apnoea or snoring in children

sometimes nose bleed

Usually the ENT surgeon will ask for CT scan to know the extend of disease.

The nasal polyps require surgical removal.Nowadays in children it is usually endoscopic approach.Sometimes transoral and other approaches are require for complete removal.

As a surgeon,I always consider the growing anatomy of sinuses,unerupted teeth and concern for facial growth in children while deciding the surgery.

Sinusitis in Children

Sinusitis is the inflammation of the sinuses.Though an adult has four pairs of sinuses,in children it is usually the maxillary and ethmoid sinuses are involved as the sphenoid and frontal sinuses are still developing.

In children,common cold or viral infection is the commonest cause of sinusitis.

Other common cause is foreign body in the nostrils or untreated allergic rhinitis leading to sinusitis.


Common symptoms the child will have are

Nasal discharge: green or yellow

fever

cough

headache

facial pain or pressure over face

swelling or redness over face or cheeks

swelling around the eyes


Child should be immediately seen by their physician who will decide the treatment starting from decongestion of the nose to allergy treatment or antibiotics depending on diagnosis.

Ocassionally scans are ordered:CT scan of sinuses especially if eye is involved.

Vertigo in children

Vertigo in children is uncommon.The attacks of vertigo in children may be less dramatic than adults,however they cause severe anxiety if a diagnosis is not reached and appropriately explained.

The clinical diagnosis involves accurate history which many adults are not capable of giving.The reason I say so is that the terms “Vertigo” “Dizziness””Giddiness” and “Imbalance” are very commonly used without proper understanding by adult patients,let alone poor child!

When a child presents with vertigo, we also need to keep in mind their distractibility,coordination capabilities and behavioral problems.Also the compliance in pediatric population to perform otoneurological examinations is limited

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