Pediatrics ENT

Dr Dennis Chua is currently a Visiting Consultant to KK Women’s and Children’s Hospital. He sees pediatric ENT conditions such as snoring and sleep disordered breathing in children, airway problems, sinus conditions, allergies, hearing problems and salivary gland diseases in children.

Nasal allergy and blockage are common in children. They experience blocked nose and runny nose and can have disturbed sleep at night. A child may be constantly rubbing his nose and eyes, and have sustained bouts of sneezing. This affects their performance in school but more importantly reduces their quality of life. Allergic rhinitis in children and precipitate sleep apnea which can have serious health consequences. (See Pediatric Sleep Apnoea link)

Prevention is often better than cure.  Skin prick testing can be performed in suitable cases to look for possible allergens. Most patients who test positive on skin prick test tend to be allergic to house dust mites. Singapore being a very humid country has high prevalence of house dust mites and measures to decrease the house dust mites load around the sleeping environment will help. This includes using dust mite proof covers, washing bed sheets in hot water and sunning them regularly.

Sublingual immunotherapy (SLIT) is an effective remedy for allergies in selected patients and arrests the ‘atopic march’ in which allergic rhinitis (nasal allergy) leads to childhood asthma.

Tonsils and adenoids are part of the immune system and are considered the “gatekeepers” to the mouth and nose. However after the age of 2, they have little useful function. When the tonsils and adenoids are enlarged they can cause obstruction to breathing. When severe a child have snoring and sleep disordered breathing from the adenotonsillar hypertrophy, they may appear to snore, choke or gasp when they sleep. This raises the possibility of Obstructive Sleep Apnoea (OSA) which can cause general health problems.

OSA in children has been recognised since the 1970s and since then the effects of paediatric OSA has been well-studied.

Consequences of untreated obstructive sleep apnoea include failure to thrive, enuresis (bed-wetting), attention-deficit disorder, behaviour problems, poor academic performance, and cardiopulmonary disease. The most common etiology of obstructive sleep apnoea in children is adenotonsillar hypertrophy.

Clinical diagnosis of obstructive sleep apnoea in the clinic is reliable and may not warrant a sleep study if the cause of OSA is obviously from the adenotonsillar hypertrophy. According to the American Academy of Otolaryngology 2011 Clinical Practice Guideline, a sleep study will be necessary in children who have comorbidities such as obesity, Down’s Syndrome, neuromuscular diseases, sickle cell disease or mucopolysaccharidoses. Overall, less than 10 per cent of children who suffer from OSA will need a sleep study before surgery.

In these cases, adenoidectomy and tonsillectomy effectively cures OSA and restores the child’s breathing pattern.

STILL IMAGE

Picture of Tonsillar hypertrophy and narrow oropharynx

Post-operative picture after tonsillectomy

Post-operative picture after tonsillectomy

Recurrent infections can lead to a decrease in quality of life for the child and several missed days of school. Tonsils may pose a problem when they get repeatedly infected. Tonsillitis is a painful condition associated with the inability to swallow normal food. There is often fever and the child requires antibiotics and is absent from school for a few days.

If a child is suffering from recurrent attacks of tonsillitis, they should have them removed. The frequency and severity of attacks are important determinants whether surgery is indicated.

Many children suffer from an episode of a middle ear infection (Acute Otitis Media) in their early life. The child may wake up in the middle of the night crying. They may tug at their ear and there may also be a fever. When pus appears in their ear canal, the pain resolves as the ear drum has perforated – easing the tense accumulation of pus in the middle ear cavity. There is a eustachian tube that connects the ear and the nose and this helps in ventilation of the middle ear. When the tube is dysfunctional or immature, fluid can collect in the middle ear. This explains why children are more prone to otitis media with effusion as the eustachian tube is still immature.

In other children, the middle ear is filled with a thick fluid causing hearing loss – this is a condition called “glue ear”. It is painless but the loss of hearing affects the child’s speech and language development. It is imperative to seek early treatment to avoid any developmental delay sequelae in children with hearing loss.

 

Right ear with otitis media with effusion “glue ears”. The orange hue of the effusion can be seen behind the ear drum.

Right ear with otitis media with effusion “glue ears”. The orange hue of the
effusion can be seen behind the ear drum.

 

A normal translucent ear drum.

A normal translucent ear drum.

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