Sleep Disordered Breathing

Breathing Easier: Sleep Disordered Breathing (SDB) in Children

What is Sleep Disordered Breathing?

Sleep Disordered Breathing (SDB) is a characterization of sleep patterns in children which  include; snoring, restless sleeping, awakening at night, obstructive events (apnea), behavioral changes during the day (hyperactivity, lethargy, increased daytime fatigue) as well as difficulty in arousal and difficulty in getting a child to sleep.

The most common cause of Sleep Disordered Breathing in children is an enlarged adenoid and/or tonsils. It is a disorder, which if left untreated, results in difficulty in cognitive function during the day, behavioral changes and significantly decreased quality of life for children.

How can I tell if my child has Sleep Disordered Breathing?

Snoring is very common in children, and in fact, it is prevalent in about 12% of children in the general population. However, 1-3% percent of children will exhibit not only snoring, but Sleep Disordered Breathing. Parents will usually notice this when families are together on vacation and the child is sleeping in the same room. Frequently, the child will exhibit signs of restless sleep, tossing and turning throughout the night, awakening in the middle of the night (usually after midnight), sleep walking, bed wetting and tiredness during the day. Other children who have to sleep in the same bedroom will usually complain about not being able to sleep well because of the noise of snoring, pauses in breathing or their bedmate sleeping restlessly and pushing them out of bed.

Why is it important to determine if my child has Sleep Disordered Breathing?

Children who have prolonged Sleep Disordered Breathing (greater than 4-months) that is not due to an acute illness, may suffer from significant decrease in their quality of life. Behavioral changes such as hyperactivity, loss of concentration and cognitive function have led to the diagnosis of Attention Deficit Disorder in children. In addition, children who have prolonged Sleep Disordered Breathing can have cognitive and learning disabilities which can extend into the teenage years. More importantly, the benefits of diagnosis and treatment Sleep Disordered Breathing leads to a significant improvement in quality of life. Greater than 80% of children who have documented and treated Sleep Disordered Breathing will benefit from long term increases in cognitive ability, behavioral stabilization and more even temperament. Prolonged bedwetting has also been associated with problems with sleeping and Sleep Disordered Breathing is no exception.

What should I do if I suspect my child has Sleep Disordered Breathing?

If your child exhibits signs not only of snoring, but of restless sleep, awakening at night, daytime sleepiness, change in behavior, bedwetting or daytime hyperactivity, it may be best to talk with your pediatrician about a referral to a pediatric ear, nose and throat specialist. Once there, your doctor will ask you several questions about symptoms and examine your child. If the physical exam matches the medical history then further studies or treatment may be offered at that time. For some small children, adenoidectomy alone may be sufficient to alleviate the symptoms. However, in most cases, tonsillectomy and adenoidectomy is the treatment of choice. There are several methods under which this is done. Your doctor will choose the method best suited for your child to make the best recovery possible.

I thought they were not removing Tonsils any longer?

Although many parents will hear from friends and physicians alike that tonsils are no longer being removed, it is still one of the most common procedures in children in the U.S.. According to the recent government numbers available, 300-400,000 tonsillectomies are performed every year in children and adolescents. The tonsils produce antibodies that are helpful to fighting infection in the first two years of life. However, after 2 years, they serve as part of the larger lymph system and are only 2 of 300 lymph nodes in the head and neck area. That is why studies have proven removal of the tonsils and/or adenoid presents no long term detriment to the child.

Lump or Mass in the Neck

Congenital Neck Masses

What is a congenital neck mass?

A congenital neck mass is a growth that is present at birth and slowly becomes noticeable to the patient or family. Although the neck abnormality is present since birth, the resulting lump may not appear until much later in life.

What are the types of congenital neck masses?

Congenital neck masses can take many forms. The most common congenital masses that are treated by an ear, nose, and throat specialist are:

Each of these causes will be discussed in detail below as well as Deep Neck Infections.

BRANCHIAL CLEFT ANOMALY

What are Branchial Cleft Anomalies?

Branchial cleft fistulas (tracts) and cysts (called anomalies) are found in the neck and are composed of tissue trapped in the developing neck. These anomalies appear as a soft lump or draining opening on one side of the neck. They can appear in any age group yet are very common in the first decade of life. Because these anomalies develop in the growing embryo, any tract that forms in combination with a cyst follows a fairly predictable pattern. The tracts connect the cyst to the inside of the throat at a specific area. It is important to understand this relationship so that the entire tract can be excised and will not recur.

There are three kinds of branchial cleft anomalies. A first branchial cleft anomaly (Fig. 1) is more unusual and may be involved with the nerve that moves the facial muscles (Facial nerve).

 

Second and third branchial anomalies are common. Fig. 2 shows how they differ by location.

If your child has been diagnosed with a branchial cleft anomaly, many times the physician will order a CT scan (cat scan). This test will allow us to identify the exact location of the mass and/or tract as well as its relation to blood vessels and nerves in the neck.

Once an anomaly has been identified, treatment consists of surgically removing the cyst before it has a chance to get infected and become an abscess. Surgery is performed under general anesthesia by making an incision over the cyst or draining area. Every effort is made to place the incision in an existing skin crease so that cosmetically the child’s scar will be minimal. Plastic surgery techniques are always used to close the incision. Branchial cleft anomalies are usually removed as an outpatient procedure. These operations usually last between one and two hours. Ear, nose and throat specialists have extensive training in surgery of the neck, making them the most qualified physicians for this type of surgery.

If the cyst has become infected (or formed an abscess) prior to removal, incision and drainage of the abscess may be necessary first, followed by treatment with antibiotics. The cyst and tract can then be safely removed at a later date.

THYROGLOSSAL DUCT REMNANTS

What are Thyroglossal Duct Cyst?

Thyroglossal duct cysts are cysts that are left over when the thyroid migrates from the base of the tongue into the neck before birth. The cyst is connected to the back of the tongue by a small tract. The cyst usually lies in the middle of the neck in front of the “Adam’s Apple” (Fig. 3).

Thyroglossal duct cysts usually show up in the first ten years of life, but may be found in older children or even adults. It is a benign cyst that usually contains mucous or even pus-like fluid. Many times, these cysts will not be evident until your child has an upper respiratory infection (cold). After which, the cyst will suddenly appear in the front of the neck. The sudden appearance or rapid enlargement of these cysts can be alarming. If a cyst is infected, many times antibiotics and/or drainage may be necessary to control the infection prior to definitive removal.

However, if the cyst appears without infection, and you wish to avoid further problems with infection, surgical removal is best performed before the cyst is ever infected.

Thyroglossal duct cysts are usually in the middle of the neck and seem to move up and down during swallowing. Because thyroid tissue may be inside the cyst, it is important to make sure that the thyroid gland has developed normally (and that not all the thyroid tissue is within the cyst). Your doctor may order an ultrasound and/or a thyroid scan to make sure the “cyst” is not the only functioning thyroid gland.

Once these tests have been completed, excision of the cyst may be performed as an outpatient procedure. This operation usually takes 45 minutes to an hour. Your child may leave the same day but will require decreased activity in the first week after surgery.

LYMPHATIC DRAINAGE ABNORMALITIES
(CYSTIC HYGROMAS)

What is a lymphangioma?

A lymphangioma is the result of an abnormal collection of lymph channels in the body. These channels usually link the disease-fighting lymph nodes together. During fetal development connections may occur causing cysts made up of these channels to grow. Large extensive collections of these are known as lymphangiomas or cystic hygromas. They grow steadily with the child and usually surround normal muscles, blood vessels, and nerves. These cysts can involve the neck, oral cavity, face and airway. They can also extend into the chest.

How are lymphangiomas recognized?

Because of their size, lymphangiomas are usually visible as a large compressible (can flatten when pushed on) mass. Those not noticed at birth are recognized before most children reach their second birthday.

Why are lymphangiomas of concern?

Lymphangiomas grow around normal muscles, blood vessels, and nerves. They may become quite extensive and cause significant cosmetic (appearance) deformities and functional disabilities. They may prevent the child from swallowing normally, speaking, or even breathing. The cysts are not cancerous. However, they continue to grow and many times cannot be completely removed without sacrificing an important normal structure.

How is a lymphangioma diagnosed and treated?

DIAGNOSIS: These lesions are first evaluated by physical examination. Magnetic Resonance imaging (MRI) is the imaging study that gives the best information regarding the extent and location of the cystic hygroma. X-rays and CT scans may also be used to help fully realize the extent of the cyst.

Once the location and extent into surrounding structures has been studied, therapy best suited for the patient can be initiated.

TREATMENT: There are generally two methods used to treat lymphangiomas:

Medical – This method utilizes medications (sclerosing agents) injected into the cyst to reduce the size of the cyst. This means that the cyst is not removed, but “scars” down on itself so that growth stops.

Surgical – This approach to treatment of a lymphangioma is excision of the cyst with a surgical procedure. *If airway involvement is present, the lymphangioma is removed as soon as it is diagnosed. Sometimes, a TRACHEOTOMY may be needed to secure the airway.

Our practice’s philosophy is to surgically remove those lesions that appear to be removable with a single operation. Many times this is done in the first few months of life. If, however, the lesion is quite extensive and places the child at risk for nerve, blood vessel, or muscle damage, or, would result in significant deformity in the appearance of the child, sclerosing agents are recommended.

HEMANGIOMA

What is a hemangioma?

A hemangioma is an abnormal growth of blood vessels that are formed before or shortly after birth. They can be very small (pinpoint) or grow to be quite large. They need to be distinguished from vascular malformations (abnormal connections between blood vessels) because treatment is different.

What do hemangiomas look like?

Hemangiomas may look like small red pimples on the skin, large bulging bluish-red masses protruding from the forehead or eyelid, or soft compressible bluish masses in the neck. Hemangiomas may also involve the breathing tube just below the voice box (subglottic area) causing noticeable breathing problems.

Hemangiomas usually start to grow larger shortly after birth (proliferative stage) reaching a peak at 18 months to 2 years of age. At that point, most hemangiomas will start to shrink (involute). This process may take several years.

How are hemangiomas diagnosed and treated?

DIAGNOSIS: Magnetic resonance imaging (MRI) is used to diagnose hemangiomas. Sometimes, a biopsy (a small amount of tissue from the lesion) is required to confirm the diagnosis.

TREATMENT: If hemangiomas are located in areas that cause the patient breathing problems (in the airway) or problems seeing (covers part of the eye), steroids may be given to shrink the mass. However, steroids only give temporary relief and therefore need to be given over long periods of time. In addition, this form of treatment has its own risks due to side effects of steroids. Should this treatment option be recommended, your physician will discuss these issues in detail with you.

If steroids are not advised, then surgical therapy is an alternative to remove or reduce the size of the hemangioma more permanently. Surgical therapy using laser has been very helpful in shrinking or excising (removing) hemangiomas.
Both the CO2 (carbon dioxide) and YAG laser are used in our practice.

DERMOID CYST

What is a dermoid cyst?

A dermoid cyst is a mass containing skin, hair, and skin glands that are trapped under the skin, usually located in a line drawn from the middle of the forehead to the bottom of the neck. An ear, nose, and throat specialist is commonly consulted to evaluate a congenital dermoid cyst located on the scalp, face, in the nose or on the neck.

How is a congenital dermoid cyst recognized?

A dermoid cyst is recognized as a small, painless swelling on the face, scalp, nose, or neck. They can range in size from 1 to 4 centimeters (about 1/2 to 3 inches) across. These cysts may need to be differentiated from other congenital neck masses, which can be done with careful physical exam. Sometimes, imaging (picture type) studies such as CT scans or MRI’s are needed. CT scans are also useful to look for any part of the dermoid cyst that may extend into the skull bone. This is especially true of nasal dermoid cysts, which look like a small hole on top of the nose, usually with a hair sticking out.

How are dermoid cysts treated?

Dermoid cysts need to be surgically removed and this is usually a simple surgical procedure. Nasal dermoid cysts, however, require more extensive evaluation looking for invasion into the skull, and may require surgical removal by an ear, nose, and throat surgeon, working with a neurosurgeon.

DEEP NECK INFECTIONS

What is a “deep neck” infection?

A “deep neck” infection refers to an infection or abscess (collection of pus) located deep under the skin near blood vessels, nerves, and muscles.

Where is the “deep neck” located?

There is a band of tissue in the neck called the cervical fascia, which divides the neck into superficial (just under the skin) and deep layers. The deep layer of the neck is then further subdivided into various spaces. A deep neck infection is an infection that is located in one of these spaces in the deep layer of the neck. Ear, Nose, and Throat surgeons are experts in the anatomy of the neck including these spaces.

Although a deep neck infection can be seen in any of the deep neck spaces, the most common spaces in which deep neck infections are found in children are:

  • RETROPHARYNGEAL SPACE
    This space is located directly behind the mouth.
    The lymph nodes (infection fighting structures) that drain the ADENOIDS, SINUSES, nose, and pharynx (back of throat) are located in this space. Infections in any of these areas can result in spread of infection to these lymph nodes, resulting in lymphadenitis (infection of the lymph nodes) and abscess formation (collection of pus). The retropharyngeal lymph nodes become significantly smaller after five years of age; therefore, this infection is usually seen only in younger children.
  • PERITONSILLAR SPACE
    Located in the tissue around the tonsil in the back of the throat.
    Infection in this space usually results from an untreated infection of the tonsils (TONSILLITIS). This type of infection is known as a peritonsillar abscess or quinsy (a collection of pus in the peritonsillar space) and is probably the most common type of deep neck infection. This infection can occur at any age.
  • PARAPHARYNGEAL SPACE
    It is located just behind the carotid artery (delivers blood to the head), just to the side of the throat. Infections in this area are due to common upper respiratory infections that spread to the lymph nodes located in this space. If an infection in this area remains untreated, the neck swells and the child stops moving the neck, indicating pain.
  • SUBMANDIBULAR SPACE
    This space is located under the jaw on each side. Infection in this space is usually the result of a dental infection and is known as Ludwig’s angina. It is more commonly seen in adolescents, but can also occur in younger children.

What causes a deep neck infection?

In children, deep neck space infections are usually caused by more common infections, such as dental abscesses, tonsillitis, or respiratory infections that are located “above” these spaces that spread into these deep spaces by the lymphatic system (system that drains fluid in the body).

Lymph nodes (contain disease fighting cells) in these spaces then become infected (lymphadenitis).

Additionally, bacteria can be directly introduced to a deep neck space by trauma affecting the area (more commonly seen in adults).
Finally, an infection from one deep space may spread to another deep space directly.

What are the symptoms of a deep neck infection?

Some of the more common symptoms of a deep neck infection include: Decreased ability to move the neck, asymmetry of the neck and back of the throat, difficulty or pain when swallowing, drooling, sick appearance, fever, and swelling in the neck, under the jaw, or on the face. Difficult or fast breathing may also be noted if airway involvement has occurred.

What are the complications of a deep neck infection?

The complications of deep neck infections can be life threatening; therefore, early detection and treatment are of extreme importance.
Some of these complications include:

  • Airway obstruction -probably the most serious initial complication; a deep neck infection can create swelling that pushes in on the airway causing partial or complete obstruction (blockage)
  • Spread of the infection – deep neck infections can spread to other deep neck spaces, as well as the mediastinum (middle chest cavity), lungs (empyema-pus in the lungs), bloodstream (sepsis), and bones (osteomyelitis)
  • Thrombus (clot) formation in arteries and veins of the neck
  • Nerve involvement - the nerves which affect vocal cord movement, eyelid closure, sweating, and pupil constriction may also be pressed upon causing nerve dysfunction

How is a deep neck infection evaluated?

Because the infection is only noted by swelling in the neck a careful history and physical examination is important when suspecting a deep neck infection.

Blood tests useful in the evaluation of a deep neck infection include blood counts (for signs of infection), chemistry profiles (to check for lack of fluid intake), and blood cultures (to check if the infection has spread to the blood).

X-rays of the neck, teeth, and chest may also be indicated depending on the type of deep neck infection suspected.

CT scans are the standard of care (test of choice) when evaluating the extent of a deep neck space infection. They give very accurate pictures of the infection’s location, which is especially useful if surgical drainage of the infection is required.

How is a deep neck infection treated?

Because of the immediate threat of airway obstruction, most deep neck infections require hospitalization. When the airway is narrowed, an endotracheal (breathing tube passed through the mouth) or nasotracheal (breathing tube passed through the nose) tube may be placed to hold open the airway until the infection can be treated. In severe cases, when a breathing tube cannot be inserted, a TRACHEOTOMY may be temporarily required.

Most patients will have a history of decreased fluid and food intake, therefore fluids given by vein will usually be required.

All patients with deep neck infections are started on antibiotics given by vein. In a select group of patients, careful hospital observation and antibiotics may be enough to treat the infection. However, surgical drainage is required in some cases. Please see DRAINAGE OF NECK ABSCESSES for details.

When is an ear, nose, and throat specialist involved in the treatment of a deep neck abscess?

Because airway obstruction is always a concern with a deep neck infection, an ear, nose and throat specialist is usually consulted immediately to help manage the airway and determine whether surgical therapy is needed.

Traumatic Injuries to the Head and Neck

How common is face and neck trauma in children?

Facial and neck trauma occurs frequently in children, however, because of the small face size, skeletal flexibility and increased fatty tissue in a child’s face, most of these injuries result in soft tissue (cuts and bruising) injuries. Fortunately, serious facial and neck fractures are uncommon. Serious injuries are not normally caused by childhood play, but are usually the result of motor vehicle accidents, kicks by animals, or fights. Serious face and neck injuries are more difficult to recognize in children compared to an adult and are often a challenge to treat.

Serious injuries to the skull (brain) and spine are actually more common in children than injuries to the face and neck. However, these regions are not within the ear, nose and throat specialty.

This topic will focus on the types of problems seen with serious injuries of the face and neck. Lacerations (cuts) that occur on the face, ear, and neck that are disfiguring are usually closed by special suturing (stitching) techniques, so as to minimize scarring. These lacerations will not be addressed in this discussion.

NASAL (nose) TRAUMA

FRACTURE

The bones in the nose are the most frequently broken (fractured) in the face. Identification of a nasal bone fracture in children is not easy, as there is usually a lot of swelling, making touching the nose difficult. Additionally, x-rays are difficult to interpret. Immediate evaluation is necessary to make sure a collection of blood (hematoma) is not present in the septum (divider of the nose). If no hematoma is found, the patient is usually re-examined in two to three days, once the swelling has gone down. If the nose looks crooked, then immediate evaluation by an ear, nose and throat surgeon is necessary.

If a fracture is found, correction is usually performed by moving the nose into its normal position (reduction), as soon as possible. This is best performed within 7 to 10 days after the fracture. In more complicated fractures, or when fracture reduction has been delayed, a SEPTORHINOPLASTY may need to be performed at a later date. For girls, this should not be performed before age 16 and with boys, not before 17 or 18 or growth abnormalities may result.

OTHER INJURIES

In newborns, the nose at birth may be stuck to one side (subluxed) as a complication of being in the womb or through pressure during delivery. This problem may correct on its own; however, if breathing problems are present, or the nose is markedly deformed, it can be moved back into its normal position by a physician experienced in this procedure.

LOWER JAW (MANDIBULAR) TRAUMA

FRACTURES

Because the jaw of a child is more flexible than an adult, few fractures result. However, the jaw joint (in front of the ear) may be pushed out of position causing the jaw to be locked open or not function normally.

The approach to fractures in the lower jaw depends on the age of the patient (how much growth the jaw has left), how the teeth are positioned in the mandible (jaw bone). Fractures are identified an x-ray.

Some general information about these fractures follows:

  • The majority of lower jaw fractures involve the part of the lower jaw that is closest to the ears (called the condyle).
  • They usually do not go through the entire jawbone and are known as “greenstick” fractures.
  • They usually heal rather well with minimal intervention (no surgery and minimal immobilization) and they usually do not go through the area of the lower jaw that is growing.
  • It is much more difficult to manage fractures that do damage the jaw area that is growing.
  • These types of fractures have the potential to result in deformities of the jaw, problems with teeth development, and damage to the joint that opens and closes the mouth (temporomandibular joint).
  • More complicated fractures involve surgical placement of the jawbone into the normal position (open reduction).
  • This is best treated by a specialist called a maxillofacial surgeon.

OTHER INJURIES

The parotid gland (in front of and below the ear) secretes saliva into the mouth to aid in food digestion. When damage to this gland occurs, there is also a possibility of damage to the nerve that moves the face (please see FACIAL NERVE INJURIES/PARALYSIS). In addition, the duct that drains saliva into the mouth (Stenson’s duct) may also be damaged and require surgical repair.

UPPER JAW (MAXILLARY) INJURIES

Because the middle of the face (including the palate) in children is such a small area, fractures here are uncommon. However, when the middle of the face is involved, it is important to make sure that the eyes (see ORBIT INJURIES below) and nose (see NASAL TRAMA above) are not involved. In addition, children are more likely to have brain injuries (concussions), skull fractures, or upper spine fractures associated with facial fractures than adults.

Special x-rays called CT scans are used to evaluate fractures and brain involvement and to help plan the surgical reconstruction procedure. More severe fractures, especially those involving the lower jaw, may require a TRACHEOTOMY. Depending on the severity of the fractures, reconstruction is usually done in stages. There are different views among surgeons about the sequencing of the surgery, but ultimately the purpose is the same; to achieve as good a functional and cosmetic outcome as possible.

EYE (ORBIT) INJURIES

FRACTURES

Evaluation of injuries in the eye should involve the consultation of an ophthalmologist (eye specialist). The initial evaluation of an eye injury does not involve touching the eye area until the eye is evaluated thoroughly by inspection and with x-rays and/or CTscans. Examination includes making sure that the eye can move in all directions, has normal vision (see normally), and that the eyeball itself looks normal, among other things. Special testing may be necessary to evaluate the retina (area in the eye responsible for seeing).

There are different types of fractures that can occur around the eye depending on where the facial injury occurred. Fractures can be located on the cheekbone (zygoma), above the eye, below the eye, or in the bones surrounding the eye socket. Early diagnosis of these fractures is important to avoid some later complications; these include the appearance of the eye sinking back into or pushing out of the eye socket, abnormal positioning of the eye, excessive tear production, double vision, or muscle spasms and nerve abnormalities around the eye area.

CUTS (LACERATIONS) IN THE EYE AREA

In addition to eye swelling, and fractures, cuts can occur around the eye. Occasionally a cut will damage the tear (lacrimal) duct, a tube that drains tears from the corner of the eye into the nose. Ophthalmologists are usually involved in the treatment of these lacerations to help prevent later complications with tear production or drainage.

TEMPORAL (SIDE OF FOREHEAD) INJURIES

Trauma to the temporal area of the head more commonly results in fractures than any other area of the skull (head). Complications from these types of fractures can include hearing loss or vertigo (feels like the room is spinning around). Although the vertigo can resolve over time, the hearing loss unfortunately is usually permanent. Fractures In this area may also involve the facial nerve (the nerve that moves the face).

IN THE MOUTH (INTRAORAL) INJURIES

PALATE INJURIES

Injuries involving the palate (roof of the mouth) are common in children. These usually occur when a child is running or playing with something in the mouth like a pencil, toothbrush or stick. Other injuries that may occur in the mouth include cuts or tears on the tongue, tonsils, and/or inside the cheek.

Cuts on the tongue if small usually heal on their own. Larger cuts may require stitches. However, it is common for stitches in the tongue to pull out because the tongue is a large muscle.

SOFT PALATE

Tears on the soft palate usually heal on their own. However, if the cut extends to the side of the roof of the mouth, the patient may be admitted to the hospital for observation to make sure a large blood vessel (carotid artery) has not been injured. A special test called an angiogram may also be necessary.

HARD PALATE

Hard Palate lacerations are also allowed to heal. However, if there is extensive swelling or a chance of AIRWAY OBSTRUCTION, hospital observation and a possible TRACHEOTOMY may be indicated.

EAR TRAUMA

Lacerations (cuts) can occur inside the ear in the outer ear canal (external auditory canal). A short-term complication with these lacerations includes infection; therefore, packing of the ear with antibiotic medicine is usually advised. A longer-term complication can include narrowing of the outer ear canal once the laceration heals, which, if problematic may require correction. The eardrum (tympanic membrane) can also tear causing a perforation. This will cause hearing loss at least temporarily. Drops should not be used in this situation because it may delay healing of the perforation. If the tear doesn’t heal on its own, TYMPANOPLASTY may be required. Your ear, nose and throat specialist will perform hearing tests after healing to ensure the hearing has returned to normal.

NECK (LAYRNGEAL) TRAUMA

Trauma to the larynx (voice box) can occur by an injury to the front of the neck, as well as a significant hit to the back of the neck (upper spine). The biggest immediate concern with this type of injury is to evaluate for signs of AIRWAY OBSTRUCTION. Complications of injury that can result in airway obstruction include cuts in the airway with swelling, VOCAL CORD PARALYSIS, and collection of blood (hematoma) of the vocal cords. Immediate treatment for this type of airway obstruction is a TRACHEOTOMY; an endotracheal tube (a tube put into the airway through the mouth) is not usually placed, as it can cause further damage to the airway.

A long-term consequence of airway trauma may be narrowing (stenosis) of the airway; this may require surgical reconstruction in the future.

Who can repair facial and neck trauma in children?

Because trauma to the face and neck can result in so many different types of injuries, more than one specialty may be involved in the evaluation and repair(s). An otolaryngologist is very experienced with injuries that involve the nose, face, neck, or ear. Other specialists that may be involved include oral surgeons and other dental specialists, neurosurgeons (brain surgeons), plastic and reconstructive surgeons, and ophthalmologists (eye specialists), among others. Please see “REPAIR OF FACIAL AND NECK TRAUMATIC INJURIES in “surgeries we perform” section for information on what types of repair procedures we perform at our office.

Tonsillitis and Related Disorders

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What are the tonsils?

The tonsils are located in the back of the throat. They are part of a group of lymphoid tissue that collect bacteria and viruses that cause upper respiratory tract (nose and throat) infections. They also help to produce proteins (immunoglobulins) that help the body fight infections. Although the tonsils have a role in helping treat infection, the tonsils can become part of the infection as well. When this happens, removal of the tonsils will improve your child’s health. Removal of the tonsils has not led to an increase in infections or a loss of immune (disease fighting) function. This is because there are hundreds of other lymph nodes in the head and neck that perform the same function.

Where are the tonsils?

Actually, there are four areas of tonsil tissue located in the back of the throat The tissue referred to as the “tonsils” is located on either side of the back of the mouth. The second area of tonsil tissue is located behind the nose, and is called the ADENOID. The fourth area of tonsil tissue is located behind the tongue; it does not usually cause any difficulties and is rarely ever removed.

What is tonsillitis?

Tonsillitis is an infection of the tonsils. This infection usually involves the back of the throat as well (pharyngitis). This infection is uncommon in children less than one year old. It is seen most frequently in children four to seven years of age, and continues less frequently throughout late childhood and adult life.

What are some of the causes of tonsillitis?

In about 85% of cases, viruses are the most common cause of tonsillitis. The second most common cause is a bacteria known as Streptococcus (Group A Beta hemolytic Streptococcus), otherwise known as “strep throat”. Other bacteria can cause tonsillitis, but much less frequently.

What are the symptoms of tonsillitis?

Tonsillitis usually results in a sore throat and difficulty swallowing. The throat visibly looks inflamed (red). In younger children, refusal to eat may be noted. Fever, headache, earache, and enlarged and tender glands in the neck may also be experienced.

How is tonsillitis treated?

It is important to have your primary care doctor determine if the cause of the infection is viral or bacterial.

Viral tonsillitis is primarily treated with bed rest, Tylenol (acetomenophen) for fever and pain relief, and lots of fluids. Antibiotics do not help treat this type of infection.

Streptococcal tonsillitis does require the use of antibiotics, primarily to help get rid of the infection quickly and prevent complications. Complications can include an infection in the bloodstream, heart problems, rash, and others.

What are some reasons that you may be referred to an ear, nose and throat specialist for evaluation of tonsil removal (TONSILLECTOMY)?

Tonsillitis can become difficult to treat (chronic tonsillitis) or infections may recur frequently. This can result in fatigue, poor weight gain, poor school attendance among other things.

Occasionally an abscess or collection of pus may develop around the tonsils and needs to be drained.

The tonsils can become so enlarged (tonsillar hypertrophy) that your child may have difficulty breathing (especially at night) or difficulty swallowing.

If enlargement of only one tonsil occurs, this may be suggestive of a malignancy (cancer) and needs to be removed for biopsy.

These are the most common indications for removing the tonsils. However, each child is evaluated based on their unique history.

Tongue Tie

What is tongue-tie?

Tongue-tie is a minor defect of the mouth that decreases the mobility of the tongue.

If you raise your tongue to the roof of the mouth, you will see a band of tissue underneath your tongue called the frenulum. This band helps anchor your tongue to the floor of your mouth. If this string of tissue is too short or tight, you cannot move your tongue well enough to touch the roof of your mouth and may result in speech problems.

Does tongue-tie cause any problems?

Tongue-tie is present at birth. Most often, the frenulum (band of tissue) gradually stretches and there is no problem. However, if the newborn child has a particularly tight frenulum, feeding may be difficult. If this is the case, treatment will be needed immediately.

If feeding problems are not present and the frenulum does not stretch by the time your child is 10-12 months old, treatment is usually recommended so that speech problems do not occur.

How is tongue-tie treated?

Treatment is surgical and consists of separating the band of tissue (frenulum) in a very quick and completely painless procedure called FRENULOPLASTY.

Thyroid Disease

What is the thyroid gland?

Gland refers to an organ in the body that secretes hormones (substances that help regulate different body functions) into the bloodstream. All glands are part of the endocrine (gland) system. The thyroid gland secretes thyroid hormones.

Where is the thyroid gland located?

The thyroid gland is located just below the larynx (voice box) or “Adam’s apple” in the front of the neck. In some thyroid diseases, the thyroid gland enlarges (goiter), which can be felt and seen as a bump in the neck. Sometimes, the first sensation with thyroid enlargement is a feeling of fullness or difficulty swallowing.

What hormones are secreted by the thyroid gland?

There are three types of thyroid hormones secreted by the thyroid gland:
Thyroxine (T4), iodothyronine (T3), and calcitonin.

What do thyroid hormones do in the body?

Both T4 and T3 are involved in energy regulation in the body (metabolism).
In children, normal levels of T4 and T3 are very important in normal growth and brain development.

Calcitonin is involved with keeping a normal level of calcium (a substance found in bones and teeth, among other places) in the bloodstream. It works closely with the hormone secreted by the PARATHYROID GLAND.

What problems can develop with the thyroid gland?

Abnormal conditions involving the thyroid gland include a localized enlargement (nodule) or overall enlargement (goiter) of the thyroid gland. Thyroid nodules and goiters can result in normal levels of thyroid hormone (euthyroid), too much hormone (hyperthyroid), or too little thyroid hormone (hypothyroid) in the bloodstream.

Infections or inflammation of the thyroid gland may also occur which usually results in hyperthyroidism first, followed by hypothyroidism. For more information, please see THYROIDITIS discussed later in this topic.

What is hypothyroidism?

When the thyroid gland produces too little hormone, the condition that results is called hypothyroidism. The symptoms noticed most commonly include being very tired, hair loss, gaining weight for no reason, and constipation among others.
In newborns, the lack of thyroid hormone results in a condition called cretinism; the child grows up mentally retarded and with growth deformities. Because of this, all newborns in the United States are screened for hypothyroidism to help prevent this condition. Hypothyroidism can also be acquired later in life if the body produces abnormal cells (antibodies) that can damage the thyroid gland (Hashimoto thyroiditis). Hashimoto’s thyroiditis is usually accompanied by a goiter (enlargement of the thyroid gland).

What is the treatment for hypothyroidism?

Hypothyroidism is treated by taking thyroid hormone medications (levothyroxine and liothyronine). Too little iodine (a mineral needed to make thyroid hormone) may also cause low thyroid hormone levels and increasing iodine in the diet may also be necessary. Iodine deficiency is rarely seen today in the United States because iodine is found in our table salt.

What is hyperthyroidism?

Hyperthyroidism is the condition that results when too much thyroid hormone is in the bloodstream. Symptoms associated with this condition include anxiety, heart palpitations (heart “racing”), sweating, weight loss for no apparent reason, and diarrhea among others.

How is hyperthyroidism treated?

Hyperthyroidism can be treated in different ways depending on why the thyroid is overactive and the age of the patient.

The patient may be treated with some medications that decrease the production of thyroid hormone or by surgical removal of part of the thyroid gland (THYROIDECTOMY).

What are some of the causes of a hyperactive thyroid gland?

GRAVES’ DISEASE
The most common cause of hyperthyroidism in children is a condition is called Graves’ disease. It is a condition in which the body produces abnormal cells (antibodies) that result in the thyroid gland’s overproduction of thyroid hormone.

The diagnosis is usually made by symptoms of hyperthyroidism, and confirmed with special blood tests specific for this disease. In children, it is usually treated with medications first. However, if medications are not effective, the thyroid gland may have to be destroyed with radioactive iodine. If that is not an option, surgical removal (SUBTOTAL THYROIDECTOMY) may be considered.

THYROIDITIS
Thyroiditis is tenderness and inflammation of the thyroid gland. While the thyroid is inflamed, excessive thyroid hormone can be released, resulting in hyperthyroidism. After the hyperthyroid stage resolves, there may also be a period of hypothyroidism. There are two types of thyroiditis:

Severe pain, and swelling around the thyroid gland and fever is known as acute suppurative thyroiditis. It is usually caused by a bacterial infection. Ultrasound can be used to look for abscesses (collections of pus). Treatment consists of antibiotics (usually given by a vein at the start of treatment), and possible surgical drainage or thyroid LOBECTOMY if an abscess is found.

A less severe form of thyroiditis is known as subacute thyroiditis. It is usually caused by a virus and presents with a low-grade fever, mild pain and tenderness in the area of the thyroid gland, and minimal enlargement of the thyroid gland.
This diagnosis is sometimes confused with Graves’ disease, but a thyroid scan can differentiate the two. Subacute thyroiditis usually resolves without treatment although supportive measures (fluids, rest and pain medicine) may make the patient more comfortable.

What are thyroid nodules?

A thyroid nodule is basically an abnormal lump in the thyroid gland. It may be felt or seen as an abnormal bump in the neck, or may produce symptoms such as hoarseness, or difficulty swallowing. As mentioned above, thyroid hormone levels can be normal, elevated, or decreased depending on the type of nodule.

Thyroid nodules most commonly are benign (not cancerous). Examples of these types of nodules include adenomas (overgrowth of thyroid tissue) and thyroid cysts (nodules containing fluid). Often, a thyroid cyst can simply be drained. If it recurs, it is usually surgically removed, as is a thyroid adenoma.

Thyroid cancer is much less common, and the overall prognosis is good. There are different types of thyroid cancer, which affects the prognosis. Thyroid cancers such as Papillary and Follicular generally have a better prognosis than Medullary and Anaplastic. However, treatment almost always consists of a THYROIDECTOMY as well as radioactive iodine destruction of any remaining thyroid tissue. Your surgeon will go over your child’s diagnosis and specific treatment in detail.

How are thyroid nodules evaluated?

The most important thing to determine in an evaluation is whether the nodule contains cancer. There are specific characteristics that a nodule has making it suspicious for cancer. Once a nodule is determined to be suspicious for cancer, a fine needle aspiration biopsy (FNA) is performed. This consists of inserting a needle into the nodule to determine what types of cells are present (a type of cancer cell, suspicious cells, or normal cells). However, this procedure is invasive and other studies are usually performed before this to decide which nodules should be biopsied.

A careful history of symptoms, a complete family and patient history and a thorough physical examination of the thyroid gland is initially performed. This is usually followed by blood tests that determine if the thyroid hormone levels are high, low, or normal.
Next an ultrasound is used to determine if the nodule is solid (contains tissue), cystic (contains fluid), or a combination of both. A cystic nodule is more likely to be non-cancerous. Finally, a thyroid scan is used to determine if the nodule is overactive (hot), active (warm), or under active (cold) compared to normal thyroid tissue. Cold nodules are more likely to be associated with cancer.

Once a fine needle aspiration biopsy is taken, the cells are examined to determine what further treatment is indicated. If cancer cells or suspicious cells are found, a THYROIDECTOMY is indicated.

Who can treat diseases of the thyroid gland?

Most commonly, non-surgical diseases of the thyroid gland are managed by an endocrinologist (a physician specializing in the glands in the body) or another physician who is experienced in managing the thyroid hormone medications and levels in the body.

Because of its location in the neck, an otolaryngologist is consulted when surgery of the thyroid gland (THYROIDECTOMY) is indicated.

Sinusitis

Where are the sinuses?

The sinuses are air filled cavities located in the bones of the face. The sinuses are divided into groups based on their location and are named maxillary, ethmoid, frontal and sphenoid sinuses.

What is sinusitis?

Sinusitis is a condition in which your child suffers from inflammation or infection of one or more of the sinuses.

Depending on the age of your child, this may occur in the pair of sinuses located between the eyes (ethmoid) and/or the pair behind the cheekbones (maxillary), as both of these sinuses are present at birth.

As children get older, they develop a pair of frontal sinuses (in the forehead) and a pair of sphenoid sinuses (behind the nose), which can also become affected.

What are the symptoms of sinusitis?

Sinusitis has symptoms of runny nose, stuffy nose, fever, headache, cough (especially at nighttime), post nasal drip (causes frequent throat clearing), bad breath, facial swelling and changes in your child’s behavior. Many times it is difficult to tell the difference between a cold and a sinus infection.

A cold has many of the same symptoms but will usually get worse around the 3rd or 4th day and be improving by a week to ten days. A sinus infection is usually worsening instead of improving at a week to ten days.

What causes sinusitis?

Sinusitis is caused by an infection within the sinus cavities. Anything which causes blockage of the natural drainage openings of the sinuses can lead to infection. This means colds, flu, allergy or bacterial infection may be responsible. Blockage may also occur from POLYPS, which may be caused by allergies or chronic infection.

Once blockage of the natural drainage passageways has occurred, mucus builds up behind the blockage. This may lead to inflammation and, eventually, infection of trapped mucus, otherwise known as acute sinusitis.

Are there any other types of sinusitis?

Another type of sinusitis is known as chronic sinusitis. Most children have acute sinusitis which resolves on antibiotics after 3 weeks. However, your child may suffer from symptoms which last for 2 to 3 months or more; this is known as chronic sinusitis. In children with chronic sinusitis, the symptoms are usually less severe, but last longer than acute sinusitis. Chronic sinusitis may be aggravated by underlying allergies or long standing illness.

How is sinusitis diagnosed?

Your doctor will diagnose sinusitis based mostly on the history you give of your child’s symptoms. You probably will be asked if your child has nasal congestion (stuffy nose) or a runny nose, a cough, post-nasal drip, bad breath, headache, swelling around the eyes, or behavior changes.

Sinusitis is also diagnosed by how long the symptoms last. If the child has a simple cold or flu, symptoms will usually last from 7 to 10 days. If the symptoms described previously persist beyond ten days, sinusitis is likely to have occurred and your child should be evaluated by a physician.

What might my doctor do during an evaluation?

After noting your child’s symptoms, the next step is an examination of the patient’s ear, nose and throat. Occasionally special nasal endoscopes will be used to see farther into the nose. In addition, your doctor might order x-rays to completely evaluate the sinuses. These x-rays may include plain x-rays of the sinuses or a computed tomography (CAT) scan, which will give your doctor the most accurate information on your child’s sinuses.

How will the doctor treat acute sinusitis?

As the first line of treatment, your doctor will probably give your child an antibiotic for several weeks to clear the sinus infection. Nasal decongestants or nasal sprays may also be prescribed. If your child has acute sinusitis, symptoms should improve within the first few days. After the first week of treatment, your child will often seem much better; however, you should continue the antibiotic therapy as described by your doctor for the full course of therapy. Otherwise, the infection may return.

If your child has a sinusitis which seems to be linked to an allergic condition, your doctor may decide to involve an allergy specialist so that the underlying allergy can be treated.

How might the doctor treat chronic sinusitis?

If your child has had several acute sinus infections in the past several years or has long standing chronic sinusitis which does not seem to go away completely with antibiotics, your doctor may recommend surgical treatment of the sinuses using FUNCTIONAL ENDOSCOPIC SINUS SURGERY (FESS). Other procedures such as SINUS CULTURE or ADENOIDECTOMY may also be recommended.

Are there any complications resulting from sinusitis?

In addition to development of chronic sinusitis, serious complications of sinusitis include orbital cellulitis (an infection in the tissues around the eye), osteomyelitis (an infection in the bones), meningitis (infection in the fluid surrounding the brain and spinal cord),or brain abscess. Thankfully, especially with treatment, these complications are rare.

Parathyroid Disease

What are the parathyroid glands?

The parathyroid glands are two pair (four in total) of glands that secrete parathyroid hormone. The parathyroid gland, like the THYROID GLAND, is part of the endocrine (gland) system.

What is parathyroid hormone?

Parathyroid hormone is a substance that helps regulate the amount of calcium in the bloodstream. Calcium is needed to make strong bones and teeth. However, a normal calcium level in the bloodstream is also very important for normal function of muscles and nerves. Parathyroid hormone raises the amount of calcium in the bloodstream by removing calcium from bones, by increasing the amount of calcium taken from the diet, and by decreasing the amount of calcium excreted in the urine.

Where are the parathyroid glands located?

The parathyroid glands are located behind the two lobes of the THYROID GLAND in the neck.

What problems can develop with the parathyroid gland?

One or more of the parathyroid glands can become overactive, secreting too much parathyroid hormone (hyperparathyroidism) or under active, secreting too little parathyroid hormone (hypoparathyroidism). The parathyroid hormone secreted may not be effective in the body for various reasons, which is considered a form of hypoparathyroidism. It is important to note that problems with the parathyroid glands, especially overactive glands, usually develop in adulthood, and are rare in children.

How are parathyroid diseases treated?

An endocrinologist (hormone specialist) usually manages a patient with hypoparathyroidism (which causes too low calcium levels in the bloodstream). Bloodstream calcium levels are important in muscle and nerve function. A low calcium level can cause painful muscle spasms (tetany). Unlike thyroid hormone, there is currently no replacement medication for parathyroid hormone, so treatment usually consists of calcium and Vitamin D (important for the absorption of calcium) supplements.

Hyperparathyroidism is most commonly caused by a benign (not cancer) tumor called an adenoma. However, less commonly, it can result from regulation problems with all the glands (hyperplasia) or parathyroid gland cancer (which is very rare).

The symptoms associated with hyperparathyroidism include generalized bone aches and pains, abdominal pain, and depression (please see “what if the overactive parathyroid glands are not removed” below). An endocrinologist or another physician experienced in parathyroid problems usually makes this diagnosis. Once this diagnosis is made, parathyroid surgery (PARATHYROIDECTOMY) is usually curative.

A more recently developed procedure called Minimally Invasive Radioguided Parathyroidectomy (MIRP) has been advocated for treatment of single parathyroid adenomas in adults. This procedure involves making the overactive parathyroid gland radioactive. An instrument can then locate the radioactive gland in the neck, and a precise incision to remove that specific parathyroid gland can be performed. It results in a much smaller incision than traditional parathyroidectomy and a more rapid recovery time. However, MIRP has not been used extensively in children and is mentioned here only for completeness.

Finally, some physicians have tried a medication that increases calcium in bone as treatment, trying to avoid surgery; however, medication alone is not generally recommended for adults, and is especially not a consideration in children.

When would an ear, nose, and throat specialist be consulted?

Because of the location of the parathyroid glands in the neck, the otolaryngologist (ear, nose, and throat specialist) is usually consulted to perform a parathyroidectomy. As mentioned above, this type of surgery is uncommon in childhood; therefore, an ear, nose, and throat specialist with significant pediatric experience is probably the best qualified to perform this procedure.

What would happen if the overactive parathyroid glands were not removed?

The parathyroid hormone acts to increase the amount of calcium in the bloodstream. As it gets this calcium from bones in the body, bones will eventually become brittle and easily broken. Parathyroid hormone also prevents calcium from being excreted by the kidneys; this extra calcium can create kidney stones. High calcium levels can also affect the lining of the stomach and the pancreas (an organ located near the stomach), causing irritation, ulcers, and inflammation. Finally, high calcium levels can cause a person to feel irritable or have difficulty falling asleep.

The longer the overactive glands remain in place, the more severe the above complications will become.

Although extremely rare, the parathyroid gland may become cancerous, and not removing it may result in spread of the cancer to other areas of the body.

How many parathyroid glands will need to be removed?

There are four parathyroid glands, however, commonly only one gland is affected (single adenoma). Removal of this overactive gland should result in normal parathyroid function. In other cases, more than one gland is involved and will need to be removed. There are specific parathyroid studies (Sestambi scanning or SPECT scanning) that are available to determine the location of the glands that are abnormal. In addition, sometimes, medicine is injected into the body, which will dye the parathyroid glands a certain color so that they are easier to located and remove during surgery.

Otitus Media (Ear Infections) and Complications

What is Otitis?

Otitis refers to an infection of the ear. There are two types: Otitis externa (outer ear infection) and otitis media (middle ear infection).

What is Otitis Externa?

Otitis externa is an infection in the outer ear canal. Another name for this infection is “swimmer’s ear” as this infection can be associated with exposure to water. This can make the skin more susceptible to infection by bacteria, yeast, and fungi. The symptoms include redness and swelling of the skin in the ear canal, significant pain of the ear canal and drainage. Treatment for this infection includes antibiotic or antifungal eardrops and possibly oral (by mouth) antibiotics. Prevention is advised in recurrent cases. Preventive treatments can include rinsing the ears with water and white vinegar mixed 50/50 after swimming. Ready-made eardrops for this purpose are also sold at various pharmacies, although these may contain alcohol that can cause further irritation.

What is Otitis Media?

Otitis media is also known as a middle ear infection (an infection in the space behind the ear drum). For children, otitis media is one of the most common infections. More than 90% of all children will have at least one infection by two years of age. There are two common forms: 1) recurrent “acute” infections, or 2) long lasting “chronic” infections. Persistent fluid behind the eardrum is known as otitis media with effusion.

What Causes Otitis Media?

Ear infections can be caused by bacteria or viruses. Risk factors include day care (usually with more than ten children) and smoking in the home. Allergies may contribute to ear disease but are not usually the direct cause of infections. Congenital syndromes such as Down syndrome, Treacher-Collins, and patients with cleft palate (Pierre-Robin) also have more infections due to difficulty in equalizing the pressure behind the ear drum.

How common is otitis media?

Middle ear infections are the most common reasons children present to the doctor’s office. By three years of age, most children have had at least one ear infection, and 30% of children have had three or more episodes. If ear infections start before 6 months of age, your child may be “otitis prone” and will suffer more than the usual number of infections in the first three years of life. Also, infections in newborn infants can lead to more severe complications of otitis media when compared to older children. (See below for more information on otitis media complications)

How do I know if my child has ear infections?

Ear infections, for some children, are very painful. Commonly associated symptoms include pulling on the ears, increased irritability or behavioral changes, awakening at night, fever, decreased appetite, not wanting to lie flat, or a loss of balance. Some children have little or no discomfort, and ear infections in these children may be picked up only upon routine doctor visits or as part of an examination for another complaint.

When should I go see the doctor?

If your child has the signs and symptoms of an ear infection, see your pediatric doctor without delay. Although doctors may differ in their opinion on how to treat ear infections, it is important for your child to be followed closely until the ear infection resolves completely. This means that the infection as well as any remaining fluid in the middle ear is gone.

What are some of the complications of untreated otitis media?

Otitis media will often resolve without any treatment. However, possible complications of untreated otitis media include a hole (perforation) of the eardrum, hearing loss, and mastoiditis (see section below). Even more life threatening complications, such as meningitis (infection in the fluid surrounding the brain), brain abscess (pocket of pus in the brain), and/or blood clots in the veins in the head brain, are uncommon, but can occur.

Because of the severity of these possible complications, many physicians recommend treatment for most ear infections with antibiotics.

What is mastoiditis?

Mastoiditis is infection or inflammation of the mastoid bone (the big hard bump felt behind the ear). Inside of the mastoid bone there is a “honeycomb” (like inside a bee hive) area filled with air. Mastoiditis occurs when otitis media spreads to this air filled area inside the mastoid bone. This complication of otitis media is uncommon today; because of the success antibiotics have in clearing up ear infections. Suspicion of mastoiditis occurs when the patient develops redness, tenderness, and swelling behind the ear. Antibiotics are used (usually in a vein) to treat this infection. If antibiotics are not effective, than a MASTOIDECTOMY is considered.

What options are available to treat ear infections?

Because most ear infections are painful or may lead to complications, the most common treatment is with antibiotics and pain medication (Tylenol, ibuprofen, or numbing ear drops). If the infection is severe, a shot may be required to help reduce symptoms more quickly.

Decongestants and antihistamines have not been found helpful in clearing ear infections unless the child has significant allergies contributing to the ear infection.

If the ear infections keep recurring, but completely clear in-between, your pediatrician or family doctor may suggest prophylactic (preventive) therapy. This involves daily low dose antibiotics (amoxicillin or gantrisin) for 4-6 weeks. This is not recommended for children in day care.

If your child has fluid that will not clear, long-term antibiotic therapy is not needed. Ninety percent of children will resolve persistent fluid from the middle ear within 3 months after the infection.

When Should I See an Ear, Nose and Throat Specialist?

If you are wondering when your child should be seen by a specialist, the following are guidelines which have been jointly adopted by the American Academy of Pediatrics and the American Academy of Otolaryngology (ear, nose and throat physicians):

  1. If your child has three or more infections prior to six months of age.
  2. If your child has four infections in six months or
  3. If your child has six or more infections in a year.
  4. If your child has fluid that lasts more than three months with associated hearing loss.
  5. If your child has signs of significant hearing loss.

When are Tubes a Consideration?

Tympanostomy tubes (tubes) may be suggested when your child has failed to improve with antibiotics or has fluid which will not clear after an appropriate length of time. Tubes are especially helpful in reversing the hearing loss due to fluid trapped behind the ear drum.

Tympanostomy tubes are small plastic or silastic tubes that allow more normal movement of air behind the ear drum (fig.2). Tubes usually fall out of the ear (as the ear drum grows) within one to two years unless specified as “permanent” by your doctor.

Placement of tubes occurs through the ear canal under a brief (five to ten minutes) general anesthetic, and rarely requires a blood test or IV. The procedure is painless and allows your child to resume normal activity upon leaving the hospital.

Although you may hear lots of “advice” about tubes from family, friends and neighbors, talk to your doctor about the treatment plan that is best for your child.

For more information see Frequently Asked Questions about Tympanostomy Tubes.

What will an ear, nose and throat specialist do?

An ear, nose, and throat specialist will help to determine whether a surgical procedure may be helpful for your child.

TYMPANOSTOMY TUBES may be suggested when your child has failed to improve with antibiotics or has fluid which will not clear after an appropriate amount of time. Tubes are especially helpful in reversing hearing loss due to fluid trapped behind the eardrum.

An ear, nose and throat specialist may also be consulted to perform a myringotomy (draining fluid from the middle ear through the ear drum). This can be used to determine the specific type of bacteria causing an infection. It is also useful in acute (with pus) otitis media, in which the FACIAL NERVE is inflamed.

Occasionally, an ADENOIDECTOMY, may be recommended if ear infections are closely related to runny nose, cough, nasal stuffiness and other sinus symptoms.
ADENOIDECTOMY is also routinely recommended when children need a second set of tympanostomy tubes.

In severe infections, when the mastoid is also involved, a MASTOIDECTOMY may be indicated.

Nasal Obstruction

What is nasal obstruction?

Nasal refers to the nose. The nasal cavity is the air passage starting at the nostril (opening of the nose) and ending at the back of the throat. Nasal Obstruction is a partial or complete blockage of one or both of these air passages.

What are some of the symptoms of nasal obstruction?

Nasal obstruction in an infant is usually noted very soon after birth. Infants primarily breathe through the nose, so any blockage of this passage will be seen early on as difficult and noisy breathing. When these children cry, their breathing actually improves, as air can move in and out of the mouth without problems. Breathing problems will be especially noticeable during feeding.

In older children, nasal obstruction usually results in noisy breathing (Darth Vader sounds), snoring, and/or mouth breathing. Your child may or may not have a runny nose as well. Mouth breathing can go unnoticed by many parents. One trick to noticing this is to look back at previous pictures of your child to see if the mouth is always open. (many times this condition is noted during summer vacation when the family sleeps closer together)

When may my child be referred to an ear nose and throat specialist for evaluation of nasal obstruction?

Although your primary care physician and other specialists may be able to manage some causes of nasal obstruction, an ear, nose and throat specialist is usually the best qualified specialist to evaluate most of these cases. If treatment started by your primary care physician does not help your child’s condition, then referral may be made to a specialist.

What are some of the causes of nasal obstruction?

There are many different causes of nasal obstruction. Some causes are present at birth (congenital). Other causes are acquired later in life. The age at which the noisy breathing started also helps to determine the specific cause. Some of the causes are listed below:

  1. Rhintis – Swelling or inflammation of the lining of the nose
    can be caused by allergies, irritants like smoke and pollution, and infection to name a few. In infants, this swelling can lead to considerable distress on the part of the child and parents. Careful evaluation of the nose will lead to the likely diagnosis. Sometimes, additional testing is necessary to confirm the cause.
  2. ADENOID HYPERTROPHY is another common cause of nasal obstruction in children. See this topic under common diagnoses.
  3. Foreign Body – A common cause of nasal obstruction in the younger child is
    an object (foreign body) placed in the nose (such as a bead, peanut, cotton,etc) during experimentation or play. These patients usually develop a foul smelling drainage from the nose on the side containing the object. Removal can many times be accomplished in the office. Occasionally, if the foreign body has been present a long time, a brief general anesthetic will be necessary to remove it painlessly.
  4. Deviated Nasal Septum – The nasal septum separates the two nasal passages in the nose. It is made up of bone in the back and cartilage (softer tissue like the top of the ear) in the front. A child may be born with a crooked (deviated) septum, or may acquire a crooked septum through injury to the nose. If this tissue is severely twisted, it can block a nasal passage. This is commonly corrected with surgery called a SEPTOPLASTY.
  5. Nasal Polyps are another cause of nasal obstruction. A nasal polyp is a growth of tissue that protrudes from the sinus lining into the nasal passage.
    Because polyps are usually the result of a chronic irritation or infection, a complete evaluation, including X-rays, is necessary to diagnose the cause and determine the extent of the problem.
  6. Hematoma: Injury to the nose can also result in a hematoma (collection of blood) that may obstruct the nasal passage. This commonly occurs after a trauma to the nose and must be treated immediately or loss of support to the nose will result.
  7. Choanal atresia can be one sided (unilateral) or affect both sides (bilateral). It means that the back opening of the nose is blocked with either tissue or bone. If both sides are involved, it is usually noted shortly after birth. In this case, surgical repair is needed immediately to allow the child to breath normally. If only one side is involved, the diagnosis may be made much later in life. Symptoms include nasal discharge, stuffiness only on one side and sometimes, one-sided sinusitis. In many cases, unilateral or one-sided atresia can be repaired using telescopes through the nose.
  8. Tumors: Among the other less common causes of nasal obstruction in children are benign or malignant tumors, which may be noted initially by persistent stuffiness on one side of the nose. This may also be associated with bleeding, drainage or swelling. After a complete physical exam, the ear, nose and throat specialists may order X-rays or other studies to aid in the diagnosis.

What is involved with an evaluation for nasal obstruction by an ear nose and throat specialist?

Again, the age of the patient and the specific symptoms will help determine the best way to evaluate the obstruction. All patients receive a careful and thorough physical exam. This may include a small flexible camera used to look into the nose.

In addition, X-rays can be helpful in looking at the nose, sinuses and surrounding tissues that cannot be seen directly. X-rays may include plain X-rays (takes 20 minutes – like a picture), CT scans (also takes 20 minutes and is taken by the child placing the head in a large white “donut”) or magnetic pictures (MRI).