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When ENT symptoms are more distressing, fail to resolve, are recurring / chronic, or especially if appear more serious (respiratory distress with noisy breathing, uncontrollable nose bleed, red swollen neck lump, red swollen eye with a history of a cold, ear sticking out with a red swelling behind it), patients should be managed by an ENT surgeon in the 1st place. If a paediatrician’s consultation is warranted, this can be arranged through the ENT Consultant.
When an ear infection is suspected, or confirmed in a child prior to a flight, how do you decide whether you need to postpone the air travel? That is, is the pain of an ear infection or the eardrum a useful indicator of whether to travel or not? And what kind of damage can occur to a child's eardrum if s/he does travel with an ear infection?
This is a case-by-case diagnosis. It would depend on how far into the course of the infection the patient is, how distressed they are, the length of the flight (and urgency), etc... For example, in the case of a patient with a resolving ear infection, already on antibiotics, and the child is ‘clinically well’, it may be reasonable to travel on a short-haul flight. Whereas if the child was very distressed, with a red drum, taking a long-haul flight, and who has not started antibiotics it may not be advisable to travel. The pain will be worsened and the drum will likely rupture/perforate. Because this is barotrauma-induced rupture/perforation of the drum, the extent of the rupture may be more than in a spontaneous case, with poor healing, and increased risk of long term hearing and infection problems.
In children with persistent ear infections, at what point do you decide inserting grommets will be helpful? And what are the short-term and longterm side effects of having grommets?
Indications:
If there is persistent hearing loss on both sides for about 3 months, with confirmed glue ear / middle ear effusion (fluid behind the drum). Children with special needs are assessed on a case-by-case basis. The success rate in improving hearing is well over 95%. Aside from hearing and speech improvements, there is an improvement in behaviour, attentiveness… If there is a history of recurring pain &/or discharge (even if on one side only) over 3 – 6 months. The success rate in eliminating recurrent infections is well over 95 %.
Children with grommets are advised to avoid water entering the ear canals for about a week, but after that can swim without ear protection. However ‘if possible’ to avoid jumping into the pool or going underwater. The grommets extrude themselves from the drum over time, and the perforation closes spontaneously 80 – 99 % of the time (the percent varies depending on the type of grommet). Also about 80 – 90 % of children who undergo grommet surgery don’t need it again. Unfortunately the remainder can require several sets of grommets. In these cases an alternative is a ‘long-stay’ grommet (with unfortunately has an increased risk (about 20 %) of leaving a residual perforation of the drum) or a hearing aid.
Complications:
Anaesthetic: with modern anaesthetics there is virtually no serious problems. The odd child may be nauseous, or groggy, but this usually settles quickly.
Surgical short-term: bleeding, infection / pain / discharge (infection usually settles with ear drops and a longer period of water avoidance, but very occasionally necessitates early removal of the grommet)
Surgical long-term: unhealed perforation of the drum (usually only a 1 - 5 % risk, which can be reversed surgically), scarring of the drum (alters the drum appearance but usually has no effect on hearing)
Swimmers ear. What is this really? Is it anything to do with swimming? And how can we prevent it?
This is known medically as otitis externa, which is an infection of the outer ear. The outer ear consists of the ear itself, and the ear canal (from the entrance to the ear drum). Swimmers ear (term not used much now) / otitis externa usually affects the ear canal. It can be an acute attack, or a chronic problem with acute exacerbations. It is called swimmers ear because patients get a painful and /or discharging ear after water exposure. They sometimes also have itching and /or hearing loss. It usually affects one side, unless there is an underlying eczematous-type skin condition. The constant moisture makes the skin more fragile to trauma from mild instrumentation, including finger nails. The natural acidic conditions of the skin, & wax can also be altered by prolonged water exposure, and this makes it more susceptible to a bacterial or fungal (less common) infection. The treatment consists of water avoidance (cotton wool coated with vaseline / petroleum jelly when showering / bathing + avoiding swimming), topical antibiotic / antifungal drops (often mixed with steroids to reduce the swelling), and painkillers. If the GP is unhappy with the response to treatment, they may refer the patient for specialist gentle suction cleansing using a microscope in the ENT outpatient clinic. Depending on patient compliance, the advantage is the ENT surgeon can view the ear drum itself to confirm this is only an outer ear infection, and not a more deep seated infection involving the ear drum, or beyond. It resolves over a matter of 1 - 4 weeks. Once the acute episode is over, patients with chronic itchy ears should practice regular water avoidance measures, including plugging with Blu-Tack when swimming (also helpful for those with chemical irritation from chlorine in the swimming pool), and cotton wool coated with vaseline / petroleum jelly when showering / bathing. Occasionally they may have to avoid swimming altogether.
What help can you give your child during an airplane flight for them to be comfortable with the pressure changes that occur?
As an airplane ascends or descends the accompanying air pressure changes will cause the ear drum to move outwards or inwards respectively. This ear drum movement is reversed by our eustachain tubes. These are the passages connecting the space behind the ear drum (known as the middle ear) to the back of the nose. Their function is to equalise pressure on either side of the drum. However babies and toddlers have ‘more dysfunctional’ eustachian tubes, and there is decreased ability of the drum to revert to a normal position, with resultant pain known as barotrauma. If a parent was worried eg: their child has a history of ear infections, painful ears with previous flights, or is flying with a cold, they could use nasal decongestant drops (eg: paediatric Otrivine, paediatric Oxynase) before and after the flight, and if long haul also during the flight. However these drops should only be used with medical advice, and should not be used simply every time a child gets a cold, as their nose can actually get more blocked over time.
As sleep patterns can be very different from one baby / child to another, what are the symptoms and signs of sleep disordered breathing?
Snoring suggests there is an obstruction to airflow in the upper airway. This can be soft and considered ‘mild’, which is not usually a problem and many will get better as they grow older. However if it is loud (suggesting greater airway obstruction) and / or associated with thrashing about and restless sleep, this may need treatment. There may also be periods of reduced breathing (known as hypopnoea) or even absence of breathing (known as apnoea), which are respiratory pauses lasting more than ten seconds. Episodes of hypopnoea and / or apnoea (which can be measured) can result in reduced blood oxygen levels (which can also be measured). Tests used are overnight pulse oximetry or polysomnography (which is a more elaborate test also known as sleep studies). They are available in Malaysia and can be done at home or in the hospital.
Frequent episodes of hypopnoea and / or apnoea with thrashing about is termed Obstructive Sleep Apnoea syndrome, a more severe version of sleep disordered breathing. The heart rate slows, blood pressure rises, the brain is aroused, and sleep is frequently disrupted. Other associated problems may be bed-wetting, daytime sleepiness, poor concentration, irritability or even hyperactive behaviour. If the parents’ history is clear regarding the ‘severity’ of their child’s snoring (suggesting Obstructive Sleep Apnoea syndrome), testing is usually not required, and treatment is suggested (see below). However if the history is not clear-cut and / or parents want objective evidence re: the possibility of Obstructive Sleep Apnoea syndrome, testing is suggested, especially before any surgical treatment.
What are the causes and how treatable are they?
Commonly the problem results from large adenoid glands, which are lymphatic tissue (part of the immune system) situated at the back of the nose, in a region called the nasopharynx. There may also be enlarged tonsils, lymphatic tissue situated at the back of the mouth, in a region called the oropharynx. When there is an upper respiratory tract infection, because there is increased swelling in these tissues the snoring worsens. If a child suffers from recurrent tonsillitis and / or is diagnosed with obstructive sleep apnoea, an operation to remove the tonsils +/- adenoids can improves things. Sometimes a combination of problems can co-exist, and thus tonsil and adenoid surgery alone may not cure sleep disordered breathing. There can be other causes of upper airway obstruction such as allergic rhinosinusitis with recurring symptoms of an itchy nose, sneezing, nasal discharge, and nasal blockage / mouth breathing. This often responds to antihistamines and /or steroid nasal sprays depending on the age of the child and compliance to type of medication. Also, some patients may need surgery to reduce the size of the inferior turbinates, which are structures situated within the nose on the side walls that warm and humidify the air we breathe, but can become enlarged in allergic rhinosinusitis. This is a temporary procedure to improve airflow, with the mainstay treatment of allergic rhinosinusitis being medications. Allergy testing is sometimes also done.
A nasal septal deviation is another cause of nasal obstruction but is not usually treated surgically in children. Nasal polyps would be a rare cause of nasal obstruction in children. Obese children carry fat deposits around the throat and neck that can narrow the upper airway and their large abdomen causes increased straining during breathing especially when lying on their back. Weight loss is thus essential. There are some children with abnormalities involving the lower jaw or tongue (such as Pierre Robin sequence or Down’s syndrome respectively), or neuromuscular deficits (such as cerebral palsy), and they need more specialised treatments, eg: Continuous Positive Airway Pressure (CPAP) or additional surgical procedures. Tracheostomy (a hole in the neck leading to the windpipe) is an exceptional last resort.
Are there any long-term related diseases / medical problems as a result of sleep disordered breathing?
There may be heart, lung, blood pressure, growth and obesity problems in the long-term. However not all patients will suffer these, and medical advice should be sought if there are any queries.
