Services For Children
Children are not just mini adults. Their anatomy, health reserve, disease presentation, development and psychosocial needs differ across the age groups of newborns, neonates, infants, toddlers, young and older children and those in their teenage years. The concerns of and support from their family and caregivers are equally important. Coordinating care across multidisciplinary medical, educational and developmental bodies is also critical for best outcomes. This is possible with support from an established Child Ear Nose Throat specialist in Singapore with a strong network of equally established multi-disciplinary specialist colleagues.
After completing general ENT specialization in 2001, Dr Lynne Lim sub-specialized in Paediatric ENT at the renowned Cincinnati Children Hospital & Medical Centre, America, from 2001-2004, under the mentorship of the giant of Paediatric ENT, Dr Robin Cotton. The CCHMC ENT is an American Otolaryngology Board accredited world leader in Paediatric care, with strong subgroups of paediatric airway/ pulmonary/ swallowing; hearing/ speech and communication; snoring and syndromes; sinus and allergy; head and neck tumor management, research and education. It has a proud tradition of training many of the alumni leaders in paediatric ENT worldwide.
- Congenital – These can occur due to infections (e.g. Rubella, CytoMegaloVirus, Toxoplasmosis, Herpes, Syphyllis) or genetic causes with or without syndromes. They can result in cochlear and middle ear hearing loss.
- Genetic hearing loss – There are over 200 types of genetic hearing loss. Only 10% of those affected are born to parents with hearing loss, as 75% of deafness is due to an autosomal recessive genetic inheritance. Only 25% of these patients are syndromic with other body systems also affected.
- Noise-induced hearing loss – This is due to very high noise level exposure for just a few minutes (e.g. 120dB for 15 minutes), or chronic high noise exposure (e.g. 80dB for 8 hours).
- Lumps and sinuses around/ on the external ear – These may be simple sebaceous cysts, keloids, pseudocysts, preauricular sinuses or more rarely, first branchial cysts/ sinuses.
- Ear wax and foreign bodies – These can cause discomfort, infection and if severely impacted, reduce hearing.
- Otitis media – This can be acute with pain and fever, with pus in the middle ear and possible rupture of the ear drum (Acute Otitis Media). It could be recurrent or chronic, with fluid in the middle ear (Otitis Media With Effusion/ Glue Ear), and associated with infections or Eustachian tube dysfunction.
- Eustachian tube dysfunction –This can be due to a more horizontal and shorter Eustachian tube of the child, bottle feeding lying down, craniofacial anomalies, tone, recurrent allergic rhinitis or sinus infections, cleft palate and adenoid enlargement. It causes blocked ear sensations that otitis media with effusion, worse during flu or cold.
- Perforated ear drum – This can result from traumatic injury to the ear drum or chronic untreated middle ear and mastoid infections, and sometimes after grommet tubes extrusions.
- Middle ear bones pathology – Malformed, dislocated, fractured, eroded or fixed. This can be congenital, traumatic, or due to a chronic infection or tumor.
- Cholesteatoma – A middle ear tumour that is not cancerous, but causes hearing loss by eroding the middle ear bones. May erode into brain, face nerve and ear balance organs. In congenital cases, it is easily mistaken as simply glue ear, as there is no perforation of the ear drum.
- Mastoid infection – Chronic infection of the mastoid air cells and bony septations due to bacteria, fungus or unusual diseases like Tuberculosis.
- Microtia auricle (malformed outer ear) and atresia ear canal (absent or narrowed ear canal). A complex reconstruction challenge, with psychological, facial nerve, middle ear bones, hearing and cosmesis concerns. May be associated with craniofacial disproportions or syndromes. Multiple combinations of management options need to be tailored to each patient’s anatomy and wishes.
- Central auditory processing disorder (CAPD) appears like hearing loss even though the child has normal hearing. Sound information, especially speech sounds in natural noise backgrounds, is not processed properly as the brain and ears don’t fully coordinate. Resulting speech, language and academic delays are common.
- Acoustic Neuroma – Tumor of the hearing nerve impairs hearing, and may cause facial nerve palsy, giddiness and increased intracranial pressure with growth. Rare in kids except those with Neurofibromatosis Type II.
- Giddiness – This is ear vestibular-related in some cases, usually from infections, and trauma. Other causes include migraine, drugs, neurological, heart and hormonal causes.
- Tinnitus – This is often a result of hearing loss. It may also be due to tumors, abnormal vessels, thyroid dysfunction and drugs.
- Hearing loss is often missed, especially in children. A hearing test is a must before diagnosing autism, attention deficit disorder, academic and speech delay conditions.
- 4 in a 1000 are born with hearing loss. In ill babies, severe jaundice, infections and trauma increases chances 4 to 10 x. Inadequate or lack of proper testing can result in speech and language delays, behavioural problems and misdiagnosis of low IQ for years if hearing loss is missed. Even mild bilateral hearing loss in children that is chronic can negatively impact learning and hearing with longer-term auditory processing and learning consequences, affecting eventual maximizing of potential and social and job options.
- Many teenagers and young adults underestimate their noise exposure and the risk of noise-induced hearing loss. Have you had ringing ears after a cinema or clubbing event? That may mean there is irreversible hearing loss that often starts at high frequencies. Listening to your music via headphones at maximum risks hearing loss in less than 15 minutes.
The hearing tests and complete range of services are available in-house in sound-proof and sound-treated rooms, allowing the children’s ENT doctor to interpret the tests together with the audiologist to offer a treatment plan on an immediate basis. Closer collaboration also allows for increased safety of investigations requiring sedation, and optimizes outcomes.
- Otoscopy and light microscopy – Otoscopy offers clear views of the ear canal and ear drum. Light microscopy magnifies these images many times, with increased clarity for diagnosis.
- Newborn hearing screening and diagnosis – Diagnosis of hearing loss is missed in over 50% of newborns without proper screening. An Otoacoustic Emission (OAE) test without Auditory Brainstem Response (ABR) may miss 20% of hearing loss. In-clinic complete testing with OAE, ABR, Tympanometry and Auditory Steady State Response (ASSR) is available. Young babies can often be in natural sleep for the 1 hour test.
- Children hearing tests – Gold standard age-appropriate hearing diagnostic tests in appropriately sized sound-proof rooms by audiology professionals allow for accurate results in challenging child testing situations. Behavioral Observation Audiometry, Visual Response Audiometry, Play Audiometry, Pure Tone Audiometry and Tympanometry are all available. Children are less cooperative, with shorter attention spans, and need to feel comfortable and engaged. In-clinic specialised tests for children of different ages will be tailored accordingly. Light sedation of older children is usually required.
- Eustachian tube dysfunction test – this can confirm if your inability to pop the ears or pressure pains – especially on airplane descent or in lifts are due to dysfunction of the cartilaginous-muscular tubes that connect your middle ears to the back of the nose
- Tympanometry – this test shows the middle ear pressure and volume, and is a reflection of the state of the ear drum and middle ear. It is often flat in patients with fluid or pus in the middle ear.
- Central auditory processing disorder tests – these are speech lists tests for children over 7 years of age or adults with normal hearing, usually requiring 2 sessions of 1-1.5 hours each under different conditions – e.g. in a noisy background or with competing sound information to both ears.
- Radiology: CT scan temporal bone, MRI brain and Internal Acoustic Meatus are required to determine the anatomy of bony and soft tissue structures of the outer, middle and inner ear, cochlear, vestibular aqueduct, hearing and facial nerves and the brain. This also excludes infections and tumors.
- Genetic testing: There are over 200 types of genetic hearing loss. Contrary to common perception, 75% of newborns or young with hearing loss do not have parents or relatives with hearing loss. The only way to exclude genetic cause is to do an appropriate blood test guided by history. In Singapore, 40% of patients with unknown cause of hearing loss and other body systems normally have a Connexin 26 gene mutation. Knowing the genetic cause guides management over a lifetime, as there may be associated eye, kidney, heart, or thyroid problems. It also suggests the progression and prognosis of hearing loss, besides helping families interested in determining the chances of hearing loss in future offspring.
- Topical ear drops, oral medications, temporary cotton stents can help eliminate ear wax, and infectious, traumatic causes.
- Gentle ear cleaning and culture sensitivity of infection fluids, removal of wax and foreign bodies under light microscopic visualization and fine instrumentation.
- Central auditory processing disorder – Treatment has to be tailored to each child. A multi-prong approach is needed: changing the learning or communication environment, recruiting higher-order skills to help compensate, and remediation of the auditory deficit itself (computer- assisted, one-on-one training with a therapist, home-based/ group programs )
- Hearing aids for a wide range of brands, sizes, types and degrees of sophistication
- Customised for needs and listening situations.
- FM systems for classrooms and halls to improve on HA performance.
- Non GA clinic procedures to release pus or fluid from the middle ear in adults.
- Under GA (day surgery) to release fluid or insert grommet tubes for glue ears, repair perforated ear drums, reconstruct or replace with simple prostheses for malformed or eroded ear bones.
- Under GA to remove ear tumors that could be malignant of benign e.g. cholesteatoma
- Under GA to eliminate chronic or dangerous mastoid ear infections via tympanomastoidectomy.
- Under GA for inserting various implants like bone anchored hearing aids, bone anchored hearing implants, middle ear implants for moderate-severe or mixed hearing loss, single-sided deafness and atresia of ear canal.
- Under GA to insert cochlear implants for profound sensorineural hearing loss. Choice of Advanced Bionics, Cochlear and MedEl implants.
Nasal causes are usually picking of the nose, especially with allergic rhinitis. It can be due to foreign body, polyp, tumor, nose bone deviation or trauma. Systemic causes include blood disorders and certain drugs.
Anterior nose can be examined with speculum and good headlight. Posterior nose and postnasal space would require flexible pediatric sized nasoendoscopy after local anaesthetic nose spray. Blood tests to exclude systemic causes.
- Local pressure on the anterior nose is taught for anterior nose bleed
- Topical silver nitrate cautery or diathermy to seal the small bleeding capillaries
- Nasal packing with Merocel, ribbon gauze or nasal balloon
- Selective endoscopic arterial ligation/ embolisation of supplying blood vessels
B. Allergic rhinitis, sinusitis, polyposis
Allergies of the nose result in sneezing, itching, runny and block nose. Sometimes there is eye and ear itch. It can be due to inhalant allergens in the air, or food allergies with either acute or subtle chronic manifestations.
Rhinosinusitis can result from acute or chronic nose passages inflammation, infection, polyps, anatomical nose and sinus structure abnormalities. It is worsened by unmanaged allergies. Less frequently, polyps of the nose are possible even in children, with increased risk in cystic fibrosis or immune-compromised cases.
Allergy and rhinosinusitis cause discomfort and obstruct breathing, disturbing sleep. Rhinosinusitis may require long term medications and antibiotics, with complication risks to eye, brain and teeth, especially in immunocompromised patients. A child with eye swelling associated with rhinosinusitis needs to be examined emergently, to exclude orbital abscesses from the sinusitis. Investigations offered:
Flexible nasoendoscopy tailored to age of patient to determine sinonasal anatomy and cause. Skin prick testing or blood sampling to identify offending allergens. X-ray and CT scans to determine extent of disease and anatomy, with image guided scan CT scan sinus protocol to guide surgery for increased safety.
- Avoidance of the offending allergen tested positive reduces the need for over-dependence on medication. Over avoidance of suspected food allergens without testing may impair dietary planning and proper nutrition for growing children.
- Medication (oral antihistamines, nasal steroid sprays) is usually needed initially and can be tailed down to maintenance or as needed doses longer term.
- Sublingual immunotherapy as simple daily single drops under the tongue.
- Injection immunotherapy for quicker relieve and for more severe cases.
- Functional endoscopic sinus surgery (FESS) guided by image guidance CT scan sinus protocol for precise and safer removal of diseased polyps, bone septations and mucopus/ fungal balls.
C. Large inferior turbinates, deviated nose bone
Inferior turbinates can be chronically hypertrophied from inflammation, allergic rhinitis or structural. The nose bone in the centre can be crooked from birth, a normal growth variation, or due to trauma.
These block the breathing, and predisposes one to rhinosinusitis.
Examination under good headlight with speculum. Flexible nasoendoscopy required for more detailed and posterior nose examination.
- Allergy avoidance and medications, nasal steroid sprays and decongestants
- Radiofrequency of inferior turbinates
- Reduction of the inferior turbinates via partial turbinectomy or turbinoplasty.
- Septoplasty to correct the crooked nose bone
D. Tumors of the nose/ Nose cancer
Tumors can be non-cancerous like polyps, inverted papilloma, angiofibroma. Some tumors are cancerous, located in the nose, sinuses or further back in the nasopharynx. Even young children can have tumors like aggressive rhabdomyosarcomas, and the first presentation of angiofibromas are usually nose bleeds in teenage males.
Even non-cancerous tumors can erode important surrounding structures, and affect the eye, teeth and cause bleeding or block breathing. Cancerous tumors benefit from early detection and treatment. Nasopharyngeal carcinoma is the 6th most common cancer in Singapore, but less common in children compared to our adults.
- Examination under good headlight with speculum and flexible nasoendoscopy.
- Biopsy of the tumor for histopathology in the clinic or under sedation.
- Radiology examinations to determine extent and spread of tumor.
Depending on the histology, local excision via endoscopic method or open excision may be needed. Nowadays, Image Guided Systems (IGS) for endoscopic surgery offers increased safety and completeness of tumor clearance. For cancerous tumors, chemotherapy and radiotherapy referrals may be needed.
A. Tonsil and adenoid enlargement or infection
Tonsils and adenoid enlargements in children may have intrinsic, unknown or infective origins.
Adenoid and tonsil enlargement may result in blocked breathing passages, and snoring, which may be associated with reduced oxygen delivery to the brain and vital organs. It is more common in children between 2-10 years of age. Long term, it may contribute to reduced attention span and learning, poor growth and weight control, reduced mandibular growth and poor dentition. Recurrent tonsillitis could be associated with sore throats, fevers, poor feeding, antibiotic resistance and absence from school/ work. Adenoid hypertrophy and adenoiditis may also predispose to chronic glue ears.
Examination in the clinic may include flexible nose endoscopy. X-ray may be needed for children who are unable to cooperate. Sleep study may be required – either home or hospital based for a night.
- Watchful waiting only if episodes are isolated, mild and without significant airway obstruction.
- Fever, pain and antibiotic medications may be required.
- Day surgery for tonsils removal may be required for chronic airway obstruction, severe or recurrent tonsillitis. Diathermy, radiofrequency and coblation methods are available.
B. Unclear speech
Can be due to tongue tie, oromotor poor coordination, wrong learning of speech, very large tonsils, cleft palate, submucous cleft, soft palate insufficiency/ weakness, disproportionate craniofacial structures, poor lateral pharyngeal wall tone, neurological disorders.
- Examination of oral cavity with good headlight
- Flexible nasoendoscopy with patient speaking
- Work with a speech therapist/paediatrician/ plastic surgeon/ dental colleagues for multidisciplinary evaluation
- Tongue tie release if severe
- Speech therapy
- Repair of submucous cleft, tonsillectomy, pharyngeal flap, sphincteroplasty as needed
C. Gastric acid reflux into larynx
The ring of muscle between the esophagus and stomach is weak or relaxes abnormally. In Laryngoesophageal reflux disease (LERD), backflow of the acid from the stomach up into the voice box and laryngeal area causes irritation, phlegm and hoarseness in the throat. Mild cases are sometimes common in children before the age of 1 year old. In more complex laryngeal and tracheal airway anomalies, often an associated condition worsening the airway pathology. Obesity, coughing, vomiting, straining or sudden physical exertion can cause increased pressure in the abdomen. Importance:
LERD may not be associated with gastric pain or heartburn sensation. More often, it is just chronic throat irritation worse after meals or sleep, or hoarseness of voice that prompts an evaluation. It also worsens airway swelling in larynx and pharynx in young children. Children may have recurrent vomiting, crying, irritability and food refusals at meal times, with poor weight gain.
- Nasolaryngoendoscopy in the clinic
- 24 hour double pH probe
- Barium swallow/ meal
- Evaluation by gastroenterology and swallow specialists
- Avoid feeding lying down or near bed time
- Dietary and lifestyle modification: reduce weight, smoking, chocolate, peppermint, fried/ fatty foods, coffee and alcohol
- Medication for reflux
- Surgery if the hiatal hernia is strangulated or there is severe reflux
A. Snoring/ Sleep apnea
Are usually due to large adenoid and tonsils, and allergic rhinitis in children. May be due to craniofacial, oropharyngeal and laryngeal structural and neurological issues in kids with various syndromes. In teenagers, blockage may be from deviated nose septum, large inferior turbinates, low lying soft palate, poor pharyngeal tone, obesity, tongue base collapse and hypertrophy.
Snoring needs to be evaluated to exclude central or obstructive sleep apnea (OSA) and upper airway resistance syndrome, where there is blood oxygen deprivation and open mouth breathing leading to disturbed sleep, hyperactivity or tiredness, dental caries, lack of mandibular jaw growth and daytime sleepiness. Long term, oxygen deprivation may increase the risks of growth, weight control, heart, blood pressure, hormonal, neurological and memory problems.
- Flexible nasolaryngoendoscopy in the clinic to determine the sites of obstruction.
- Sleep study (home or hospital based) to determine the severity and pattern of obstructive/ central sleep apnea.
- Non-surgical treatment targeted to the obesity and allergic rhinitis
- Continuous positive airway pressure mask (CPAP) is not usual as first line treatment
- Surgery addresses the adenoid, tonsil and inferior turbinate sites of blockage
- Surgery tailored to the soft palate, base of tongue and larynx sites of blockage
- Tongue base and mandibular advancement surgery in some syndromic cases
B. Head and neck lumps
The most common lumps are neck lymph nodes swelling from infections and congenital thyroglossal and branchial cysts. Other lumps are vascular lesions, lymphangiomas, salivary gland (parotid, thyroid and sublingual) and floor of mouth lesions. Cancers are less common in children, with many malignancies being blood cell origin.
Lymph nodes more than 2 cm diameter, rubbery, enlarging or fixed require further evaluation. Repeated infections, pain, discharge is possible. Swallowing and voice may sometimes be affected. Malignancies though rarer must be excluded.
- Clinic examination and palpation may need to be supplemented with flexible nasolaryngoscopy of the upper airway
- Ultrasound scans of the neck and superficial lumps
- Fine needle aspiration cytology
- CT or MRI scans
- Medication (oral, injectable) for infections, hemangioma, lymphangioma
- Surgical excision for bioipsy, noresolving lumps and for definitive diagnosis
- Lymphangiomas and vascular hemangiomas can be particularly challenging with infiltration between important head and neck regions harboring key vessels and structures, with higher risk of residual and recurrent disease
In young children, chronic hoarseness is usually due to voice abuse and screaming resulting in vocal cord nodules and hemorrhage. It can be aggravated by laryngoesophageal reflux disease. Other causes are trauma, respiratory papillomas, post intubation and post surgery for pathology in the chest, head and neck.
The voice may become raspy, harsh, of different pitch and low volume.
- Throat examination
- Flexible nasolaryngoendoscopy with patient voicing
- Biopsy via endoscopic non-open methods under general anesthesia (Endoscopic Laryngeal Microscopic Surgery)
- CT scan and MRI radiology of the base of skull, neck and chest
- Observation for spontaneous recovery in acute infections.
- Voice rest. Avoid voice overuse of wrong use. Voice training and rehabilitation by speech and swallow therapist
- Better control of gastroesophageal reflux
- Medications for cough, gastroesophageal reflux and allergies
- Surgery for benign nodules, cysts, and polyps
- Surgery for trauma to the larynx or vocal cords
D. Feeding/ Swallowing Disorder
- Problems gathering food and sucking, chewing, or swallowing it
- Due to reflux, metabolic, nervous system disorders (e.g., cerebral palsy, meningitis, encephalopathy), prematurity and/or low birth weight, airway conditions, laryngeal cleft, vocal cord palsy, laryngoesophageal fistula, heart and lung disease, cleft lip and/or palate, muscle weakness
- Easily missed with unusual signs during feeding: arching or stiffening of the body/ irritability/ coughing or gagging/ refusing food or liquid/ only wants certain types of foods eg pureed/ long feeding times/ difficulty chewing
- Other signs are: drooling or food coming out of the mouth or nose/ difficulty breathing when feeding/ gurgly or hoarse voice, frequent vomiting/ recurrent lung infections/ poor weight gain
Multidisciplinary consults with pediatricians, gastroenterologists, speech-language swallow pathologists, physiotherapists.
- Observe patient’s posture, behaviour, and oral movements during feeding
- Modified barium swallow
- Swallow process is viewed on an X-ray (Videofluoroscopy)
- Nasolaryngoendoscopy when patient feeds with different foods
- Medication for acid reflux
- Address the underlying cause
- Swallow therapy to improve feeding coordination and acceptance of different food
- Individualised direct feeding therapy
- Nutritional changes (optimize calories and types of food)
Stridor is the sound arising from blocked vocal cord or trachea sites airway obstruction, and different from stertor arising from nose block or wheezing from bronchial airway block. A specialized multidisciplinary medical, surgical, therapist, anaesthetist and HD/ ICU team carefully coordinating the care is a must. In young children especially, the condition may be associated with complex and multiple system issues and the oxygen reserve is tenuous.
Usually include inhaled or swallowed foreign body obstruction, prolonged intubation with subglottic stenosis, laryngomalacia, congenital airway anomalies which are often complex, vocal cord palsy, hemangioma and lymphangioma, epiglottis infection, recurrent respiratory papillomatosis and vagal nerve injury from chest surgeries. Congenital cases may have heart and chest vasculature anomalies.
Stridor is noisy breathing arising from blocked airway at the level of the voice box and trachea. There is risk of acute oxygen lack, respiratory distress, cardiac arrest and death. Feeding, swallowing, voice and lung function are often affected.
- Nasolaryngoendoscopy in the clinic
- Xray neck and chest, CT scan and MRI
- Microlaryngobronchoscopy (MLB) to evaluate tracheobronchial airway and biopsy
- Feeding, swallowing, voice and lung function evaluation
- Emergency medications or intubation for swelling of vocal cords
- Surgical tracheotomy (limits learning, work, social options, risk of dislodgement and blockage, 24 hour care needed)
- Treatment tailored to the underlying cause (eg laser or microdebrider removal of papillomatosis, lateralisation of vocal cords, repositioning of dislocated vocal cartilages, cardiothoracic surgery)
- In subglottic/ trachea stenosis, balloon dilatation, plastic and wire stents, anterior and posterior rib graft trachea reconstruction, cricotracheal resection, segmental trachea resection and tracheoplasty options to avoid permanent tracheotomy