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 investigations frequently need to be more comprehensive, with the full armamentarium available, to tailor for newborns to children across all ages, and with different temperaments and stages of development. Extra time at the visit is needed. 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 Dr Lynne Lim, an established Child Ear Nose Throat ENT specialist in Singapore with a strong network of equally established multi-disciplinary specialist colleagues. Her ENT specialist centre staff are experienced in caring for children.
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.
- Newborn – hearing loss – Can occur due to congenital infections (e.g. Rubella, CytoMegaloVirus, Toxoplasmosis, Herpes, Syphilis) or genetic causes with or without syndromes. Associated with some toxic drugs, ICU stay, hypoxaemia episodes, severe jaundice. Can result in cochlear, middle or outer 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.
- Childhood hearing loss – Can be delayed presentation of newborn hearing loss, or due to new infections, toxic drugs, neurological disease.(Read More: How Hearing Loss Looks Like); (Read More: 10 things someone with hearing loss wish others know); (Read More: 10 Things to Know About Hearing Loss); (Read More: Through The Ears)
- Noise-induced hearing loss – This is due to very high noise level exposure for just a few minutes (e.g. 110dB loudness for 15 minutes), or chronic high noise exposure (e.g. 80dB for 8 hours).(Read More: Noise-induced Hearing Loss); (Read More: Teaching Kids to Value Their Hearing)
- 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. First branchial conditions needing surgery can put facial nerve and ear structures at risk and must be approached carefully.
- Ear wax and foreign bodies – These can cause discomfort, infection and if severely impacted, reduce hearing.
- Ear canal infection – This can arise from ear digging or trauma, swimming in dirty pools, skin pimple or abscess. Presents with foul smelling discharge and pain.(Read More: Little Ears, Big Problem)
- Acute otitis media – This can be sudden onset, with pain and fever, pus in the middle ear and possible rupture of the ear drum. In young children, can cause brain abscess if treatment is delayed.
- Chronic Otitis media – Also known as Otitis Media With Effusion/ Glue Ear, this can be recurrent or chronic, with fluid in the middle ear, and associated with infections or Eustachian tube dysfunction. Very easily missed by even doctors, due to ear wax and as changes in appearance of the ear drum may be subtle. May require hearing tests to confirm. Can result in significant and prolonged hearing loss, with speech and language delay.
- 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, flu, cold, allergic rhinitis or sinus infections, cleft palate and adenoid enlargement. It leads to fluid trapped in the middle ear, resulting in blocked ear, hearing loss, poor balance, ringing ears.
- Perforated ear drum – This can result from traumatic injury to the ear drum or chronic untreated middle ear and mastoid infections. Occasionally, perforations result from repeated or long term grommet tubes.
- 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, unlikethat for adults, it is easily mistaken as fluid in the middle ear, as there is no perforation of the ear drum and no ear discharge.
- Mastoid infection – Chronic infection of the mastoid air cells and bony septations due to bacteria, fungus or unusual diseases like Tuberculosis.Risk of brain of neck abscess if untreated.
- 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.
- Auditory neuropathy – Diagnosis is easily missed. Child may pass usual awake simple hearing test or have only mild hearing loss. They will require special electrophysiological hearing tests like Auditory Brainstem Response test conducted by an alert audiologist working in consult with the ENT. A hearing aid alone may not help, and resulting speech, language and academic delays are common, with usual speech therapy treatment ineffective. Some will require cochlear implant surgery.
- Central auditory processing disorder (CAPD) – Diagnosis is easily missed. Appears like hearing loss but child passes the usual hearing tests and can hear well. However, the brain cannot process properly what the ear hears. Sound information, especially speech sounds in noisy environments, competing sounds or longer instructions may not be processed properly by the brain. Resulting speech, language and academic delays are common, with usual speech therapy treatment ineffective.(Read More: Central auditory processing disorder CAPD); (Read More: When the Brain Does Not Hear)
- 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.
- Dizziness/ Vertigo – This is ear vestibular-related in some cases, usually from infections, and trauma. Other causes include migraine, drugs, neurological, heart and hormonal causes.(Read More: Dizziness and Vertigo); (Read More: When the Room Starts to Spin)
- Tinnitus – This is often a result of hearing loss. It may also be due to tumors, abnormal vessels, thyroid dysfunction and drugs.(Read More: Tinnitus)
- Hearing loss is often missed, especially in children. Even moderate 50% hearing loss may be missed, and the speech problems attributed wrongly to the child’s young age. As the brain is most plastic before 4 years old, and can still improve a lot till 12 years of age, it is critical to diagnose a hearing loss early. 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 to 2 hour test..
- Children hearing tests – tests – Gold standard age-appropriate hearing diagnostic tests in appropriately sized sound-proof rooms by pediatric 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. Tests for children of different ages will be tailored accordingly.
- 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. Pediatric anesthetists will give a short intravenous sedation if the child cannot tolerate the scans awake.
- 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 – a wide range of brands, sizes, types and degrees of sophistication, with customized choices for different ages and listening situations.(Read More: Hearing Aids); (Read More: Things New Technology Hearing Aids Can Do)
- Customized ear and swim plugs
- FM systems for teachers, classrooms and halls to improve on HA performance. Personal and discrete Roger Pens microphone systems.(Read More: 10 Ways Technology Improves Hearing Now)
- Tinnitus treatment – Medications, education, psychological counselling, avoidance of stress factors and stimulating substances ( e.g. caffeine), tinnitus maskers, customized music therapy
- Non general anesthetic (GA) clinic procedures to help release pus or fluid from the middle ear in adults, or insertion of grommet tubes.
- Under GA (day surgery) – To release fluid or insert grommet tubes for glue ears – To repair perforated ear drums – To reconstruct or replace with simple prostheses for malformed or eroded ear bones.
- Under GA(1 night stay) – To remove ear tumors that could be malignant of benign e.g. cholesteatoma – To eliminate hronic or dangerous mastoid ear infections via tympanomastoidectomy – To insert various implants (bone anchored hearing aids, middle ear implants or cochlear implants)(Read More: Cochlear and Middle Ear Implants ); (Read More: We Felt Helpless, Lost); (Read More: Did I Hear You Say Ear Implant?)
- Under GA (few nights stay) – To perform microtia and atresia surgery – For hearing: possible reconstruction of ear canal (canalplasty) and malformed ossicles (ossiculoplasty), or bone anchored hearing aids/ bone anchored active implants, or middle ear implants
– For outer ear auricle reconstruction: choices include a prosthetic ear, Medpore (artificial graft) or patient’s own rib graft in the first stage, followed by the second stage with split skin graft from the abdomen and superficial temporal artery revascularisation.
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.(Read More: First Aid for Nose Bleeds)
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.
- Proper local pressure on the anterior nose is taught
- Topical silver nitrate cautery or diathermy to seal the small bleeding capillaries
- Nasal packing with Merocel, ribbon gauze or nasal balloon for severe bleeds
- 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, ear and throat itch, skin eczema or asthma. It can be due to inhalant airborne allergens, or food allergies. Food allergy is more common than airborne allergy in those below 3 to 4 years of age. (Read More: More Than a Tickle); (Read More: Beyond A Snort and Sniffle); (Read More: Is This A Cold, Flu, Allergy Or Sinusitis)
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. Untreated allergies increase the risk of sinusitis, chronic cough and asthma. Rhinosinusitis can also be aggravated by immune problems, poor general health, lack of important vitamins or minerals.
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.
Flexible nasoendoscopy tailored to age of patient to determine sinonasal anatomy and cause. Skin prick testing or RAST blood sampling to identify offending allergens. Food diary to better guide allergy testing. X-ray and CT scans to determine extent of disease and anatomy. Blood tests to identify systemic disorders or mineral deficiencies. Biopsy to exclude cancer or tumor in polyps
- 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 drops or oral tablet immunotherapy- this offers a chance for long term cure, desensitizing the body to the allergens, instead of just treating the symptoms arising from the allergen attacking the body.
- Functional Endoscopic Sinus Surgery (FESS) guided by special image-guidance system (IGS) CT scan protocol, precisely angled microdebriders and endoscopic micro-instruments allows for precise removal of diseased polyps, bone septations. Inflamed mucosa and mucopus/ fungal balls. This can be done without any external incisions, going through the nose. This real-time tracking of the anatomy and precision of instruments reduce risk to the eyes, base of skull, vessels and allow a more complete removal of disease.
- Balloon Sinuplasty helps in cases where there is very limited sinus disease, and may be of some help to identify sinus openings in complex cases in older children.
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, increase snoring and obstructive sleep apnea, 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 or coblation reduction or partial turbinoplasty of inferior turbinates
- Septoplasty to correct the crooked nose bone in teenage children
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. Long term, it may contribute to reduced attention span and learning, bed-wetting, 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 is often worse in children between 2 to 10 years of age. It also predisposes to chronic fluid in the middle ear (glue ear).
Examination in the clinic may include flexible nose endoscopy. X-ray evaluation if child cannot cooperate. Sleep study in complex cases – home or hospital based.
- Watchful waiting only if episodes are isolated, mild and without significant airway obstruction.
- Fever, pain and antibiotic medications
- 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.(Read More: Hypernasality: Get Rid Of This Speech Problem)
- 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
- Work with speech therapy professionals
- Repair of submucous cleft, tonsillectomy, pharyngeal flap, sphincteroplasty as needed
C. Gastroesophageal Reflux Disease (GERD)
The ring of muscle between the esophagus and stomach is weak or relaxes abnormally. In Gastroesophageal reflux disease (GERD), backflow of the acid and non-acid stomach contents up into the voice box and laryngeal area causes irritation, phlegm and hoarseness in the throat. It is more common in children before the age of 1 year old. In more complex laryngeal and tracheal airway anomalies, it further narrows the airway via inflammation and swelling. Obesity, coughing, vomiting, straining or sudden physical exertion can also increase GERD.
Gastroesophageal reflux disease GERD 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 nose, throat and trachea in babies and young children, leading to noisy breathing. Children may have recurrent vomiting, crying, irritability and food refusals at meal times, with poor weight gain. GERD also increases the risk of chronic middle ear fluid and sorethroat.
- Nasolaryngoendoscopy in the clinic
- 24 hour double pH probe
- Barium swallow/ meal
- Evaluation by gastroenterology and swallow specialists
- Esophageal manometry or Pepsin test (for non-acid gastric reflux)
- Avoid bottle feeding lying down or near bed time
- Dietary and lifestyle modification: reduce weight, chocolate, peppermint, fried/ fatty foods
- Medication for reflux
- Refer to gastroenterologist for strangulated hiatal hernia or severe reflux
A. Snoring/ Sleep apnea
Usually due to large adenoid and tonsils, hypertrophic edematous inferior turbinates 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.(Read More: Snoring Across The Ages)
For children, instead of snoring, many have open mouth breathing as their nose passages are tiny. The child is restless, tossing and turning in sleep with mouth open and often bed wetting. 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, poor focus and concentration in school, dental caries and lack of lower jaw growth. Long term, oxygen deprivation may reduce growth, cause underweight or overweight, heart strain, high blood pressure and diabetes.
- Full evaluation of weight, nose throat neck and flexible nasolaryngoendoscopy in clinic to determine the sites of obstruction
- Sleep study (home or hospital based) to determine the severity and pattern of obstructive/ central sleep apnea in some cases
- Non-surgical treatment for obesity and nose allergy
- Continuous positive airway pressure mask (CPAP) is not usual as first line treatment for children
- First line 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
- Surgery for 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 to differentiate benign and cancer lumps
- CT or MRI scan
- 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.(Read More: Listen To Your Voice)
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
- Control of cough, gastroesophageal reflux and allergies
- Endoscopic minimally invasive surgery for benign nodules, cysts, and polyps
- Endoscopic or open neck 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.(Read More: Help! My Baby’s Turned Blue)
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
Some babies may be born with outer ears that are malformed (smaller or constricted). Others may be born with ears that are deformed (differently shaped, lacking or having extra folds). Some may have prominent (cupped, “bat” or “telephone”) ears. This is different from babies who have microtia. (HYPERLINK To MICROTIA page on my website)
Though most of these babies will have normal hearing, the difference in outer ear pinna shape can be distressing for caregivers. However, the good news is that there is now a painless, non-invasive and non-surgical treatment available – the EAR WELL system.
A baby’s outer ears (pinna) are soft and elastic at birth, allowing for reshaping if the Ear Well is applied early. The cosmetic results are especially good if correction is started within the first 2 weeks of life, although satisfactory results can still be achieved up to 2 months after birth. The Ear Well system may allow for babies with malformed or deformed ears to avoid surgery later in life. With experienced and careful placement of the Ear Well system in our clinic, side effects are rare – example, superficial pin-point skin abrasion from the Ear Well cradles should it happen, heal completely within a day or 2 with.
The Ear Well system comes in small, middle and large sizes that can be tailored to different ears. Usually, babies will need at least 2 to 3 sets of the Ear Well cradles over 4 to 6 weeks. Each set of cradle is applied for 2 weeks, before changing to a larger set as the ears grow. The malformed or deformed ears are gradually shaped back to a normal appearance. Babies can continue to drink, sleep and play as normal.
- Baby AL with Malformed Ear, Before Ear Well
- Baby AL with Malformed Ear, After Ear Well
- Baby ZT with Deformed Ear: Before Ear Well, With Ear Well cradle, After Ear Well treatment
An allergy happens when our body’s immune system produces an exaggerated response to a normally harmless substance (allergen). An overwhelming response with antibodies results in powerful inflammatory chemicals released. The symptoms are itchy ears, nose and throat; sneezing, runny or blocked nose, headache; cough, sore throat and hoarseness; dark circles under the eyes and conjunctivitis. Long term, recurrent rhinosinusitis, large edematous inferior turbinates, middle ear infections, snoring and sleep apnea can result. For patients with crooked nose bone (deviated septum), an allergy of the nose can rapidly block the breathing when there is exposure to the allergen.
- Large inferior turbinate swelling next to the nose septum bone
- Cobblestone appearance of back of throat suggestive of allergy
Differentiating a cold, allergy and sinusitis. Fever is not needed for diagnosing a cold or sinus infection. Symptoms of cold continue throughout the day, and can last 1 to 2 weeks. A house dust mite allergy will cause symptoms in the morning and night, as the bedrooms with soft furnishings have a high burden of dust mite allergens, and we spend many hours there. Symptoms of sinusitis are more severe and can last for weeks to months.
- In sinusitis, air spaces (normally black in CT scan pictures) in the facial bones (sinuses) are filled with pus, polyps and inflamed mucosa.
Worldwide, allergies affect 35% of people. There is a genetic predisposition – 33% risk for a child with one allergic parent, and 70% risk if both parents have allergies. Over use of antimicrobial agents, processed foods and environmental pollutants have also been thought to increase the risk of allergies.
Haze from forest fires have dust, smoke particles, chemicals and gases. Haze exposure aggravates the allergic ENT symptoms. During a haze reaching an unhealthy PSI, I see a 25% increase in ENT allergy related problems. During Covid19 novel coronavirus times, when people stay at home a lot more, if they are allergic to allergens at home, they may also have more allergies of the ear, nose and throat.
- Skin Prick Test for children and adults can identify air-borne and food allergens
Diagnosis of ENT Allergy. Not all chronic runny and blocked nose are allergy related – 1 in 3 are non-allergic rhinitis. Allergies in ENT are usually air-borne (inhalant), but may also be food related. Testing for allergies is complex, especially for those with delayed allergy reactions and non-IgE food allergies, with differences in management philosophies common amongst doctors. Indiscriminate and over testing, without careful clinical correlation is unhelpful.
At our clinic, Skin Prick Tests (SPT) of diluted extracts from common local allergens (eg house dust mite, dog and cat dander, grass and tree pollen, cockroach, mold) is deposited onto the skin surface. Babies and adults alike manage this well, and results are known after 20 minutes. Prior to the test, our clinic will advise on a list of medications and food to avoid, so that the test is accurate. Some patients have severe skin eczema, or are unable to stop medications that interfere with the SPT; and our clinic will suggest a blood RAST test instead.
Treatment include avoiding and reducing the offending allergens. This can be challenging sometimes –eg tree and grass pollens in an outdoor lover, or pet dander floating from houses miles away and present even 4 months after removal of the animals. Face masks and medications are helpful. Medications usually used are nasal rinse, antihistamine, decongestant, corticosteroid and leukotriene inhibitor. Many patients confuse nasal steroid sprays with anabolic oral steroids. Nasal steroid sprays are not associated with the more significant side effects of oral steroids, and can be safely used from 2 years of age if appropriately dosed. Nowadays, sublingual or tablet immunotherapy taken orally are allowing many patients to control their allergies more effectively, and reduce the need for long term steroid sprays or antihistamine medications. Immunotherapy can be used from 4 years of age, and desensitizes the patient to the offending allergen, so that he/ she does not have start on the cascade of inflammation when encountering the allergen.
Challenges with food allergy. Ninety percent of reported food allergies come from a few foods – egg, milk, peanut, tree nut, shellfish, soy, wheat, and fish. Sometimes, ENT symptoms or abdominal discomfort may manifest hours or days after consumption, making identification difficult. Not all food antigens survive processing into standard extracts for skin tests. Selected blood tests may be needed, but the amount of antibody measured may not always reflect the severity of the allergy. Very careful history, diet charting, clinical examination over time, targeted testing and a trial of diet revision is required.
8 Things to Know
- The tonsils and adenoids are lymphoid tissue that trap bacteria and viruses in the sides of our throat and the back of our nose. Usually, they are largest between 2 to 8 years old. They may also increase in size and not go down after repeated infections and untreated nasal allergies. In young babies and toddlers, severe gastroesophageal reflux of stomach contents up to the back of the nose may also aggravate the swelling. A small tonsil can also be recurrently infected.
- When tonsils and adenoids become very large, they may block the breathing or affect swallowing. Some patients will have nasal speech and prefer to take softer food. Some are mistaken as picky eaters. The obstruction can cause snoring and obstructive sleep apnea (OSA), with reduced blood oxygenation in sleep leading to poor concentration, irritability, bed-wetting, frequent coughs and colds. Long term block in a growing child can result in poor lower jaw growth, increased risk of snoring continuing into adulthood, narrow palate and upper face, and poor dentition. OSA can cause poor weight gain, obesity and even heart failure.
- A large adenoid can cause chronic runny nose, bad breath and recurrent sinusitis. This is often mistaken for allergy. It may cause recurrent middle ear infections and hearing loss and speech delay. Recurrent infections of the adenoid and tonsils give pain and fever, bad breath and nose bleed. Children may then require repeated medications and antibiotics.
- Large adenoid seen in a neck xray
- Rarer problems are stone-like debri trapped in the tonsil, causing discomfort, infection and bad breath. The risk of a tonsil cancer is increased if the tonsils are asymmetrically enlarged, and there is a chronic ulcer or bleeding of the tonsil.
- The adenoid can be seen only with a flexible pediatric or adult nose scope, or on an xray. In cases of significant sleep apnea or in a patient with more complex other systems problems, your doctor may order a sleep study. Swabs for throat cultures can be taken to identify infections, and blood tests are sometimes done to identify infectious mononucleosis.
- Chronically infected and enlarged tonsils removed via surgery
- After managing conservatively for allergies, reflux and recurrent infections with medications like antibiotics, antihistamines and lifestyle changes, surgery may be needed for certain cases like: Obstructive sleep apnea, Impaired speech and eating, and recurrent infections, fits during fever, hearing loss and poor growth.
- Patients usually ask if their immunity will be impaired after adenoid and tonsil removal. Long term follow up of patients who have undergone those surgeries do not show any increased risk of immune problems, lymphoma, infections nor cancers.
- Removal of tonsils and adenoids is under general anaesthesia through the mouth, with no external incisions. Adenoids can be removed via curettage, coblator or suction diathermy. Tonsils can be removed via diathermy, or coblator ( intra or extracapsular). Surgeries are usually done as day surgery, unless the child is very young.