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
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:
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:
Signs of airway obstruction:
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:
Toxicityis 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:
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.
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
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:
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.
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.
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.
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:
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:
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:
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:
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.
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.
Do not hesitate to seek clarification from your physician if he or she uses a term that you do not fully understand.
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:
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:
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:
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.
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:
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:
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!
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:
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.
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.
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:
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.
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:
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.
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:
If you are troubled about any phase of your child’s recovery, contact your physician immediately.
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
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 factors lead to tonsillitis and its complications. Nearly all children in the United States experience at least one episode of tonsillitis. Because of improvements in medical and surgical treatments, complications associated with tonsillitis, including mortality, are rare.
Who gets tonsillitis?
Tonsillitis most often occurs in children; however, the condition rarely occurs in children younger than two years. Tonsillitis caused by Streptococcus species typically occurs in children aged five to 15 years, while viral tonsillitis is more common in younger children. A peritonsillar abscess is usually found in young adults but can occur occasionally in children. The patient’s history often helps identify the type of tonsillitis (i.e., acute, recurrent, chronic) that is present.
What causes tonsillitis?
The herpes simplex virus, Streptococcus pyogenes (GABHS) and Epstein-Barr virus (EBV), cytomegalovirus, adenovirus, and the measles virus cause most cases of acute pharyngitis and acute tonsillitis. Bacteria cause 15-30 percent of pharyngotonsillitis cases; GABHS is the cause for most bacterial tonsillitis.
What are the symptoms of tonsillitis?
The type of tonsillitis determines what symptoms will occur.
Acute tonsillitis: Patients have a fever, sore throat, foul breath, dysphagia (difficulty swallowing), odynophagia (painful swallowing), and tender cervical lymph nodes. Airway obstruction due to swollen tonsils may cause mouth breathing, snoring, nocturnal breathing pauses, or sleep apnea. Lethargy and malaise are common. These symptoms usually resolve in three to four days but may last up to two weeks despite therapy.
Recurrent tonsillitis: This diagnosis is made when an individual has multiple episodes of acute tonsillitis in a year.
Chronic tonsillitis: Individuals often have chronic sore throat, halitosis, tonsillitis, and persistently tender cervical nodes.
Peritonsillar abscess: Individuals often have severe throat pain, fever, drooling, foul breath, trismus (difficulty opening the mouth), and muffled voice quality, such as the “hot potato” voice (as if talking with a hot potato in his or her mouth).
What happens during the physician visit?
Your child will undergo a general ear, nose, and throat examination as well as a review of the patient’s medical history.
A physical examination of a young patient with tonsillitis may find:
Tonsillitis is usually treated with a regimen of antibiotics. Fluid replacement and pain control are important. Hospitalization may be required in severe cases, particularly when there is airway obstruction. When the condition is chronic or recurrent, a surgical procedure to remove the tonsils is often recommended.
Why Do Children Have Earaches?
To understand earaches you must first know about the Eustachian tube, a narrow channel connecting the inside of the ear to the back of the throat, just above the soft palate. The tube allows drainage — preventing fluid in the middle ear from building up and bursting the thin ear drum. In a healthy ear, the fluid drains down the tube, assisted by tiny hair cells, and is swallowed.
The tube maintains middle ear pressure equal to the air outside the ear, enabling free eardrum movement. Normally, the tube is collapsed most of the time in order to protect the middle ear from the many germs residing in the nose and mouth. Infection occurs when the Eustachian tube fails to do its job. When the tube becomes partially blocked, fluid accumulates in the middle ear, trapping bacteria already present, which then multiply. Additionally, as the air in the middle ear space escapes into the bloodstream, a partial vacuum is formed that absorbs more bacteria from the nose and mouth into the ear.
Why do children have more ear infections than adults?
Children have Eustachian tubes that are shorter, more horizontal, and straighter than those of adults. These factors make the journey for the bacteria quick and relatively easy. A child’s tube is also floppier, with a smaller opening that easily clogs.
Inflammation of the middle ear is known as “otitis media.” When infection occurs, the condition is called “acute otitis media.” Acute otitis media occurs when a cold, allergy or upper respiratory infection, and the presence of bacteria or viruses lead to the accumulation of pus and mucus behind the eardrum, blocking the Eustachian tube.
When fluid forms in the middle ear, the condition is known as “otitis media with effusion,” which can occur with or without infection. This fluid can remain in the ear for weeks to many months. When infected fluid persists or repeatedly returns, this is sometimes called “chronic middle ear infection.” If not treated, chronic ear infections have potentially serious consequences such as temporary or permanent hearing loss.
How are recurrent acute otitis media and otitis media with effusion treated?
Some child care advocates suggest doing nothing or administering antibiotics to treat the infection. More than 30 million prescriptions are written each year for ear infections, accounting for 25 percent of all antibiotics prescribed in the United States. However, antibiotics are not effective against viral ear infections (30 to 50 percent of such disorders), may cause uncomfortable side effects such as upset stomach, and can contribute to antibiotic resistance. Medical researchers believe that 25 percent of all pneumococcus strains, the most common bacterial cause of ear infections, are resistant to penicillin, and ten to 20 percent are resistant to amoxicillin.
Is surgery effective against recurrent otitis media and otitis media with effusion? Before the procedure: Prior to the procedure, the otolaryngologist will examine the patient for a description of the tympanic membrane (eardrum) and the middle ear space. An audiometry may be performed to assess patient hearing. A tympanometry will be performed that tests compliance of the tympanic membrane at various levels of air pressure. This test provides a measurement of the extent of middle ear effusion, Eustachian tube function, and otitis media.
The procedure: During the procedure, a small incision is made in the ear drum, the fluid is suctioned out, and a tube is placed. In young children, this is usually done under a light, general anesthesia; older patients may have the procedure performed under local anesthesia. There are over 50 different tube designs, all in different shapes, color, and composition. In general, smaller tubes stay in for a shorter duration, while large inner flanges hold the tube in place for a longer time. Some recent tubes have special surface coatings or treatments that may reduce the likelihood of infection.
After the procedure: Immediately after the procedure, the surgeon will examine the patient for persistent or profuse bleeding or discharge. After one month, the tube placement will be reviewed, and the patient’s hearing may be tested. Later, the physician will assess the tube’s effectiveness in alleviating the ear infection.
In some cases, surgery may be the only effective treatment for chronic ear infections. Some physicians recommend the use of laser myringotomy, using a laser to create a tiny hole in the eardrum. The treatment is done in the doctor’s office using topical anesthesia (ear drops). Laser myringotomy works by providing several weeks of ventilation for the middle ear. Proponents suggest this can reduce the many courses of antibiotic treatment for severe ear infections and eliminates the need for surgical insertion of tubes with general anesthesia.
What is the most common surgical treatment for ear infections?
The most common surgical procedure administered to children under general anesthesia is myringotomy with insertion of tympanostomy tubes (TT). A tube is inserted in the middle ear to allow continuous drainage of fluid. The procedure is recommended for treatment of: chronic otitis media with effusion (lasting longer than three months), recurrent acute otitis media (more than three episodes in six months or more than four episodes in 12 months), severe acute otitis media, otitis media with effusion and a hearing loss greater than 30 dB, non-responsiveness to antibiotics, and impending mastoiditis or intra-cranial complication due to otitis media.
If the patient is age six or younger, it is recommended that tubes remain in place for up to two years. Most tubes will fall out without assistance. Otherwise, the specialist will determine when the tubes should be removed.
Your ENT physician will recommend the most effective treatment for your child’s ear infection.