Overview

Children are not little adults, with their consult, investigations and treatment needing to be tailored to their specific ages. Their spectrums of diseases do overlap with adults, but often with different presentations, progression, severity and specific cause. Adults are not merely big children either, with similar unique challenges and concerns. The clinic manages many families, facilitating integrated care and support.

We are a premier ENT Ear Nose Throat, Pediatric ENT and Hearing Loss ENT treatment specialist center in Singapore. We provide a range of treatments for different conditions related to the ear and vertigo/balance, the nose, and sinus, the throat and mouth, and the head and neck. We manage holistically conditions of snoring, allergic rhinitis, adenoid and tonsils, hoarseness, gastroesophageal reflux laryngitis, and laryngotracheal airway narrowing and stridor. Many of these conditions can be determined from gentle awake flexible nasoendoscopy tailored specifically for different ages. Flexible nasoendoscopy is a procedure that is both insurance and medisave claimable.

Conductive hearing loss is a common problem that can occur with pathologies in the external and middle ear. Examples are ear wax, ear infections, middle ear fluid build-up or hole in the ear drum. Sensorineural hearing loss and tinnitus from aging, noise, drugs, congenital or genetic deafness can also be helped by medication, hearing aids or hearing implants. The good news is that rapid advances in medicine and technology now ensure that no patient needs to continue living with a poor quality of life.

Conditions for children and adults managed at the clinic include:

Ear / Balance
  • Photo 15 Cochlear implantsNewborn hearing loss (non-syndromic/ syndromic; genetic/ non-genetic)
  • Children’s hearing loss at different ages
  • Cochlear hearing loss
  • Central auditory processing disorder CAPD
  • Adult Hearing loss (e.g. Age-related hearing loss/ presbyacusis, Noise-induced hearing loss)
  • Ringing Ears (Tinnitus)
  • iStock_000019907117_MediumEar-related giddiness/ vertigo
  • Ear wax and foreign bodies
  • Middle ear fluid and infection (Otitis media effusion, acute otitis media, glue ear, post air flights/ diving)
  • Torn ear drum
  • Malformed, eroded, dislocated or fixed ear bones
  • Tumor (cholesteatoma, bony, polyp, vascular, skin)
  • Microtia auricle (malformed outer ear)
  • Atresia ear canal (absent ear canal)
Nose / Sinus
  • Photo 17 Nose Polyps Allergic rhinitis (airborne, food)
  • Vasomotor or medical related rhinitis
  • Rhinitis/ sinusitis/ polyposis
  • Epistaxis (Nose bleed)
  • Blocked nose (eg deviated nose septum, large inferior turbinates, tumors)
  • Exclusion of nose cancer
Throat / Mouth
  • Photo 18 TonsilsTonsil and adenoid (swelling, infection)
  • Unclear speech – tongue tie, pharynx/ soft palate (velopharyngeal) insufficiency, hearing loss
  • Throat irritation/ phlegm, gastroesophageal acid reflux laryngitis
  • Mouth ulcers/ lumps
Head & Neck
  • Photo 19 Neck LumpAdenoid and tonsil disease
  • Snoring/ Noisy Breathing/ Obstructive sleep apnea (due to nose, adenoid/ tonsil, soft palate, tongue, laryngeal, weight pathology)
  • Head and neck lumps – congenital, acquired (eg neck lymph nodes, branchial and thyroglossal cysts, parotid, thyroid, submandibular gland lumps)
  • Hoarse voice – vocal cord cysts/ nodules/ lumps, poor mobility, inflammation, scarring, smoking, hypothyroidism
  • Swallowing disorders
  • Stridor – vocal cord, laryngeal, subglottic or trachea airway pathology and narrowing
Snoring & Sleep Apnea

A quarter of the world’s adults are snoring every night. However, snoring is not just noise, as it can be a sign of sleep disordered breathing (SDB). This can be Simple Snoring, Upper Airway Resistance Syndrome (UARS), or Obstructive Sleep Apnea (OSA). In OSA, there is reduced oxygen in the blood from obstruction or collapse of the airway during sleep.

Adults experience daytime sleepiness, irritability, depression, impaired concentration/memory, fatigue and morning headaches. At night, there may be choking/obstructed breathing, teeth grinding, increased urination. There can be poor libido. There is reduced quality of life. Sleep has become a source of stress, instead of a way of repair and rejuvenation.

Regular snorers have a five-fold increase in risks for hypertension, raised cholesterol, diabetes, heart attack and stroke. Half of those with pregnancy pre-eclampsia blood pressure problems have OSA that were not addressed prior to pregnancy.

Children, instead of snoring, may have open mouth breathing as their nose passages are tiny. They may be restless, tossing and turning in sleep with mouth open, often bed-wetting and waking up irritable and hyperactive. They may be misdiagnosed with attention deficit, poor behaviour, and learning and grades may be affected. They get sick more often. Long-term effects include heart, hypertension and memory problems. There can also be long narrow faces, dental over-bite and reduced lower jaw growth.

Common causes of snoring for children are allergic rhinitis, adenoid and tonsil enlargement. For adults, it can be nose block from allergic rhinitis, a deviated nose bone, enlarged nose inferior turbinates, nose polyps, soft palate redundancy and medialisation, receded lower jaw, prolapsed large tongue base, poor muscle tone or obesity.

Treatment needs to be tailored for the individual patient, as no two patients will be alike. For occasional and mild snoring, patients can try to change sleep position, avoid alcohol and smoking, commit to weight loss and treat nasal conditions. Oral devices and medication may be needed. There are over 2,000 devices on the global market which people use to self-manage their snoring. However, it is better to consult an ENT, sleep physician or neurologist for a proper examination of the airway, and a formal sleep study to determine the cause, the sites of obstruction, and severity of the sleep problem.

Continuous positive airway pressure (CPAP) is the gold standard treatment. But some patients cannot tolerate the discomfort of the CPAP mask without first managing the nasal obstruction.

Surgery may sometimes be needed. This can range from correction of a deviated nose septum bone, radiofrequency reduction or turbinoplasty of enlarged inferior turbinates;  adenoid and tonsil surgery, to soft palate and tongue base surgery. More extensive reconstructive surgery with maxilla- mandibular advancement surgery will need a multidisciplinary team with orofacial maxilla and dental surgeons. For severe obesity, bariatric surgery to control food intake may be required.

For children, most with only need adenoid, tonsil and inferior turbinates reduction if medication does not help. CPAP is not the first choice for children as very few can tolerate it. However, children with complex cranio-facial syndromes may need tracheotomy, nasal airway stents and multi-disciplinary cranio-facial and airway surgeries.

  • Enlarged inferior tubinate blocking the nose airway, Before and After radiofrequency reduction of inferior turbinate.

  • Before surgery, low lying redundant and medialised tonsil fossa pillars blocking the oral airway
  • After soft palate surgery
Nose Bleed/ Epistaxis

The nose is very vascular, with a rich supply of blood vessels. The mucosa membrane covering the blood vessels is thin and easily traumatised, exposing underlying blood vessels which can be torn.

Ninety percent of nose bleeds are anterior and of small capillary blood vessels. Thus, the bleed is usually only a slow ooze. Nose bleeds from the posterior nose are more often arterial in origin, and these can be profuse and harder to stop.

  • Anterior nasal septum capillary nose vessels that can be traumatised and bleed

Causes: The risk of bleeding is increased when there is a flu or nose infection, dry air, violent sneezing or rubbing of the nose in allergic rhinitis, and crooked nasal bone. Patients in pregnancy, with hypertension and on blood thinning medication (eg warfarin, Plavix, aspirin and non-steroidal anti inflammation, Ginko and vitamin E drugs) are more at risk. Rarer causes include snorting of cocaine, tumors, blood coagulation disorders. However, as nose cancer is relatively common in Singapore, recurrent nose bleeds in adults must raise a red flag.

Treatment: One should be concerned if a baby has nose bleed, if the bleeding is large volume, rapid and not stopped by simple nose pressure, or from significant head trauma.  If the nose bleed is recurrent or associated with headache, infection, neck lump or ear block sensation, do consult your doctor.

For minor bleeds, simple self-help measures include

  1. Do not dig or stuff tissue into the nose. Do not blow your nose or sneeze with your mouth closed.
  2. Sit and tilt your head forward. Do not lie down nor put your head lower than your body.
  3. Press tightly on both sides of the lower third soft part of the nose with the pulps of your first 3 fingers for at least 10 minutes. Breathe through your mouth. Repeat if bleeding recurs.
  4. Rest, with head propped up. Avoid straining, carrying heavy things or physical exercises.
  5. Saline or Oxymetazoline nose drops, hemostatic gel, lubricating or antibiotic nasal ointment.

For major bleeds, go to the A&E

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