Child's Hearing Loss
Children and Facial Paralysis
Facial Sports Injuries
Allergic Rhinitis (Hay Fever)
Child Screening
Children and Facial Trauma
Cochlear-Meningitis Vaccination
Could My Child Have Sleep Apnea?
Day Care and Ear, Nose, and Throat Problems
How Allergies Affect your Child's Ears, Nose, and Throat
Laryngopharyngeal Reflux and Children
Noise-Induced Hearing Loss in Children
Pediatric Food Allergies
Pediatric GERD (Gastro-Esophageal Reflux Disease)
Pediatric Head and Neck Tumors

Pediatric Thyroid Cancer
When Your Child Has Tinnitus
Why Do Children Have Earaches?
Is My Child's Hearing Normal?
Pediatric Sinusitis
Pediatric Obesity and Ear, Nose, and Throat Disorders
Nodules, Polyps, and Cysts
Pediatric GERD (Gastro-Esophageal Reflux Disease)
Pediatric Obesity and Ear, Nose, and Throat Disorders
Tonsillectomy Procedures
Tonsillitis
Tonsils and Adenoids PostOp
Tonsils and Adenoids
Tongue-tie (Ankyloglossia)

Pediatric Thyroid Cancer

The thyroid is a butterfly shaped gland located at the base of the throat. It has two lobes separated in the middle by a strip of tissue (the isthmus). The thyroid itself secretes three main hormones: (1) Thyroxine contains iodine, needed for growth and metabolism; (2) Triiodothyronine, similar in function to Thyroxine, effects body size, tissues growth, and function: and (3) Calcitonin, which decreases the concentration of calcium in the blood and increases calcium in the bones. All three of these hormones have an important role in your child’s growth.

Thyroid cancer is the third most common tumor malignancy in children. It occurs six times more often in females than males and shares several characteristics with adult thyroid cancer patients. Surgery is the preferred treatment for this cancer and although the procedure is often uncomplicated, one of the risks of thyroid surgery involves vocal cord paralysis. Consequently, an otolaryngologist—head and neck surgeon should be consulted.

Types of thyroid cancer in children:

Papillary: This form of thyroid cancer occurs in cells that produce thyroid hormones containing iodine. This type, the most common form of thyroid cancer in children, grows very slowly.

Follicular: This type of thyroid cancer also develops in cells that produce thyroid hormones containing iodine. The disease afflicts a slightly older age group and is less common in children. This type of thyroid cancer is more likely to spread to the neck via blood vessels causing the cancer to spread to other parts of the body, making the disease difficult to control.

Medullary: This rare form of thyroid cancer develops in cells that produce calcitonin, a hormone that does not contain iodine. This cancer tends to spread to other parts of the body and constitutes about 5-10 percent of all thyroid malignancies. Medullary thyroid carcinoma (MTC) in the pediatric population is usually associated with multiple endocrine neoplasia type 2 (MEN2), an inherited genetic form of the cancer.

Anaplastic: This is the fastest growing of the thyroid cancers, with extremely abnormal cells that grow and spread rapidly, especially locally in the head and neck region. This form of cancer usually is found in older patients.

Symptoms:

The symptoms of this disease vary. Your child may have a lump in the neck, continuous swollen lymph nodes, a tight or full feeling in the neck, and/or trouble with breathing or swallowing, hoarseness.

Diagnosis:

If any of these symptoms occur, consult your child’s physician for a diagnosis. The diagnosis could consist of a head and neck examination to determine if unusual lumps are present; a blood test to indicate how the thyroid is functioning; a sonography, which uses high-frequency sound waves and a computer to create an image of the thyroid gland; a radioactive iodine scan, which provides information about the thyroid shape and function, identifying areas in the thyroid that do no absorb iodine in the normal way; fine needle biopsy, removal for study of a small part of the tumor; and surgery, where a procedure known as a thyroid lobectomy, necessitates removal of the lobe of the thyroid gland that contains the tumor, for analysis.

Treatments for thyroid cancer:

If the tumor is found to be malignant then surgery is used to remove as much of the tumor as possible either by lobectomy or subtotal thyroidectomy (removal of at least one thyroid lobe and up to a near-total removal of the thyroid gland). If necessary, the otolaryngologist— head and neck surgeon may remove the entire thyroid, in a procedure called a total thyroidectomy. Surgery may be followed by radioactive iodine therapy which destroys cancer cells that are left after surgery and help prevent the disease from returning Thyroid hormone therapy may need to be administered throughout your child’s life when he/she has had surgery to remove the thyroid followed by radioactive iodine treatment to replace normal hormones and slow the growth of cancer cells. If cancer has spread to other parts of the body, chemotherapy, the treatment of disease by means of chemical substances or drugs, may be given. This therapy interferes with the cancer cell’s ability to grow or reproduce. Different groups of drugs work in different ways to fight cancer cells and shrink tumors. In general, treatment outcomes for this type of cancer in children tend to be excellent. The best outcome is achieved with teenage girls, papillary type cancer, and a tumor localized to the thyroid gland.

Source: National Cancer Institute “Populationbased Outcomes for Pediatric Thyroid Carcinoma,” by Nina L. Shapiro MD, and Neil Bhattacharyya MD, Laryngoscope. 2005 Feb;115(2):337-40.

When Your Child Has Tinnitus

Tinnitus is a condition where the patient experiences ringing or other head noises that are not produced by an external source. This disorder can occur in one or both ears, range in pitch from a low roar to a high squeal, and may be continuous or sporadic. This often debilitating condition has been linked to ear injuries, circulatory system problems, noise-induced hearing loss, wax build-up in the ear canal, medications harmful to the ear, ear or sinus infections, misaligned jaw joints, head and neck trauma, Ménière’s disease, and an abnormal growth of bone of the middle ear. In rare cases, slow-growing tumors on auditory, vestibular, or facial nerves can cause tinnitus as well as deafness, facial paralysis, and balance problems. The American Tinnitus Association estimates that more than 50 million Americans have tinnitus problems to some degree, with approximately 12 million people have symptoms severe enough to seek medical care.

This condition is not uncommon in the pediatric population. Although tinnitus in children is as common as in the adult population, children generally do not complain spontaneously of having tinnitus. Researchers believe that the child with tinnitus considers the noise in the ear to be a normal event, as it has usually been present for a long period of time. A second explanation of this discrepancy lies in the fact that the child may not distinguish between the psychological impact of the tinnitus and its medical significance.

Continuous tinnitus can be annoying and distracting, and in severe cases it can cause psychological distress and interfere with your child’s ability to lead a normal life. The good news is that most children with tinnitus seem to eventually outgrow the symptom. It is unusual to see a child carry the problem into adulthood.

If you think your child has tinnitus:

You should first arrange an appointment with your family physician or pediatrician. If the child does not have a specific problem with the ears such as middle ear inflammation with thick discharge then it may be necessary to have your child referred to an otolaryngologist or ear, nose, and throat specialist.

What treatment your child may be offered.

Most people, including children, who are diagnosed with tinnitus find that there is no specific problem underlying their tinnitus. Consequently, there is no specific medicine or operation to ‘cure’ tinnitus. However, experts suggest that the following steps be taken with the child diagnosed with tinnitus:

1. Reassure the child: Explain that this condition is common and they are not alone. Ask your physician to describe the condition to the child in terms and images that they can understand.
2. Explain that he/she may feel less distressed by their tinnitus in the future: Many children find it helpful to have their tinnitus explained carefully to them and to know about ways to manage it. This is partly due to a medical concept known as “neural plasticity,” resulting in children’s brains being more able to change their response to all kinds of stimulation. If it is carefully managed, childhood tinnitus may not be a serious problem.
3. Use sound generators or provide background noise: Sound therapy has been used to treat adults with tinnitus for some time, and can also be used with children. Sound therapy aims to make tinnitus less noticeable. If tinnitus occurs on a regular basis, then the child’s nervous system can, with soundtherapy, adapt to the condition. The sound can be environmental, such as a fan or quiet background music.
4. Have hearing-impaired children wear hearing aids: A child with tinnitus and a hearing loss may find that hearing aids can help improve the tinnitus. Hearing aids do this by picking up sounds your child may not normally hear, which in turn will help their brain filter out their tinnitus. It may also help them by taking the strain out of listening. Straining to hear can make your child’s brain focus on the tinnitus noises.
5. Helping your child to sleep with debilitating tinnitus: Severe tinnitus may lead to sleep difficulties for the young patient. Ask your otolaryngologist the best strategy to adopt when the child cannot sleep.
6. Finally, help your child to relax. Some children believe their tinnitus gets worse when they are under stress. Discuss appropriate stress relieving techniques with your pediatrician or family physician.

Why Do Children Have Earaches?

To understand earaches you must first know about the Eustachian tube, a narrow channel connecting the inside of the ear to the back of the throat, just above the soft palate. The tube allows drainage -- preventing fluid in the middle ear from building up and bursting the thin ear drum. In a healthy ear, the fluid drains down the tube, assisted by tiny hair cells, and is swallowed.

The tube maintains middle ear pressure equal to the air outside the ear, enabling free eardrum movement. Normally, the tube is collapsed most of the time in order to protect the middle ear from the many germs residing in the nose and mouth. Infection occurs when the Eustachian tube fails to do its job. When the tube becomes partially blocked, fluid accumulates in the middle ear, trapping bacteria already present, which then multiply. Additionally, as the air in the middle ear space escapes into the bloodstream, a partial vacuum is formed that absorbs more bacteria from the nose and mouth into the ear.

Why do children have more ear infections than adults?

Children have Eustachian tubes that are shorter, more horizontal, and straighter than those of adults. These factors make the journey for the bacteria quick and relatively easy. A child’s tube is also floppier, with a smaller opening that easily clogs.

Inflammation of the middle ear is known as “otitis media.” When infection occurs, the condition is called "acute otitis media." Acute otitis media occurs when a cold, allergy or upper respiratory infection, and the presence of bacteria or viruses lead to the accumulation of pus and mucus behind the eardrum, blocking the Eustachian tube.

When fluid forms in the middle ear, the condition is known as "otitis media with effusion," which can occur with or without infection. This fluid can remain in the ear for weeks to many months. When infected fluid persists or repeatedly returns, this is sometimes called “chronic middle ear infection.” If not treated, chronic ear infections have potentially serious consequences such as temporary or permanent hearing loss.

How are recurrent acute otitis media and otitis media with effusion treated?

Some child care advocates suggest doing nothing or administering antibiotics to treat the infection. More than 30 million prescriptions are written each year for ear infections, accounting for 25 percent of all antibiotics prescribed in the United States. However, antibiotics are not effective against viral ear infections (30 to 50 percent of such disorders), may cause uncomfortable side effects such as upset stomach, and can contribute to antibiotic resistance. Medical researchers believe that 25 percent of all pneumococcus strains, the most common bacterial cause of ear infections, are resistant to penicillin, and ten to 20 percent are resistant to amoxicillin.

Is surgery effective against recurrent otitis media and otitis media with effusion?

In some cases, surgery may be the only effective treatment for chronic ear infections. Some physicians recommend the use of laser myringotomy, using a laser to create a tiny hole in the eardrum. The treatment is done in the doctor's office using topical anesthesia (ear drops). Laser myringotomy works by providing several weeks of ventilation for the middle ear. Proponents suggest this can reduce the many courses of antibiotic treatment for severe ear infections and eliminates the need for surgical insertion of tubes with general anesthesia.

Before the procedure:

Prior to the procedure, the otolaryngologist will examine the patient for a description of the tympanic membrane (eardrum) and the middle ear space. An audiometry may be performed to assess patient hearing. A tympanometry will be performed that tests compliance of the tympanic membrane at various levels of air pressure. This test provides a measurement of the extent of middle ear effusion, Eustachian tube function, and otitis media.

The procedure: During the procedure, a small incision is made in the ear drum, the fluid is suctioned out, and a tube is placed. In young children, this is usually done under a light, general anesthesia; older patients may have the procedure performed under local anesthesia. There are over 50 different tube designs, all in different shapes, color, and composition. In general, smaller tubes stay in for a shorter duration, while large inner flanges hold the tube in place for a longer time. Some recent tubes have special surface coatings or treatments that may reduce the likelihood of infection.

After the procedure: Immediately after the procedure, the surgeon will examine the patient for persistent or profuse bleeding or discharge. After one month, the tube placement will be reviewed, and the patient’s hearing may be tested. Later, the physician will assess the tube’s effectiveness in alleviating the ear infection.

What is the most common surgical treatment for ear infections?

The most common surgical procedure administered to children under general anesthesia is myringotomy with insertion of tympanostomy tubes (TT). A tube is inserted in the middle ear to allow continuous drainage of fluid. The procedure is recommended for treatment of: chronic otitis media with effusion (lasting longer than three months), recurrent acute otitis media (more than three episodes in six months or more than four episodes in 12 months), severe acute otitis media, otitis media with effusion and a hearing loss greater than 30 dB, non-responsiveness to antibiotics, and impending mastoiditis or intra-cranial complication due to otitis media.

If the patient is age six or younger, it is recommended that tubes remain in place for up to two years. Most tubes will fall out without assistance. Otherwise, the specialist will determine when the tubes should be removed.

Your ENT physician will recommend the most effective treatment for your child’s ear infection.

Is My Child's Hearing Normal?

Insight into behavioral benchmarks, risk indicators, and hearing tests

• Checklist for determining hearing loss
• Hearing tests: How, when, and why
• What you should do
• and more...

Three million children under the age of 18 have some hearing loss including four out of every thousand newborns. So, every parent and caregiver should be watchful of the signs of hearing loss in his/her child and seek a professional diagnosis. Hearing loss can increase the risk of speech and language developmental delays.

Indicators for hearing loss

During pregnancy

• Mother had German measles, a viral infection or flu.
• Mother drank alcoholic beverages.

Newborn (birth to 28 days of age)

• Weighed less than 3.5 pounds at birth.
• Has an unusual appearance of the face or ears.
• Was jaundiced (yellow skin) at birth and had an exchange blood transfusion.
• Was in neonatal intensive care unit (NICU) for more than five days.
• Received an antibiotic medication given through a needle in a vein.
• Had meningitis.
• Failed newborn hearing screening test.

Family

• Has one or more individuals with permanent or progressive hearing loss that was present or developed early in life.

Infant (29 days to 2 years)

• Received an antibiotic medication given through a needle in a vein.
• Had meningitis.
• Has a neurological disorder.
• Had a severe injury with a fracture of the skull with or without bleeding from the ear.
• Has recurring ear infections with fluid in ears for more than three months.

Response to the environment

(speech and language development)

Newborn (Birth to 6 Months)

• Does not startle, move, cry or react in any way to unexpected loud noises.
• Does not awaken to loud noises.
• Does not freely imitate sound.
• Cannot be soothed by voice alone.
• Does not turn his/her head in the direction of
  your voice.
• Does not point to familiar persons or objects
  when asked.
• Does not babble, or babbling has stopped.
• By 12 months does not understand simple phrases by listening alone, such as “wave bye-bye,” or “clap hands.”

Infant (3 months to 2 years)

• Does not accurately turn in the direction of a soft voice on the first call.
• Is not alert to environmental sounds.
• Does not respond on first call.
• Does not respond to sounds or does not locate where sound is coming from.
• Does not begin to imitate and use simple words for familiar people and things around the home.
• Does not sound like or use speech like other
  children of similar age.
• Does not listen to TV at a normal volume.
• Does not show consistent growth in the understanding and the use of words.

Hearing tests: How, when, and why

If you suspect that your child may have hearing loss, discuss it with your doctor. Children of any age can be professionally tested.

Tests for newborns and infants under one year

Hearing tests are painless, and they normally take less than half-an-hour.

Newborns are tested with either the otoacoustic emissions (OAE) test or the automated auditory brainstem response (AABR) test. During the OAE test, a microphone is placed in the baby’s ear. It sends soft clicking sounds, and a computer then records the inner ear’s response to the sounds. In the AABR test the child must wear earphones. Sensors are placed on his/her head to measure brain wave activity in response to the sound.

For infants over six months of age, the diagnostic auditory brainstem response and the visual reinforcement audiometry (VRA) tests are commonly used. The diagnostic auditory brainstem response test is similar to the AABR test, but it provides more information. The VRA test presents a series of sounds through earphones. The child is asked to turn toward the sound, then he/she is rewarded with an entertaining visual image.

Tests for older children and adults

Children between two and four years old are tested through conditioned play audiometry (CPA). The children are asked to perform a simple play activity, such as placing a ring on a peg, when they hear a sound. Older children and adults may be asked to press a button or raise their hand.

All children should have their hearing tested before they start school. This could reveal mild hearing losses that the parent or child cannot detect. Loss of hearing in one ear may also be determined in this way. Such a loss, although not obvious, may affect speech and language.

Hearing loss can even result from earwax or fluid in the ears. Many children with this type of temporary hearing loss can have their hearing restored through medical treatment or minor surgery.

In contrast to temporary hearing loss, some children have nerve deafness, which is permanent. Most of these children have some usable hearing. Few are totally deaf. Early diagnosis, early fitting of hearing aids, and an early start on special educational programs can help maximize the child’s existing hearing.

Please note that this leaflet is not a substitute for an ear examination or a hearing test.

What you should do

If you have checked one or more of these indicators, your child might have hearing loss and you should take him or her for an ear examination and a hearing test. This can be done at any age, as early as just after birth.

If you did not check any of these factors but you suspect that your child is not hearing normally, even if your child’s doctor is not concerned, have your child’s hearing tested by an audiologist and when appropriate, have his or her speech evaluated by a speech and language pathologist. The test will not hurt your child.

Pediatric Sinusitis

Your child’s sinuses are not fully developed until age 20. Although small, the maxillary (behind the cheek) and ethmoid (between the eyes) sinuses are present at birth. Unlike in adults, pediatric sinusitis is difficult to diagnose because symptoms can be subtle and the causes complex.

How Do I Know When My Child Has Sinusitis?

The following symptoms may indicate a sinus infection in your child:

• a “cold” lasting more than 10 to 14 days, sometimes with a low-grade fever
• thick yellow-green nasal drainage
• post-nasal drip, sometimes leading to or exhibited as sore throat, cough, bad breath, nausea and/or vomiting
• headache, usually in children age six or older
• irritability or fatigue
• swelling around the eyes

Young children have immature immune systems and are more prone to infections of the nose, sinus, and ears, especially in the first several years of life. These are most frequently caused by viral infections (colds), and they may be aggravated by allergies. However, when your child remains ill beyond the usual week to ten days, a serious sinus infection is likely.

You can reduce the risk of sinus infections for your child by reducing exposure to known environmental allergies and pollutants such as tobacco smoke, reducing his/her time at day care, and treating stomach acid reflux disease.

How Will the Doctor Treat Sinusitis?

Acute sinusitis: Most children respond very well to antibiotic therapy. Nasal decongestants or topical nasal sprays may also be prescribed for short-term relief of stuffiness. Nasal saline (saltwater) drops or gentle spray can be helpful in thinning secretions and improving mucous membrane function.

If your child has acute sinusitis, symptoms should improve within the first few days. Even if your child improves dramatically within the first week of treatment, it is important that you continue therapy until all the antibiotics have been taken. Your doctor may decide to treat your child with additional medicines if he/she has allergies or other conditions that make the sinus infection worse.

Chronic sinusitis: If your child suffers from one or more symptoms of sinusitis for at least twelve weeks, he or she may have chronic sinusitis. Chronic sinusitis or recurrent episodes of acute sinusitis numbering more than four to six per year, are indications that you should seek consultation with an ear, nose, and throat (ENT) specialist. The ENT may recommend medical or surgical treatment of the sinuses.

Diagnosis of sinusitis: If your child sees an ENT specialist, the doctor will examine his/her ears, nose, and throat. A thorough history and examination usually leads to the correct diagnosis. Occasionally, special instruments will be used to look into the nose during the office visit. An x-ray called a CT scan may help to determine how your child's sinuses are formed, where the blockage has occurred, and the reliability of a sinusitis diagnosis.

When Is Surgery Necessary For Sinusitis?

Surgery is considered for the small percentage of children with severe or persistent sinusitis symptoms despite medical therapy. Using an instrument called an endoscope, the ENT surgeon opens the natural drainage pathways of your child's sinuses and makes the narrow passages wider. This also allows for culturing so that antibiotics can be directed specifically against your child's sinus infection. Opening up the sinuses and allowing air to circulate usually results in a reduction in the number and severity of sinus infections.

Also, your doctor may advise removing adenoid tissue from behind the nose as part of the treatment for sinusitis. Although the adenoid tissue does not directly block the sinuses, infection of the adenoid tissue, called adenoiditis, or obstruction of the back of the nose, can cause many of the symptoms that are similar to sinusitis, namely, runny nose, stuffy nose, post-nasal drip, bad breath, cough, and headache.

Summary

Sinusitis in children is different than sinusitis in adults. Children more often demonstrate a cough, bad breath, crankiness, low energy, and swelling around the eyes along with a thick yellow-green nasal or post-nasal drip. Once the diagnosis of sinusitis has been made, children are successfully treated with antibiotic therapy in most cases. If medical therapy fails, surgical therapy can be used as a safe and effective method of treating sinus disease in children.

Pediatric Obesity and Ear, Nose, and Throat Disorders

Today in the United States, studies estimate that 34 percent of U.S. adults are overweight and an additional 31 percent (approximately 60 million) are obese. Combined, approximately 127 million Americans are overweight or obese. Some 42 years ago, 13 percent of Americans were obese, and in 1980 15 percent were considered obese.

Alarmingly, the number of children who are overweight or obese has doubled in the last two decades as well. Currently, more than 15 percent of 6- to 11-year-olds and more than 15 percent of 12- to 19-year-olds are considered overweight or obese.

What is the difference between designated “obese” versus “overweight?”

Unfortunately, the words overweight and obese are often interchanged. There is a difference:

• Overweight: Anyone with a body mass index (BMI) (a ratio between your height and weight) of 25 or above (e.g., someone who is 5-foot-4 and 145 pounds) is considered overweight.
• Obesity: Anyone with a BMI of 30 or above (e.g., someone who is 5-foot-4 and 175 pounds) is considered obese.
• Morbid obesity: Anyone with a BMI of 40 or above (e.g., someone who is 5-foot-4 and 233 pounds) is considered morbidly obese. "Morbid" is a medical term indicating that the risk of obesity related illness is increased dramatically at this degree of obesity.

Obesity can present significant health risks to the young child. Diseases are being seen in obese children that were once thought to be adult diseases. Many experts in the study of children’s health suggest that a dysfunctional metabolism, or failure of the body to change food calories to energy, precedes the onset of disease. Consequently, these children are at risk for Type II Diabetes, fatty liver, elevated cholesterol, SCFE (a major hip disorder), menstrual irregularities, sleep apnea, and irregular metabolism. Additionally, there are psychological consequences; obese children are subject to depression, loss of self-esteem, and isolation from their peers.

Pediatric obesity and otolaryngic problems

Otolaryngologists, or ear, nose, and throat specialists, diagnose and treat some of the most common children’s disorders. They also treat ear, nose, and throat conditions that are common in obese children, such as:

Sleep apnea:

Children with sleep apnea literally stop breathing repeatedly during their sleep, often for a minute or longer, usually ten to 60 times during a single night. Sleep apnea can be caused by either complete obstruction of the airway (obstructive apnea) or partial obstruction (obstructive hypopnea—hypopnea is slow, shallow breathing), both of which can wake one up. There are three types of sleep apnea—obstructive, central, and mixed. Of these, obstructive sleep apnea (OSA) is the most common. Otolaryngologists have pioneered the treatment for sleep apnea; research shows that one to three percent of children have this disorder, often between the age of two-to-five years old.

Enlarged tonsils, which block the airway, are usually the key factor leading to this condition. Extra weight in obese children and adults can also interfere with the ability of the chest and abdomen to fully expand during breathing, hindering the intake of air and increasing the risk of sleep apnea.

The American Academy of Pediatrics has identified obstructive sleep apnea syndrome (OSAS) as a “common condition in childhood that results in severe complications if left untreated." Among the potential consequences of untreated pediatric sleep apnea are growth failure; learning, attention, and behavior problems; and cardio-vascular complications. Because sleep apnea is rarely diagnosed, pediatricians now recommend that all children be regularly screened for snoring.

Middle ear infections:

Acute otitis media (AOM) and chronic ear infections account for 15 to 30 million visits to the doctor each year in the U.S. In fact, ear infections are the most common reason why an American child sees a doctor. Furthermore, the incidence of AOM has been rising over the past decades. Although there is no proven medical link between middle ear infections and pediatric obesity there may be a behavioral association between the two conditions. Some studies have found that when a child is rubbing or massaging the infected ear the parent often responds by offering the child food or snacks for comfort.

When a child does have an ear infection the first line of treatment is often a regimen of antibiotics. When antibiotics are not effective, the ear, nose and throat specialist might recommend a bilateral myringotomy with pressure equalizing tube placement (BMT), a minor surgical procedure. This surgery involves the placement of small tubes in the eardrum of both ears. The benefit is to drain the fluid buildup behind the eardrum and to keep the pressure in the ear the same as it is in the exterior of the ear. This will reduce the chances of any new infections and may correct any hearing loss caused by the fluid buildup.

Postoperative vomiting (POV) is a common problem after bilateral myringotomy surgery. The overall incidence is 35 percent, and usually occurs on the first postoperative day, but can occur up to seven days later. Several factors are known to affect the incidence of POV, including age, type of surgery, postoperative care, medications, co-existing diseases, past history of POV, and anesthetic management. Obesity, gastroparesis, female gender, motion sickness, pre-op anxiety, opiod analgesics, and the duration of anesthetic all increase the incidence of POV. POV interferes with oral medication and intake, delays return to normal activity, and increases length of hospital stay. It remains one of the most common causes of unplanned postoperative hospital admissions.

Tonsillectomies:

A child’s tonsils are removed because they are either chronically infected or, as in most cases, enlarged, leading to obstructive sleep apnea. There are several surgical procedures utilized by ear, nose, and throat specialists to remove the tonsils, ranging from use of a scalpel to a wand that emits energy that shrinks the tonsils.

Research conducted by otolaryngologists found that Morbid obesity was a contributing factor for requiring an overnight hospital admission for a child undergoing removal of enlarged tonsils. Most children who were diagnosed as obese with sleep apnea required a next-day physician follow-up.

A study from the University of Texas found that morbidly obese patients have a significant increase of additional medical disorders following tonsillectomy and adenoidectomy for obstructive sleep apnea or sleep-disordered breathing when compared to moderately obese or overweight patients undergoing this procedure for the same diagnosis. On average they have longer hospital stays, a greater need for intensive care, and a higher incidence of the need for apnea treatment of continuous positive airway pressure upon discharge from the hospital. The study found that although the morbidly obese group had a greater degree of sleep apnea, they did benefit from the procedure in regards to snoring, apneic spells, and daytime somnolence.

What you can do

If your child has a weight problem, contract your pediatrician or family physician to discuss the weight’s effect on your child’s health, especially prior to treatment decisions. Second, ask your physician about lifestyle and diet changes that will reduce your child’s weight to a healthy standard.

Nodules, Polyps, and Cysts

The term vocal cord lesion (physicians call them vocal “fold” lesions) refers to a group of noncancerous (benign), abnormal growths (lesions) within or along the covering of the vocal cord. Vocal cord lesions are one of the most common causes of voice problems and are generally seen in three forms; nodules, polyps, and cysts.

Vocal Cord Nodules (also called Singer's Nodes, Screamer's Nodes)

Vocal cord nodules are also known as “calluses of the vocal fold.” They appear on both sides of the vocal cords, typically at the midpoint, and directly face each other. Like other calluses, these lesions often diminish or disappear when overuse of the area is stopped.

Vocal Cord Polyp

 A vocal cord polyp typically occurs only on one side of the vocal cord and can occur in a variety of shapes and sizes. Depending upon the nature of the polyp, it can cause a wide range of voice disturbances.

• Vocal fatigue 
• Unreliable voice 
• Delayed voice initiation
• Low, gravelly voice
• Low pitch
• Voice breaks in first passages of sentences
• Airy or breathy voice 
• Inability to sing in high, soft voice
• Increased effort to speak or sing
• Hoarse and rough voice quality
• Frequent throat clearing
• Extra force needed for voice
• Voice "hard to find"

When a vocal cord lesion is present, symptoms may increase or decrease in degree, but will persist and do not go away on their own.

How Is The Diagnosis Of A Benign Vocal Cord Lesion Made?

Diagnosis begins with a complete history of the voice problem and an evaluation of speaking method. The otolaryngologist will perform a careful examination of the vocal cords, typically using rigid laryngoscopy with a stroboscopic light source. In this procedure, a telescope-tube is passed through the patient's mouth that allows the examiner to view the voice box (images are often recorded on video). The stroboscopic light source allows the examiner to assess vocal fold vibration. Sometimes a second exam will follow a trial of voice rest to allow the otolaryngologist an opportunity to assess changes in the vocal cord lesion. Other associated medical problems can contribute to voice problems, such as: reflux, allergies, medication’s side effects, and hormonal imbalances. An evaluation of these conditions is an important diagnostic factor.

How Are Benign Vocal Cord Lesions Treated?

The most common treatment options for benign vocal cord lesions include: voice rest, voice therapy, singing voice therapy, and phonomicrosurgery, a type of surgery involving the use of microsurgical techniques and instruments to treat abnormalities on the vocal cord.

Treatment options can vary according to the degree of voice limitation and the exact voice demands of the patient. For example, if a professional singer develops benign vocal cord lesions and undergoes voice therapy, which improves speaking but not singing voice, then surgery might be considered to restore singing voice. Successful and appropriate treatment is highly individual and includes consideration of the patient’s vocal needs and the clinical judgment of the otolaryngologist.

Pediatric GERD (Gastro-Esophageal Reflux Disease)

Everyone has gastroesophageal reflux (GER), the backward movement (reflux) of gastric contents into the esophagus. Extraesophageal Reflux (EER) is the reflux of gastric contents from the stomach into the esophagus with further extension into the throat and other upper aerodigestive regions. In infants, more than 50 percent of children three months or younger have at least one episode of regurgitation a day. This rate peaks at 67 percent at age four months. But an infant’s improved neuromuscular control and the ability to sit up will lead to a spontaneous resolution of significant GER in more than half of infants by age ten months and four out of five at age 18 months.

Researchers have found that 10 percent of infants (younger than 12 months) with GER develop significant complications. The diseases associated with reflux are known collectively as Gastro-Esophageal Reflux Disease (GERD).  Physically, GERD occurs when a muscular valve at the lower end of the esophagus malfunctions. Normally, this muscle closes to keep acid in the stomach and out of the esophagus. The continuous entry of acid or refluxed materials into areas outside the stomach can result in significant injury to those areas. It is estimated that some five to eight percent of adolescent children have GERD.

What symptoms are displayed by a child with GERD?

GER and EER in children often cause relatively few symptoms until a problem exists (GERD). The most common initial symptom of GERD is heartburn. Heartburn is more common in adults, whereas children have a harder time describing this sensation. They usually will complain of a stomach ache or chest discomfort, particularly after meals.

More frequent or severe GER and EER can cause other problems in the stomach, esophagus, pharynx, larynx, lungs, sinuses, ears and even the teeth.  Consequently, other typical symptoms could include crying/irritability, poor appetite/feeding and swallowing difficulties, failure to thrive/weight loss, regurgitation (“wet burps” or outright vomiting), stomach aches (dyspepsia), abdominal/chest pain (heartburn), sore throat, hoarseness, apnea, laryngeal and tracheal stenoses, asthma/wheezing, chronic sinusitis, ear infections/fluid, and dental caries. Effortless regurgitation is very suggestive of GER. However recurrent vomiting (which is not the same) does not necessarily mean a child has GER.

Unlike infants, the adolescent child will not necessarily resolve GERD on his or her own. Accordingly, if your child displays the typical symptoms of GERD, a visit to a pediatrician is warranted. However, in some circumstances, the disorder may cause significant ear, nose, and throat disorders. When this occurs, an evaluation by an otolaryngologist is recommended.

How is GERD diagnosed?

Most of the time, the physician can make a diagnosis by interviewing the caregiver and examining the child. There are occasions when testing is recommended. The tests that are most commonly used to diagnose gastroesophageal reflux include:

• pH probe: A small wire with an acid sensor is placed through the nose down to the bottom of the esophagus.  The sensor can detect when acid from the stomach is "refluxed" into the esophagus.  This information is generally recorded on a computer. Usually, the sensor is left in place between 12 and 24 hours.  At the conclusion of the test, the results will indicate how often the child "refluxes" acid into his or her esophagus and whether he or she has any symptoms when that occurs.
• Barium swallow or upper GI series:  The child is fed barium, a white, chalky, liquid. A video x-ray machine follows the barium through the upper intestinal tract and lets doctors see if there are any abnormal twists, kinks or narrowings of the upper intestinal tract.
• Technetium gastric emptying study: The child is fed milk mixed with technetium, a very weakly radioactive chemical, and then the technetium is followed through the intestinal tract using a special camera.  This test is helpful in determining whether some of the milk/technetium ends up in the lungs (aspiration).  It may also be helpful in determining how long milk sits in the stomach.
• Endoscopy with biopsies: This most comprehensive test involves the passing down of a flexible endoscope with lights and lenses through the mouth into the esophagus, stomach, and duodenum. This allows the doctor to get a directly look at the esophagus, stomach, and duodenum and see if there is any irritation or inflammation present.  In some children with gastroesophageal reflux, repeated exposure of the esophagus to stomach acid causes some inflammation (esophagitis).  Endoscopy in children usually requires a general anesthetic.
• Fiberoptic Laryngoscopy: A small lighted scope is placed in the nose and the pharynx to evaluate for inflammation.

What treatments for GERD are available?

Treatment of reflux in infants is intended to lessen symptoms, not to relieve the underlying problem, as this will often resolve on its own with time. A useful simple treatment is to thicken a baby's milk or formula with rice cereal, making it less likely to be refluxed.

Several steps can be taken to assist the older child with GERD:

• Lifestyle changes: Raise the head of the child’s bed about 30 degrees while they sleep and have the child eat smaller, more frequent meals instead of large amounts of food at one sitting.  Avoid having the child eat right before they go to bed or lie down; instead, let two or three hours pass.  Try a walk or warm bath or even a few minutes on the toilet.  Some researchers believe that certain lifestyle changes such as losing weight or dressing in loose clothing my assist in alleviating GERD. Even chewing sugarless gum may help.
• Dietary changes: Avoid chocolate, carbonated drinks, caffeine, tomato products, peppermint, and other acidic foods as citrus juices.  Fried foods and spicy foods are also known to aggravate symptoms.  Pay attention to what your child eats and be alert for individual problems.
• Medical Treatment: Most of the medications prescribed to treat GERD either break down or lessen intestinal gas, decrease or neutralize stomach acid, or improve intestinal coordination. Your physician will prescribe the most appropriate medication for your child.
• Surgical Treatment: It is rare for children with GERD to require surgery.  For the few children who do require surgery, the most commonly performed operation is called Nissen fundoplication. With this procedure, the top part of the stomach (the fundus) is wrapped around the bottom of the esophagus to create a collar. After the operation, every time the stomach contracts, the collar around the esophagus contracts preventing reflux.

Pediatric Obesity and Ear, Nose, and Throat Disorders

Today in the United States, studies estimate that 34 percent of U.S. adults are overweight and an additional 31 percent (approximately 60 million) are obese. Combined, approximately 127 million Americans are overweight or obese. Some 42 years ago, 13 percent of Americans were obese, and in 1980 15 percent were considered obese.

Alarmingly, the number of children who are overweight or obese has doubled in the last two decades as well. Currently, more than 15 percent of 6- to 11-year-olds and more than 15 percent of 12- to 19-year-olds are considered overweight or obese.

What is the difference between designated “obese” versus “overweight?”

Unfortunately, the words overweight and obese are often interchanged. There is a difference:

• Overweight: Anyone with a body mass index (BMI) (a ratio between your height and weight) of 25 or above (e.g., someone who is 5-foot-4 and 145 pounds) is considered overweight.
• Obesity: Anyone with a BMI of 30 or above (e.g., someone who is 5-foot-4 and 175 pounds) is considered obese.
• Morbid obesity: Anyone with a BMI of 40 or above (e.g., someone who is 5-foot-4 and 233 pounds) is considered morbidly obese. "Morbid" is a medical term indicating that the risk of obesity related illness is increased dramatically at this degree of obesity.

Obesity can present significant health risks to the young child. Diseases are being seen in obese children that were once thought to be adult diseases. Many experts in the study of children’s health suggest that a dysfunctional metabolism, or failure of the body to change food calories to energy, precedes the onset of disease. Consequently, these children are at risk for Type II Diabetes, fatty liver, elevated cholesterol, SCFE (a major hip disorder), menstrual irregularities, sleep apnea, and irregular metabolism. Additionally, there are psychological consequences; obese children are subject to depression, loss of self-esteem, and isolation from their peers.

Pediatric obesity and otolaryngic problems

Otolaryngologists, or ear, nose, and throat specialists, diagnose and treat some of the most common children’s disorders. They also treat ear, nose, and throat conditions that are common in obese children, such as:

Sleep apnea:

Children with sleep apnea literally stop breathing repeatedly during their sleep, often for a minute or longer, usually ten to 60 times during a single night. Sleep apnea can be caused by either complete obstruction of the airway (obstructive apnea) or partial obstruction (obstructive hypopnea—hypopnea is slow, shallow breathing), both of which can wake one up. There are three types of sleep apnea—obstructive, central, and mixed. Of these, obstructive sleep apnea (OSA) is the most common. Otolaryngologists have pioneered the treatment for sleep apnea; research shows that one to three percent of children have this disorder, often between the age of two-to-five years old.

Enlarged tonsils, which block the airway, are usually the key factor leading to this condition. Extra weight in obese children and adults can also interfere with the ability of the chest and abdomen to fully expand during breathing, hindering the intake of air and increasing the risk of sleep apnea.

The American Academy of Pediatrics has identified obstructive sleep apnea syndrome (OSAS) as a “common condition in childhood that results in severe complications if left untreated." Among the potential consequences of untreated pediatric sleep apnea are growth failure; learning, attention, and behavior problems; and cardio-vascular complications. Because sleep apnea is rarely diagnosed, pediatricians now recommend that all children be regularly screened for snoring.

Middle ear infections:

Acute otitis media (AOM) and chronic ear infections account for 15 to 30 million visits to the doctor each year in the U.S. In fact, ear infections are the most common reason why an American child sees a doctor. Furthermore, the incidence of AOM has been rising over the past decades. Although there is no proven medical link between middle ear infections and pediatric obesity there may be a behavioral association between the two conditions. Some studies have found that when a child is rubbing or massaging the infected ear the parent often responds by offering the child food or snacks for comfort.

When a child does have an ear infection the first line of treatment is often a regimen of antibiotics. When antibiotics are not effective, the ear, nose and throat specialist might recommend a bilateral myringotomy with pressure equalizing tube placement (BMT), a minor surgical procedure. This surgery involves the placement of small tubes in the eardrum of both ears. The benefit is to drain the fluid buildup behind the eardrum and to keep the pressure in the ear the same as it is in the exterior of the ear. This will reduce the chances of any new infections and may correct any hearing loss caused by the fluid buildup.

Postoperative vomiting (POV) is a common problem after bilateral myringotomy surgery. The overall incidence is 35 percent, and usually occurs on the first postoperative day, but can occur up to seven days later. Several factors are known to affect the incidence of POV, including age, type of surgery, postoperative care, medications, co-existing diseases, past history of POV, and anesthetic management. Obesity, gastroparesis, female gender, motion sickness, pre-op anxiety, opiod analgesics, and the duration of anesthetic all increase the incidence of POV. POV interferes with oral medication and intake, delays return to normal activity, and increases length of hospital stay. It remains one of the most common causes of unplanned postoperative hospital admissions.

Tonsillectomies:

A child’s tonsils are removed because they are either chronically infected or, as in most cases, enlarged, leading to obstructive sleep apnea. There are several surgical procedures utilized by ear, nose, and throat specialists to remove the tonsils, ranging from use of a scalpel to a wand that emits energy that shrinks the tonsils.

Research conducted by otolaryngologists found that Morbid obesity was a contributing factor for requiring an overnight hospital admission for a child undergoing removal of enlarged tonsils. Most children who were diagnosed as obese with sleep apnea required a next-day physician follow-up.

A study from the University of Texas found that morbidly obese patients have a significant increase of additional medical disorders following tonsillectomy and adenoidectomy for obstructive sleep apnea or sleep-disordered breathing when compared to moderately obese or overweight patients undergoing this procedure for the same diagnosis. On average they have longer hospital stays, a greater need for intensive care, and a higher incidence of the need for apnea treatment of continuous positive airway pressure upon discharge from the hospital. The study found that although the morbidly obese group had a greater degree of sleep apnea, they did benefit from the procedure in regards to snoring, apneic spells, and daytime somnolence.

What you can do

If your child has a weight problem, contract your pediatrician or family physician to discuss the weight’s effect on your child’s health, especially prior to treatment decisions. Second, ask your physician about lifestyle and diet changes that will reduce your child’s weight to a healthy standard.

Tonsillectomy Procedures

Unfortunately, there may be a time when medical therapy (antibiotics) fails to resolve the chronic tonsillar infections that affect your child. In other cases, your child may have enlarged tonsils, causing loud snoring, upper airway obstruction, and other sleep disorders. The best recourse for both these conditions may be removal or reduction of the tonsils and adenoids. The American Academy of Otolaryngology—Head and Neck Surgery recommends that children who have three or more tonsillar infections a year undergo a tonsillectomy; the young patient with a sleep disorder should be a candidate for removal or reduction of the enlarged tonsils.

The Tonsillectomy Today

The first report of tonsillectomy was made by the Roman surgeon Celsus in 30 AD. He described scraping the tonsils and tearing them out or picking them up with a hook and excising them with a scalpel. Today, the scalpel is still the preferred surgical instrument of many ear, nose, and throat specialists. However, there are other procedures available – the choice may be dictated by the extent of the procedure (complete tonsil removal versus partial tonsillectomy) and other considerations such as pain and post-operative bleeding. A quick review of each procedure follows:

• Cold knife (steel) dissection: Removal of the tonsils by use of a scalpel is the most common method practiced by otolaryngologists today. The procedure requires the young patient to undergo general anesthesia; the tonsils are completely removed with minimal post-operative bleeding.
  
• Electrocautery: Electrocautery burns the tonsillar tissue and assists in reducing blood loss through cauterization. Research has shown that the heat of electrocautery (400 degrees Celsius) results in thermal injury to surrounding tissue. This may result in more discomfort during the postoperative period.
  
• Harmonic scalpel: This medical device uses ultrasonic energy to vibrate its blade at 55,000 cycles per second. Invisible to the naked eye, the vibration transfers energy to the tissue, providing simultaneous cutting and coagulation. The temperature of the surrounding tissue reaches 80 degrees Celsius. Proponents of this procedure assert that the end result is precise cutting with minimal thermal damage.
  
• Radiofrequency ablation (Somnoplasty): Monopolar radiofrequency thermal ablation transfers radiofrequency energy to the tonsil tissue through probes inserted in the tonsil.  The procedure can be performed in an office setting under light sedation or local anesthesia. After the treatment is performed, scarring occurs within the tonsil causing it to decrease in size over a period of several weeks. The treatment can be performed several times. The advantages of this technique are minimal discomfort, ease of operations, and immediate return to work or school. Tonsillar tissue remains after the procedure but is less prominent. This procedure is recommended for treating enlarged tonsils and not chronic or recurrent tonsillitis.
  
• Carbon dioxide laser: Laser tonsil ablation (LTA) finds the otolaryngologist employing a hand-held CO2 or KTP laser to vaporize and remove tonsil tissue. This technique reduces tonsil volume and eliminates recesses in the tonsils that collect chronic and recurrent infections. This procedure is recommended for chronic recurrent tonsillitis, chronic sore throats, severe halitosis, or airway obstruction caused by enlarged tonsils.
  The LTA is performed in 15 to 20 minutes in an office setting under local anesthesia. The patient leaves the office with minimal discomfort and returns to school or work the next day. Post-tonsillectomy bleeding may occur in two to five percent of patients. Previous research studies state that laser technology provides significantly less pain during the post-operative recovery of children, resulting in less sleep disturbance, decreased morbidity, and less need for medications. On the other hand, some believe that children are adverse to outpatient procedures without sedation.
  
• Microdebrider: What is a “microdebrider?” The microdebrider is a powered rotary shaving device with continuous suction often used during sinus surgery. It is made up of a cannula or tube, connected to a hand piece, which in turn is connected to a motor with foot control and a suction device.
  The endoscopic microdebrider is used in performing a partial tonsillectomy, by partially shaving the tonsils. This procedure entails eliminating the obstructive portion of the tonsil while preserving the tonsillar capsule. A natural biologic dressing is left in place over the pharyngeal muscles, preventing injury, inflammation, and infection. The procedure results in less post-operative pain, a more rapid recovery, and perhaps fewer delayed complications. However, the partial tonsillectomy is suggested for enlarged tonsils – not those that incur repeated infections.
  
• Bipolar Radiofrequency Ablation (Coblation): This procedure produces an ionized saline layer that disrupts molecular bonds without using heat. As the energy is transferred to the tissue, ionic dissociation occurs. This mechanism can be used to remove all or only part of the tonsil. It is done under general anesthesia in the operating room and can be used for enlarged tonsils and chronic or recurrent infections. This causes removal of tissue with a thermal effect of 45-85 C°. The advantages of this technique are less pain, faster healing, and less post operative care.

Consult with an otolaryngologist regarding the optimum procedure to remove or reduce your tonsils and adenoids.

Tonsillitis

What is tonsillitis? Tonsillitis refers to inflammation of the pharyngeal tonsils. The inflammation may involve other areas of the back of the throat including the adenoids and the lingual tonsils (areas of tonsil tissue at the back of the tongue). There are several variations of tonsillitis: acute, recurrent, and chronic tonsillitis and peritonsillar abscess.

Viral or bacterial infections and immunologic factors lead to tonsillitis and its complications. Nearly all children in the United States experience at least one episode of tonsillitis. Because of improvements in medical and surgical treatments, complications associated with tonsillitis, including mortality, are rare.

Who gets tonsillitis?

Tonsillitis most often occurs in children; however, the condition rarely occurs in children younger than two years. Tonsillitis caused by Streptococcus species typically occurs in children aged five to 15 years, while viral tonsillitis is more common in younger children. A peritonsillar abscess is usually found in young adults but can occur occasionally in children. The patient's history often helps identify the type of tonsillitis (i.e., acute, recurrent, chronic) that is present.

What causes tonsillitis?

The herpes simplex virus, Streptococcus pyogenes (GABHS) and Epstein-Barr virus (EBV), cytomegalovirus, adenovirus, and the measles virus cause most cases of acute pharyngitis and acute tonsillitis. Bacteria cause 15-30 percent of pharyngotonsillitis cases; GABHS is the cause for most bacterial tonsillitis.

What are the symptoms of tonsillitis?

The type of tonsillitis determines what symptoms will occur.

• Acute tonsillitis: Patients have a fever, sore throat, foul breath, dysphagia (difficulty swallowing), odynophagia (painful swallowing), and tender cervical lymph nodes. Airway obstruction due to swollen tonsils may cause mouth breathing, snoring, nocturnal breathing pauses, or sleep apnea. Lethargy and malaise are common. These symptoms usually resolve in three to four days but may last up to two weeks despite therapy.
  
  
• Recurrent tonsillitis: This diagnosis is made when an individual has multiple episodes of acute tonsillitis in a year.
  
  
• Chronic tonsillitis: Individuals often have chronic sore throat, halitosis, tonsillitis, and persistently tender cervical nodes.
  
  
• Peritonsillar abscess: Individuals often have severe throat pain, fever, drooling, foul breath, trismus (difficulty opening the mouth), and muffled voice quality, such as the “hot potato” voice (as if talking with a hot potato in his or her mouth).

What happens during the physician visit?

Your child will undergo a general ear, nose, and throat examination as well as a review of the patient’s medical history.

A physical examination of a young patient with tonsillitis may find:

• Fever and enlarged inflamed tonsils covered by pus.
• Group A beta-hemolytic Streptococcus pyogenes (GABHS) can cause tonsillitis associated with the presence of palatal petechiae (minute hemorrhagic spots, of pinpoint to pinhead size, on the soft palate). Neck nodes may be enlarged. A fine red rash over the body suggests scarlet fever. GABHS pharyngitis usually occurs in children aged 5-15 years.
• Open-mouth breathing and muffled voice resulting from obstructive tonsillar enlargement. The voice change with acute tonsillitis usually is not as severe as that associated with peritonsillar abscess.
• Tender cervical lymph nodes and neck stiffness (often found in acute tonsillitis).
• Signs of dehydration (found by examination of skin and mucosa).
• The possibility of infectious mononucleosis due to EBV in an adolescent or younger child with acute tonsillitis, particularly when cervical, axillary, and/or groin nodes are tender. Severe lethargy, malaise and low-grade fever accompany acute tonsillitis.
• A grey membrane covering tonsils that are inflamed from an EBV infection. (This membrane can be removed without bleeding.) Palatal petechiae (pinpoint spots on the soft palate) may also be seen with an EBV infection.
• Red swollen tonsils that may have small ulcers on their surfaces in individuals with herpes simplex virus (HSV) tonsillitis.
• Unilateral bulging above and to the side of one of the tonsils when peritonsillar abscess exists. A stiff jaw may be present in varying severity.

Treatment

Tonsillitis is usually treated with a regimen of antibiotics. Fluid replacement and pain control are important. Hospitalization may be required in severe cases, particularly when there is airway obstruction. When the condition is chronic or recurrent, a surgical procedure to remove the tonsils is often recommended.

Tonsils and Adenoids PostOp

The tonsils are two pads of tissue located on both sides of the back of the throat. Adenoids sit high on each side of the throat behind the nose and the roof of the mouth. Tonsils and adenoids are often removed when they become enlarged and block the upper airway, leading to breathing difficulty. They are also removed when recurrence of tonsil infections or strep throat cannot be successfully treated by antibiotics.

The procedure to remove the tonsils is called a tonsillectomy; excision of the adenoids is an adenoidectomy. Both are usually performed concurrently; hence the procedure is known as a tonsillectomy and adenoidectomy or T&A.

T&A is an outpatient surgical procedure lasting between 30 and 45 minutes and performed under general anesthesia. Normally, the young patient will remain at the hospital or clinic for about four hours after surgery for observation. An overnight stay may be required if there are complications such as excessive bleeding or poor intake of fluids.

When the tonsillectomy patient comes home

Most children require seven to ten days to recover from the surgery. Some may recover more quickly; others can take up to two weeks for a full recovery. The following guidelines are recommended:

Drinking: The most important requirement for recovery is for the patient to drink plenty of fluids. Milk products should be avoided in the first 24 hours after surgery. Offer juice, soft drinks, popsicles, and Jell-O (pudding, yogurt, and ice-cream after 24 hours). Some patients experience nausea and vomiting after the surgery caused by the general anesthetic. This usually occurs within the first 24 hours and resolves on its own. Contact your physician if there are signs of dehydration (urination less than 2-3 times a day or crying without tears).

Eating: Generally, there are no food restrictions (other than milk products) after surgery. The sooner the child eats and chews, the quicker the recovery. Tonsillectomy patients may be reluctant to eat because of sore throat pain; consequently, some weight loss may occur, which is gained back after a normal diet is resumed.

Fever: A low-grade fever may be observed several days after surgery. Contact your physician if the fever is greater than 102º.

Activity: Bed rest is recommended for several days after surgery. Activity may be increased slowly, with a return to school after normal eating and drinking resumes, pain medication ceases, and the child sleeps through the night. Travel away from home is not recommended for two weeks following surgery.

Breathing: The parent may notice abnormal snoring and mouth breathing due to swelling in the throat. Breathing should return to normal when swelling subsides, 10-14 days after surgery.

Scabs: A scab will form where the tonsils and adenoids were removed. These scabs are thick, white, and cause bad breath. This is not unexpected. Most scabs fall off in small pieces five to ten days after surgery and are swallowed.

Bleeding: With the exception of small specks of blood from the nose or in the saliva, bright red blood should not be seen. If such bleeding occurs, contact your physician immediately or take your child to the emergency room. Bleeding is an indication that the scabs have fallen off too early, and medical attention is required.

Pain: Nearly all children undergoing a tonsillectomy/adenoidectomy will have mild to severe pain in the throat after surgery. Some may complain of an earache (because stimulation of the same nerve that goes to throat also travels to the ear), and a few may incur pain in the jaw and neck (due to positioning of the patient in the operating room).

Pain control: Your physician will prescribe appropriate pain medications for the young patient such as codeine, hydrocodone, Tylenol with codeine liquid, or Lortab (hydrocodone with Tylenol). Generally, an acetaminophen (Tylenol, Tempra, Panadol) teaspoon solution is recommended for regular administration to the patient for three or four days after surgery.

If you are troubled about any phase of your child’s recovery, contact your physician immediately.

Tonsils and Adenoids

Insight into tonsillectomy and adenoidectomy

• What affects tonsils and adenoids?
• When should I see a doctor?
• Common symptoms of tonsillitis and enlarged adenoids
• and more...

Tonsils and adenoids are on the body’s first line of defense—our immune system. They “sample” bacteria and viruses that enter the body through the mouth or nose at the risk of their own infection. But at times, they become more of a liability than an asset and may even trigger airway obstruction or repeated bacterial infections. Your ear, nose, and throat specialist can suggest the best treatment options.

What are tonsils and adenoids?

Two masses of tissue that are similar to the lymph nodes or “glands” found in the neck, groin, and armpits. Tonsils are the two masses on the back of the throat. Adenoids are high in the throat behind the nose and the roof of the mouth (soft palate) and are not visible through the mouth without special instruments.

What affects tonsils and adenoids?

The most common problems affecting the tonsils and adenoids are recurrent infections (throat or ear) and significant enlargement or obstruction that causes breathing, swallowing, and sleep problems.

Abscesses around the tonsils, chronic tonsillitis, and infections of small pockets within the tonsils that produce foul-smelling, cheese-like formations can also affect the tonsils and adenoids, making them sore and swollen. Tumors are rare, but can grow on the tonsils.

When should I see a doctor?

You should see your doctor when you or your child suffer the common symptoms of infected or enlarged tonsils or adenoids.

Your physician will ask about problems of the ear, nose, and throat and examine the head and neck. He or she will use a small mirror or a flexible lighted instrument to see these areas.

Other methods used to check tonsils and adenoids are:

• Medical history
• Physical examination
• Throat cultures/Strep tests - helpful in determining infections in the throat
• X-rays - helpful in determining the size and shape of the adenoids
• Blood tests - helpful in determing infections such as mononucleosis

How are tonsil and adenoid diseases treated?

Bacterial infections of the tonsils, especially those caused by streptococcus, are first treated with antibiotics. Sometimes, removal of the tonsils and/or adenoids may be recommended if there are recurrent infections despite antibiotic therapy, and/or difficulty breathing due to enlarged tonsils and/or adenoids. Such obstruction to breathing causes snoring and disturbed sleep that leads to daytime sleepiness in adults and behavioral problems in children.

Chronic infection can affect other areas such as the eustachian tube – the passage between the back of the nose and the inside of the ear. This can lead to frequent ear infections and potential hearing loss. Recent studies indicate adenoidectomy may be a beneficial treatment for some children with chronic earaches accompanied by fluid in the middle ear (otitis media with effusion).

In adults, the possibility of cancer or a tumor may be another reason for removing the tonsils and adenoids. In some patients, especially those with infectious mononucleosis, severe enlargement may obstruct the airway. For those patients, treatment with steroids (e.g., cortisone) is sometimes helpful.

How to prepare for surgery

Children

• Talk to your child about his/her feelings and provide strong reassurance and support
• Encourage the idea that the procedure will make him/her healthier.
• Be with your child as much as possible before and after the surgery.
• Tell him/her to expect a sore throat after surgery.
• Reassure your child that the operation does not remove any important parts of the body, and that he/she will not look any different afterward.
• If your child has a friend who has had this surgery, it may be helpful to talk about it with that friend.

Adults and children

For at least two weeks before any surgery, the patient should refrain from taking aspirin or other medications containing aspirin. (WARNING: Children should never be given aspirin because of the risk of developing Reye’s syndrome).

• If the patient or patient’s family has had any problems with anesthesia, the surgeon should be informed. If the patient is taking any other medications, has sickle cell anemia, has a bleeding disorder, is pregnant, has concerns about the transfusion of blood, or has used steroids in the past year, the surgeon should be informed.
• A blood test and possibly a urine test may be required prior to surgery.
• Generally, after midnight prior to the operation, nothing may be taken by mouth (including chewing gum, mouthwashes, throat lozenges, toothpaste, water.) Anything in the stomach may be vomited when anesthesia is induced, and this is dangerous.

When the patient arrives at the hospital or surgery center, the anesthesiologist or nursing staff may meet with the patient and family to review the patient’s history. The patient will then be taken to the operating room and given an anesthetic. Intravenous fluids are usually given during and after surgery.

After the operation, the patient will be taken to the recovery area. Recovery room staff will observe the patient until discharged. Every patient is unique, and recovery time may vary.

Your ENT specialist will provide you with the details of preoperative and postoperative care and answer any questions you may have.

After surgery

There are several postoperative symptoms that may arise. These include, but are not limited to, swallowing problems, vomiting, fever, throat pain, and ear pain. Occasionally, bleeding may occur after surgery. If the patient has any bleeding, your surgeon should be notified immediately.

Any questions or concerns you have should be discussed openly with your surgeon.

Tonsillitis and its symptoms

Tonsillitis is an infection in one or both tonsils. One sign is swelling of the tonsils. Other signs or symptoms are:

• Redder than normal tonsils
• A white or yellow coating on the tonsils
• A slight voice change due to swelling
• Sore throat
• Uncomfortable or painful swallowing
• Swollen lymph nodes (glands) in the neck
• Fever
• Bad breath

Enlarged adenoids and their symptoms

If your or your child’s adenoids are enlarged, it may be hard to breathe through the nose. Other signs of constant enlargement are:

• Breathing through the mouth instead of the nose most of the time
• Nose sounds “blocked” when the person speaks
• Noisy breathing during the day
• Recurrent ear infections
• Snoring at night
• Breathing stops for a few seconds at night during snoring or loud breathing (sleep apnea)

Tongue-tie (Ankyloglossia)

Most of us think of tongue-tie as a situation we find ourselves in when we are too excited to speak. Actually, tongue-tie is the non-medical term for a relatively common physical condition that limits the use of the tongue, ankyloglossia.

Before we are born, a strong cord of tissue that guides development of mouth structures is positioned in the center of the mouth. It is called a frenulum. After birth, the lingual frenulum continues to guide the position of incoming teeth. As we grow, it recedes and thins. This frenulum is visible and easily felt if you look in the mirror under your tongue. In some children, the frenulum is especially tight or fails to recede and may cause tongue mobility problems.

The tongue is one of the most important muscles for speech and swallowing. For this reason having tongue-tie can lead to eating or speech problems, which may be serious in some individuals.

When Is Tongue-tie a Problem That Needs Treatment?

In Infants

Feeding – A new baby with a too tight frenulum can have trouble sucking and may have poor weight gain. Such feeding problems should be discussed with your child’s pediatrician who may refer you to an otolaryngologist—head and neck surgeon (ear, nose, and throat specialist) for additional treatment.

NOTE: Nursing mothers who experience significant pain while nursing or whose baby has trouble latching on should have their child evaluated for tongue tie. Although it is often overlooked, tongue tie can be an underlying cause of feeding problems that not only affect a child’s weight gain, but lead many mothers to abandon breast feeding altogether.

In Toddlers and Older Children

Speech – While the tongue is remarkably able to compensate and many children have no speech impediments due to tongue-tie, others may. Around the age of three, speech problems, especially articulation of the sounds - l, r, t, d, n, th, sh, and z may be noticeable. Evaluation may be needed if more than half of a three–year–old child’s speech is not understood outside of the family circle. Although, there is no obvious way to tell in infancy which children with ankyloglossia will have speech difficulties later, the following associated characteristics are common:

• V-shaped notch at the tip of the tongue
• Inability to stick out the tongue past the upper gums
• Inability to touch the roof of the mouth
• Difficulty moving the tongue from side to side

As a simple test, caregivers or parents might ask themselves if the child can lick an ice cream cone or lollipop without much difficulty. If the answer is no, they cannot, then it may be time to consult a physician.

Appearance – For older children with tongue-tie, appearance can be affected by persistent dental problems such as a gap between the bottom two front teeth. Your child’s physician can guide you in the diagnosis and treatment of tongue-tie. If he/she recommends surgery, an otolaryngologist—head and neck surgeon (ear, nose, and throat specialist), can perform a surgical procedure called a frenulectomy.

Tongue-tie Surgery Considerations

Tongue-tie surgery is a simple procedure and there are normally no complications. For very young infants (less than six-weeks-old), it may be done in the office of the physician. General anesthesia may be recommended when frenulectomy is performed on older children. But in some cases, it can be done in the physician’s office under local anesthesia. While frenulectomy is relatively simple, it can yield big results. Parents should consider that this surgery often yields more benefit than is obvious by restoring ease of speech and self-esteem.