Paediatric ENT- Summary Mr. Azhar Shaida, Consultant ENT Surgeon, The Royal National Throat Nose and Ear Hospital, London and The Harley Street ENT Clinic, 109Harley Street, London W1G 6AN doctor@ent-doctor.co.uk www.ent-doctor.co.uk Tonsillectomy: Still one of the commonest ENT surgical procedures, but with much more strictly defined indications than in the past. Indications: Recurrent acute tonsillitis- 7 or more attacks in last year, 5 or more per year in preceding 2 years, 3 or more per year preceding 3 years (SIGN 2010, ENT UK 2013) Genuine tonsillitis with fever, dysphagia, enlarged tonsils, malaise Obstructive symptoms- particularly OSA Quinsy (Peritonsillar abscess)- hot tonsillectomy if no improvement with I+D, elective tonsillectomy if 2xQuinsy or Quinsy + history of tonsillitis Suspected neoplasia / unilateral hypertrophy Access to deeper structures e.g. styloid process Associated problems- febrile convulsions, exacerbation psoriasis, time off school, particularly severe attacks Soft indications: Halitosis Chronic tonsillitis Risks of surgery: Pain (like a bad attack of tonsillitis) for 7-10 days Bleeding- 3%- often 5 days after going home, occasionally leads to death. Occasionally change in voice noted by professional singers. Natural history is of spontaneous resolution, so wait if possible. Often recurrent attacks when children start school, so wait a little longer at this stage. Can still get sore throats/pharyngitis afterwards. Plenty of other lymphoid tissue, so tonsillectomy does not predispose to increased susceptibility to infection. Laser? Coblation? Diathermy? Evidence suggests that pain/secondary haemorrhage are least with traditional cold steel dissection tonsillectomy, although coblation may be even better- but cost greater. Adenoidectomy: Carried out alone or with tonsillectomy / grommets. Symptoms of adenoid hypertrophy: Nasal obstruction, snoring, mouth breathing, rhinorrhea, OSA Predisposes to glue ear / recurrent ear infections Predisposes to sinusitis Symptoms often worst age 2-3 (small head, large adenoids), start to improve age 6-7 (adenoids regress, head enlarges), usually settled in young adult life, but can persist. Simple snoring- wait Significant nasal obstruction, teasing at school, disturbed sleep, OSA, glue earadenoidectomy
Risks of surgery: Not especially painful Bleeding- usually primary or reactionary, noted within a few hours of surgery. Reduced by use of suction diathermy Occasional risk nasal regurgitation / escape, especially if submucous cleft palate. Glue Ear and Grommets: Very common, but often transient or fluctuating. Common in children due to impaired immune function (age related), shorter more horizontal Eustachian tube, functional immaturity of Eustachian tube, enlarged adenoids. Hearing loss (conductive) Speech and language delay Recurrent ear infections (>3-4 per year indication for treatment) Clumsy/off balance Behavioural problems (? Due to hearing loss) Mild Otalgia (may be due to mild infection) May lead to damage to tympanic membrane (enzymes or infections), retraction pockets, erosion of ossicles, cholesteatoma (small risk) Short term- wait Persistent glue ear for >= 3 months, with hearing loss, speech delay, recurrent infections- treat Persistent > 1 year, no symptoms- treat to prevent irreversible TM damage Treatment options: Steroids- oral- no good evidence. Nasal spray- may have small adjunctive role. Long term prophylactic low dose Amoxycillin/ Trimethoprim 6 weeks- some short term efficacy Otovent nasal balloon- some short term efficacy- small children cannot use. Hearing aids- help hearing loss, but not infections / balance problems / TM damage. Grommets- effective while in situ and patent. Risk of recurrence of glue when grommets extrude. Adenoidectomy and grommets- less risk of recurrence when grommets extrude Long stay grommets / Permavent tubes / T-tubes- stay in for many years. 33% risk of residual perforation when do extrude compared to 1% for standard grommets- but perforation may be desirable to continue middle ear ventilation. Complications of grommets: Risk of infection: Water through grommet especially soapy water- some studies suggest ear plugs not necessary, most ENT surgeons in UK recommend ear plugs or cotton wool/vaseline for baths and a hat for swimming. Infection from nose / sinuses / adenoids / tonsils- may need treating.
Ear drops with grommets? Most ear drops contain aminoglycosides and are potentially ototoxic- but PUS is more ototoxic, so OK to use drops for short period e.g.1 week. Now have Ciproxin drops (off licence use). Scarring / tympanosclerosis of TM- very common, looks dramatic, but very rarely large enough to be of clinical significance e.g. cause hearing loss. Recurrence of glue ear when grommets extrude- further surgery. Residual perforation 1% grommets, 33% for T-tubes. Tympanic membrane perforations: In children, often traumatic or secondary to AOM (acute otitis media). Many perforations, especially if small, heal spontaneously, so in initial stages wait 3/12. Recurrent ear infections Hearing loss Reduce infections by taking water precautions. Hearing aid for hearing loss- but may cause ear to get moist, lead to infection. Myringoplasty- to prevent recurrent infections if water precautions ineffective, or patient activities limited e.g. swimming. Overall 80% success rate, reduced if ear infected or large perforation. Hearing- often improves if perforation repaired/ ossiculoplasty carried out, but cannot guarantee improvement e.g. if scarring and ossicular fixation in attic. However, successful repair may allow hearing aid use more easily. CSOM / Cholesteatoma: Chronic discharge Hearing loss Complications- facial palsy, intracranial infection (meningitis, intracranial abscess), postaural abscess, intracranial thrombosis. Findings: Pus/ discharge in ear canal Defect in tympanic membrane (beware the crust of wax in the attic covering a defect!) Pearly keratin in middle ear Surgery. Modified radical mastoidectomy- potentially only one operation -but left with large mastoid cavity, recurrent wax build up and infection, children do not allow cleaning, poorer hearing results, problems swimming. Combined approach tympanoplasty- need at least one follow up operation after 1 year- but eventually normal looking ear canal, no regular cleaning / recurrent infections, easier for children, better hearing, can get ear wet. Foreign Body in Ear: May be anything!
Asymptomatic, ear discharge and pain, hearing loss. Remove with appropriate tools. Paper/ material that can be gripped- remove with forceps. Smooth beads- may be able to syringe out or hook out. Insects- drown with mineral oil / dilute alcohol solution, then refer to remove dead insect. Vegetable matter- do not syringe- likely to swell up, may get infected. Have 1 attempt but do not persevere if unsuccessful- child becomes traumatized, may not allow anyone else to try, may need GA. Syringing: Often very effective. Aim along posterior canal wall, water bounces off TM and washes out wax / foreign body. Not effective if wax totally occluding ear canal. Not recommended if perforation Not recommended if history of recurrent otitis externa. Epistaxis: In children, usually from Little s area on anterior nasal septum. Acute- pressure (pinch nostrils 5 minutes), head forward, ice. Chronic- Exclude family history bleeding diathesis. Naseptin cream 2 weeks If can identify bleeding point- Silver nitrate cautery after local anaesthetic spray Persistent- electrocautery under general anaesthetic. Adolescent males with recurrent profuse epistaxis- beware of juvenile angiofibroma! Rhinitis: Common problem. Skin prick testing most sensitive and specific technique to identify allergens, but not always possible in children. RAST tests may be required. Rhinorrhoea, sneezing bouts, nasal itching, catarrh and postnasal drip, hyposmia. Secondary sinusitis, glue ear. Findings: bilateral rhinorrhoea/ excess mucus Nasal obstruction/ reduced airflow Allergic crease / allergic salute Allergen reduction Avoidance e.g. hoover bedroom, wooden floor, hypoallergenic covers Wash out allergens e.g. sinus rinse kit Antihistamine Nasal steroid- spray safe to use long term. Flixonase from age 4, others from age of 6. Betnesol nose drops 4-6 week courses intermittently. Combination of steroid and antihistamine more effective than either alone. Oral steroids rarely used. Monteleukast- adjunctive therapy in children above 2, especially if asthmatic. Immunotherapy- allergen shots -
Best if only allergic to 1 or 2 allergens, esp. pollens, animal dander, dust mite, moulds, cockroaches Injection of dilute allergen, slowly increase concentration. Injections once or twice a week for approx 20 weeks until reach maintenance dose, then monthly for 6 months. If symptoms improve, continue monthly injections up to 3 years. When stopped, benefit may last up to another 3 years. - may be of no or limited benefit, may need to continue other medication. - Risk of anaphylaxis, so limited use in UK. SLIT- sublingual immunotherapy- drops or tablets of allergen extract placed under tongue. Daily, then many times a week, for years. Used in Europe, now being introduced in UK. Results more variable than standard immunotherapy, but no anaphylaxis reported, only minor GI upset etc. Surgery- only to improve airway obstruction symptoms. SMD or trimming of inferior turbinates. Underlying allergy means swelling may recur. Foreign Body in nose: Again may be anything! Unilateral offensive discharge, unilateral obstruction- suspect f.b. May be able to see and grab with forceps Smooth objects/beads- may be able to hook out. Can also try Otrivine nose drops and ask child to blow out the object. Again, 1 attempt only and then refer otherwise child may be traumatized and refuse to allow anyone to examine him. Choanal Atresia: Congenital, failure of disappearance of nasopharyngeal membrane. May be unilateral or bilateral, total or partial, membranous or bony. Bilateral total- presents as neonatal emergency Partial- nasal obstruction, rhinorrhoea, unilateral or bilateral Treatment- surgical. Endoscopic resection/drilling, mucosal flap, stent. May restenose and require revision. Transpalatal approach less used nowadays. Neck Lumps: Differential diagnosis includes lymphadenopathy, skin cysts, embryological remnants e.g. branchial cyst, thyroglossal cyst. Position of lump / attachment to skin or deeper structures / movement with swallowing may aid diagnosis. Often need ultrasound. Treatment often surgical (except reactive lymphadenopathy) Hoarse voice / stridor: Infants- often congenital e.g. laryngomalacia, papilloma, web, subglottic stenosis or haemangioma, cleft. Need endoscopic examination and appropriate treatment. Older children: Milder versions of same pathologies can present when older. Hoarse voice often due to screamer s nodules, but can only make diagnosis after endoscopic examination, so all these should be referred.