• How Allergies Affect Your Child’s Ear, Nose and Throat
• Ear Infections and Hearing Loss in Children
• Sinusitis in Children
• Pediatric Sleep Disordered Breathing and Obstructive Sleep Apnea

National health statistics reveal that pediatric ear, nose, and throat disorders remain among the primary reasons children visit a physician, with ear infections ranking as the Number 1 reason for an appointment. From earaches to enlarged tonsils, kids can suffer from a variety of ailments that require prompt diagnosis and treatment. Children can also suffer from conditions normally only associated with adults, like chronic acid reflux and sleep apnea, which may require a visit to a specialist.

As parents ourselves, we know as much about kids as we do about pediatric healthcare. We're good at easing kids' fears about doctors and making their visits positive experiences. From infants to teenagers, your children are in excellent hands with Charleston ENT Associates: 

• Complete pediatric care, including tubes and tonsils
• Comprehensive allergy testing and treatment
• Precise hearing testing and evaluation for children and infants
• Thorough diagnosis and treatment of sinus problems and ear infections
• Treatment for breathing problems and apnea

How Allergies Affect Your Child’s Ear, Nose and Throat
Does your child have allergies? Allergies can cause many ear, nose, and throat symptoms in children, but allergies can be difficult to separate from other causes. Here are some clues that allergy may be affecting your child.

Children with nasal allergies often have a history of other allergic tendencies (or atopy). These may include early food allergies or atopic dermatitis in infancy. Children with nasal allergies are at higher risk for developing asthma.

Nasal allergies can cause sneezing, itching, nasal rubbing, nasal congestion, and nasal drainage. Usually, allergies are not the primary cause of these symptoms in children under four years old. In allergic children, these symptoms are caused by exposure to allergens (mostly pollens, dust, mold, and dander). Observing which time of year or in which environments the symptoms are worse can be important clues to share with your doctor.

Ear infections:
One of children’s most common medical problems is otitis media, or middle ear infection. In most cases, allergies are not the main cause of ear infections in children under two years old. But in older children, allergies may play role in ear infections, fluid behind the eardrum or problems with uncomfortable ear pressure. Diagnosing and treating allergies may be an important part of healthy ears.
 
Sore throats:
Allergies may lead to the formation of too much mucus which can make the nose run or drip down the back of the throat, leading to "post-nasal drip." It can lead to cough, sore throats, and a husky voice.
 
Sleep disorders:
Chronic nasal obstruction is a frequent symptom of seasonal allergic rhinitis and perennial (year-round) allergic rhinitis. Nasal congestion can contribute to sleep disorders such as snoring and obstructive sleep apnea, because the nasal airway is the normal breathing route during sleep. Fatigue is one of the most common, and most debilitating, allergic symptoms. Fatigue not only affects children’s quality of life, but has been shown to affect school performance.
 
Pediatric sinusitis:
Allergies should be considered in children who have persistent or recurrent sinus disease. Depending on the age of your child, their individual history, and an exam, your doctor should be able to help you decide if allergies are likely. Some studies suggest that large adenoids (a tonsil-like tissue in the back of the nose) are more common in allergic children.
 
Food Allergies in Children

Dust, mites, pet dander, and ragweed are not the only allergic threats to your child. Food allergies and sensitivities may cause a wide range of adverse reactions to the skin, respiratory system, stomach, and other physiological functions of the body.

Determining what foods are the cause of an allergic reaction is key to treatment. Before you identify the ingestible culprit you must consider what type of food allergy your child has. There are two types, classified as:

• Fixed (immediate) food allergies: A fixed food allergy may be very apparent, such as the child whose lips swell and throat itches immediately in response to eating peanuts. The cause for this type of food allergy is similar to that of inhalant allergies, so the diagnosis is more easily reached. Blood testing (i.e., RAST test) is typically used to verify fixed food allergies. Approximately 5 to 15 percent of food allergies are of the fixed variety.
• Cyclic (delayed) food allergies: These allergies are far more common but less understood. Delayed food allergy symptoms can take up to three days to appear. This type of reaction is associated with the body’s immunogobulin G (IgG) or antibodies. Unlike fixed food allergies, this allergic response is cyclical in nature. As an example, a child may be IgG sensitive to milk. Consequently, symptoms might appear if the child increases the intake and/or frequency of milk consumption.
• Both children and adults are susceptible to food allergies. The bad news for children is that they often have more skin reactions, such as eczema, to foods than do adults. But the good news for the young patient is that a child often outgrows his or her food sensitivities over time, even those that are positive on a RAST test. Food allergies may fade, and then inhalant (e.g, dust, ragweed) allergies may begin to manifest themselves.

Diagnosing and treating the cyclic food allergy

If your child is experiencing allergic reactions to food of unknown origin, you should ask, “Are there any foods that my child craves or any food that I avoid offering?” These foods may be the ones that are causing difficulties for the young patient.

Your physician may also suggest the Elimination and Challenge Diet. This dietary test consists of the following steps:

1. Keep a detailed food diary, tracking what was eaten (including ingredients), when it was eaten, medications taken, and any symptoms that developed. Be honest! Some well-meaning parents or caregivers often create a food diary that looks healthier than it really is. Your child can receive the best diagnosis if the diet records are accurate, timed precisely, and truthful. The diet diary can be evaluated by the doctor to identify food items that may be the culprits.
2. Conduct an elimination and challenge diet at home based upon your physician’s assessment of your child’s diet diary. It is best if you carefully maintain a new diet diary for your child during this period. During this diet, your child must abstain from one, and only one, of the possible food culprits at a time for a period of four days. This can be difficult to carry out if the food is very common, such eggs or cereal, so you need to pay strict attention to your child’s diet during the elimination phase. Any cheating will invalidate the results. On the fifth day, you will be asked to feed your child the suspected culprit food item. This is the challenge! Provide your child an average-sized portion of the food in question to be eaten in five minutes. In one hour the child should eat another half portion if no symptoms have developed. Any symptoms that develop are then timed and recorded. With a true cyclic food allergy, you would expect a significant worsening of the symptoms described in the original diet diary, although the challenge symptoms may vary as well.
3. If the Elimination and Challenge Diet confirms a cyclic food allergy, then you will be asked to abstain from feeding your child this food for a period of three to six months. After this time you can slowly reintroduce the food on a rotary basis; it is not to be eaten more frequently than every four days (once or twice a week).

For minor, moderate discomfort from the testing, the caregiver may choose to offer one the following: 1) a child’s laxative to decrease the transit time through the digestive system; 2) Alka Seltzer Gold; 3) Buffered Vitamin C (one gram).

Fixed food allergies should never be deliberately challenged unless under the direct supervision of a physician.

Ear Infections and Hearing Loss in Children

What is otitis media and ear infection?

Otitis media refers to inflammation of the middle ear. When an abrupt infection occurs, the condition is called "acute otitis media." Acute otitis media occurs when a cold, allergy, and the presence of bacteria or viruses lead to the accumulation of pus and mucus behind the eardrum, blocking the Eustachian tube. This can cause earache and fever.

When fluid sits in the middle ear for weeks, the condition is known as "otitis media with effusion." This occurs in a recovering ear infection. Fluid can remain in the ear for weeks to many months. If not treated, chronic ear infections have potentially serious consequences such as temporary hearing loss.

Why do children have more ear infections than adults?

To understand earaches, and ear infections, 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 and uvula. The tube allows drainage of fluid from the middle ear, which prevents it 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 prevent the many germs residing in the nose and mouth from entering the middle ear. 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.

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. It also makes it harder for the ears to clear the fluid, since it cannot drain with the help of gravity. A child’s tube is also floppier, with a smaller opening that easily clogs.

How does otitis media affect hearing?
Most people with middle ear infection or fluid have some degree of hearing loss. The average hearing loss in ears with fluid is 24 decibels...equivalent to wearing ear plugs. (Twenty-four decibels is about the level of the very softest of whispers.) Thicker fluid can cause much more loss, up to 45 decibels (the range of conversational speech).

Suspect hearing loss if one is unable to understand certain words and speaks louder than normal.

Types of hearing loss

Conductive hearing loss is a form of hearing impairment where the transmission of sound from the environment to the inner ear is impaired, usually from an abnormality of the external auditory canal or middle ear. This form of hearing loss can be temporary or permanent. Untreated chronic ear infections can lead to conductive hearing loss. If fluid is filling the middle ear, hearing loss can be treated by draining the middle ear and inserting a tympanostomy tube. The other form of hearing loss is sensorineural hearing loss, hearing loss due to abnormalities of the inner ear or the auditory division of the 8th cranial nerve. Historically, this condition can occur at all ages, and is usually permanent.

When should a hearing test be performed related to frequent infections or fluid?
A hearing test should be performed for children who have frequent ear infections, hearing loss that lasts more than six weeks, or fluid in the middle ear for more than three months. There are a wide range of medical devices now available to test a child’s hearing, Eustachian tube function, and flexibility of the ear drum. They include the otoscopy, tympanometer, and audiometer.
Do people lose their hearing for reasons other than chronic otitis media?

Children and adults can incur temporary hearing loss for other reasons than chronic middle ear infection and Eustachian tube dysfunction. They include:

• Cerumen impaction (compressed earwax)
• Otitis externa: Inflammation of the external auditory canal, also called “swimmer's ear.”
• Cholesteatoma: A mass of horn shaped squamous cell epithelium and cholesterol in the middle ear, usually resulting from chronic otitis media.
• Otosclerosis: This is a disease of the otic capsule (bony labyrinth) in the ear, which is more prevalent in adults and characterized by formation of soft, vascular bone leading to progressive conductive hearing loss. It occurs due to fixation of the stapes (bones in the ear). Sensorineural hearing loss may result because of involvement of the cochlear duct.
• Trauma: A trauma to the ear or head may cause temporary or permanent hearing loss.

Sinusitis in Children
Your child’s sinuses are not fully developed until late in the teen years. 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 of sinusitis can be caused by other problems, such as viral illness and allergy.

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 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, if your child remains ill beyond the usual week to ten days, a sinus infection may be the cause.

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 Do Our Doctors Treat Sinusitis?
Acute sinusitis: Most children respond very well to antibiotic therapy. Nasal decongestant sprays or saline 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. Over-the-counter decongestants and antihistamines are not generally effective for viral upper respiratory infections in children, and the role of such medications for treatment of sinusitis is not well defined. Such medications should not be given to children younger than two years old.

If your child has acute sinusitis, symptoms should improve within the first few days of treatment. Even if your child improves dramatically within the first week of treatment, it is important that you complete the antibiotic therapy. 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 12 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 us. The ENT may recommend medical or surgical treatment of the sinuses.

Diagnosis of sinusitis: If your child sees one of our ENT specialists, 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 completely your child's sinuses are developed, where any blockage has occurred, and confirm the diagnosis of sinusitis. The doctor may look for factors that make your child more likely to get sinus infection, including structural changes, allergies, and problems with the immune system.

When Is Surgery Necessary?

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 (obstruction of the back of the nose), can cause many 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. In the rare child where medical therapy fails, surgical therapy can be used as a safe and effective method of treating sinus disease in children.

Pediatric Sleep Disordered Breathing and Obstructive Sleep Apnea

Overview of Sleep Disordered Breathing
Sleep-disordered breathing (SDB) is a general term for breathing difficulties occurring during sleep. SDB can range from frequent loud snoring to Obstructive Sleep Apnea (OSA) a condition involving repeated episodes of partial or complete blockage of the airway during sleep. When a child’s breathing is disrupted during sleep, the body perceives this as a choking phenomenon. The heart rate slows, blood pressure rises, the brain is aroused, and sleep is disrupted. Oxygen levels in the blood can also drop.

Approximately 10 percent of children snore regularly and about 2-4 % of the pediatric population has OSA.   Recent studies indicate that mild SDB or snoring may cause many of the same problems as OSA in children.

Could my child have Obstructive Sleep Apnea?
The most obvious symptom of sleep disordered breathing is loud snoring that is present on most nights. The snoring can be interrupted by complete blockage of breathing with gasping and snorting noises and associated with awakenings from sleep. Due to a lack of good quality sleep, a child with sleep disordered breathing may be irritable, sleepy during the day, or have difficulty concentrating in school. Busy or hyperactive behavior may also be observed. Bed-wetting is also frequently seen in children with sleep apnea.

A common physical cause of airway narrowing contributing to SDB is enlarged tonsils and adenoids.  Overweight children are at increased risk for SDB because fat deposits around the neck and throat can also narrow the airway. Children with abnormalities involving the lower jaw or tongue or neuromuscular deficits such or cerebral palsy have a higher risk of developing sleep disordered breathing.

Potential consequences of untreated pediatric sleep disordered breathing:

• Social: Loud snoring can become a significant social problem if a child shares a room with siblings or at sleepovers and summer camp.
• Behavior and learning:  Children with SDB may become moody, inattentive, and disruptive both at home and at school.   Sleep disordered breathing can also be a contributing factor to attention deficit disorders in some children.
• Enuresis: SDB can cause increased nighttime urine production, which may lead to bedwetting.
• Growth:  Children with SDB may not produce enough growth hormone, resulting in abnormally slow growth and development.
• Obesity: SBD may cause the body to have increased resistance to insulin or daytime fatigue with decreases in physical activity.  These factors can contribute to obesity.
• Cardiovascular:   OSA can be associated with an increased risk of high blood pressure or other heart and lung problems.

How is sleep apnea diagnosed?
Sleep disordered breathing in children should be considered if frequent loud snoring, gasping, snorting, and thrashing in bed or unexplained bedwetting is observed.  Behavioral symptoms can include changes in mood, misbehavior, and poor school performance.  Not every child with academic or behavioral issues will have SDB, but if a child snores loudly on a regular basis and is experiencing mood, behavior, or school performance problems, sleep disordered breathing should be considered. If you notice that your child has any of those symptoms, have them checked by an otolaryngologist at Charleston ENT.  Sometimes physicians will make a diagnosis of sleep disordered breathing based on history and physical examination.  In other cases, such as in children suspected of having severe OSA due to craniofacial syndromes, morbid obesity, or neuromuscular disorders or for children less than 3 years of age, additional testing such as a sleep test may be recommended.

The sleep study or polysomnogram (PSG) is an objective test for sleep disordered breathing. Wires are attached to the head and body to monitor brain waves, muscle tension, eye movement, breathing, and the level of oxygen in the blood. The test is not painful and is generally performed in a sleep laboratory or hospital. Sleep tests can occasionally produce inaccurate results, especially in children. Borderline or normal sleep test results may still result in a diagnosis of SDB based on parental observations and clinical evaluation.

Treatment for sleep disordered breathing

Enlarged tonsils and adenoids are a common cause for SDB. Surgical removal of the tonsils and adenoids (T&A) is generally considered the first line treatment for pediatric sleep disordered breathing if the symptoms are significant and the tonsils and adenoids are enlarged. Of the over 500,000 pediatric T&A procedures performed in the U.S. each year, the majority are currently being done to treat sleep disordered breathing. Many children with sleep apnea show both short and long- term improvement in their sleep and behavior after T & A.

Not every child with snoring should undergo T&A as the procedure does have risks. Potential problems can include anesthesia or airway complications, bleeding, infection and problems with speech and swallowing.  If the SDB symptoms are mild or intermittent, academic performance and behavior is not an issue, the tonsils are small, or the child is near puberty (tonsils and adenoids often shrink at puberty), it may be recommended that a child with SDB be watched conservatively and treated surgically only if symptoms worsen.

Recent studies have shown that some children have persistent sleep disordered breathing after T & A. A post-operative PSG may be necessary after surgical intervention, especially in children with persistent symptoms or increased risk factors for persistent apnea after T & A such as obesity, craniofacial anomalies or neuromuscular problems. Additional treatments such as weight loss, the use of Continuous Positive Airway Pressure (CPAP) or additional surgical procedures may sometimes be required.