Introduction
Children are prone to ENT conditions because many structures within the ENT region are developmentally immature and are prone to dysfunction (poor functioning). For example, the eustachian tube (fig 1) is shorter and does not open effectively until the child reaches puberty resulting in middle ear conditions, sinuses are only fully developed at 8 years old and tonsils and adenoids are often large and only shrink in the teens. Children also do not complain of their symptoms resulting in many conditions being inadequately managed or left completely undetected.
Common Ear Conditions
1. External Ear Infections – swimming and excessive cotton bud usage predispose to bacterial infections of the outer ear canal.
Treatment – Cleaning the ear with suction, avoidance of water and use of antibiotic eardrops will clear the infection effectively.
2. Middle Ear Infection (Acute Otitis Media) – upper respiratory tract infections (URTI) can track up the immature Eustachian tube and infect the middle ear. Symptoms include pain, fever and hearing loss. In some cases, the pus will burst through the eardrum and result in purulent ear discharge.
Treatment – Oral medications with antibiotics for the infection and analgesics for pain relief is all that is required. If the condition is complicated by perforation of the eardrum, then ear cleaning with suction followed by eardrops together with oral medication is required.
3. Middle Ear Effusion/ Fluid (Otitis Media with Effusion OME) – one of the functions of the Eustachian tube is to allow air from the nose into the middle ear so as to equalize the pressure in the middle ear compartment. If the Eustachian tube cannot perform this function effectively, fluid fills the middle ear space and leads to hearing loss (Fig 2). Common causes of ineffective Eustachian tube function include large adenoids and sinusitis.
Treatment – Options include observation for a few weeks, a full course of antibiotics and surgical drainage via a myringotomy and grommet tube insertion (fig 3). The best treatment will depend on age of the child, speech and language development and number of previous episodes.
Common Nasal Conditions
1. Allergy – up to 30% of children demonstrate symptoms of nasal allergy such as rhinorrhea (runny nose), blockage, sneezing and itchiness. The most common allergen in the world is house dust mite. Children can also be allergic to food.
Treatment – The principles in the management of allergy include allergen avoidance, nasal sprays, antihistamines, immunotherapy and surgery for nasal blockage eg radiofrequency turbinate reduction.
2. Epistaxis (bleeding from the nose) – spontaneously bleeding from the nose is a common occurrence in children. This is due to a multitude of factors including an immature thin mucosa of the nasal cavity (prominent blood vessels are commonly found at the front of the septum called Little’s area), trauma from digging, rubbing, blowing and infection.
Treatment – Management of underlying cause such as allergy. Blood vessels can be cauterized with silver nitrate as a clinic procedure.
3. Chronic Sinusitis – the maxillary sinus is most often infected in children as they are developed at birth while the rest of the sinuses develop later. Symptoms include persistent nasal discharge, blockage, cough and facial pain.
Treatment – when symptoms last longer than 3 months, a prolonged course of antibiotics (at least 4 weeks) should be tried. It may be combined with a sinus washout to flush out pus trapped in the sinus. Treatment of underlying allergy is also important.
Common Throat Conditions
1. Chronic Cough – Persistent and chesty coughs lasting more than 3 weeks require assessment. Coughs as a result of viral pharyngitis generally last a maximum of 2 weeks. Causes of chronic cough include postnasal drip (mucous dripping from nose into throat from allergy), reflux pharyngitis (gastric acid escaping up towards the throat) and infection eg mycoplasma pneumoniae and sinusitis. Nocturnal cough can be disruptive to a child’s sleep as lying down results in pooling of mucous and phlegm in the throat.
Treatment – Chest x-rays in children with chronic cough should be performed. Treatment of underlying allergy with nasal sprays and antihistamines, reflux disease with anti-gastric medications and infection with antibiotics generally resolve the problem. If asthma is suspected, a consultation with a paediatrician is recommended.
Snoring and Obstructive Sleep Apnea
Tonsils are adenoids are often large in children (fig 4). This results in narrowing of the upper airway causing nasal obstruction and mouth breathing. They are large from 2 to 3 years of age and peak in size at about 6 to 8 years old. It generally stays the same size till puberty when the sudden increase in skull size reduces the size of the adenoids and tonsils in relation to the airway. In some children, the adenoids and tonsils remain large into adulthood.
During sleep, snoring is loud with choking or gasping spells. The increased upper airway resistance results in repeated and frequent episodes of oxygen desaturation and can stress the heart over time. Sleep is of poor quality and children wake up tired and listless. When the condition is severe and prolonged, behavioral changes such as irritability, temper tantrums and poor concentration are commonly observed. These represent symptoms of chronic sleep deprivation. Many studies have also shown poorer academic performance in children with significant obstructive sleep apnea.
Besides large tonsils and adenoids, nasal obstruction from allergy can also aggravate sleep apnea. Swollen turbinates can obstruct the nasal passage as much as large adenoids and tonsils.
Treatment – snoring and sleep apnea due to large tonsils and adenoids are easily managed by surgical removal (see Tonsils & Adenoids). The procedure is performed under general anaesthesia as a day case. Improvement is usually seen the same night. Treatment for nasal obstruction can also be instituted if present