As parents ourselves, we’re good at easing kids fears about doctors and making their visits a positive experience. From infants to teenagers, your children are in excellent hands with Ear, Nose and Throat 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

Diagnosis and treatment of Sinus Problems

What is sinusitis?

Sinusitis is infection or inflammation of the lining of the sinus cavities. These are hollow spaces in your cheeks and around your eyes. Sinus infections often follow a cold and cause pain and pressure in your head and face.

Sinusitis can be either acute (sudden) or chronic (long-term). With chronic sinusitis, the infection or inflammation does not completely go away for 8 weeks or more.

What causes sinusitis?

Sinusitis can be caused by three things:

• Viruses
• Bacteria
• Fungi

The same viruses that cause the common cold cause most cases of sinusitis.

When the lining of the sinus cavities gets inflamed from a viral infection like a cold, it swells. This is viral sinusitis. The swelling can block the normal drainage of fluid from the sinuses into the nose and throat. If the fluid cannot drain and builds up over time, bacteria or fungi (plural of fungus) may start to grow in it. These bacterial or fungal infections can cause more swelling and pain. They are more likely to last longer, get worse with time, and become chronic.

Nasal allergies or other problems that block the nasal passages and allow fluid to build up in the sinuses can also lead to sinusitis.

What are the symptoms?

The main symptoms of sinusitis are a runny or stuffy nose and pain and pressure in your head and face. You may also have a yellow or green drainage or drip from your nose or down the back of your throat (postnasal discharge). Where you feel the pain and tenderness depends on which sinus is affected.

Other common symptoms of sinusitis may include:

• A headache.
• Bad breath.
• A cough that produces mucus.
• A fever.
• Pain in your teeth.
• A reduced sense of taste or smell.

What are the symptoms of sinusitis vs. a cold or allergy?

Rhinosinusitis: Clarifying The Relationship Between The Sinuses And Rhinitis

Recent studies by otolaryngologist–head and neck surgeons have better defined the association between rhinitis and sinusitis. They have concluded that sinusitis is often preceded by rhinitis and rarely occurs without concurrent rhinitis. The symptoms, nasal obstruction/discharge and loss of smell, occur in both disorders. Most importantly, computed tomography (CT scan) findings have established that the mucosal linings of the nose and sinuses are simultaneously involved in the common cold (previously, thought to affect only the nasal passages). Otolaryngologists, acknowledging the inter-relationship between the nasal and sinus passages, now refer to sinusitis as rhinosinusitis.

The catalyst relating the two disorders is thought to involve nasal sinus overflow obstruction, followed by bacterial colonization and infection leading to acute, recurrent, or chronic sinusitis. Likewise, chronic inflammation due to allergies can lead to obstruction and subsequent sinusitis.

Diagnosis and treatment of Ear Infections

What is otitis media?

Otitis media refers to inflammation of the middle ear. When infection occurs, the condition is called “acute otitis media.” Acute otitis media occurs when a cold, allergy, or upper respiratory infection, and the presence of bacteria or viruses lead to the accumulation of pus and mucus behind the eardrum, blocking the Eustachian tube. This causes earache and swelling.

When fluid forms in the middle ear, the condition is known as “otitis media with effusion.” This occurs in a recovering ear infection or when one is about to occur. Fluid can remain in the ear for weeks to many months. When a discharge from the ear persists or repeatedly returns, this is sometimes called chronic middle ear infection. Fluid can remain in the ear up to three weeks following the infection. If not treated, chronic ear infections have potentially serious consequences such as temporary or permanent hearing loss.

How does otitis media affect a child’s hearing?

All children 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).

Your child may have hearing loss if he or she is unable to understand certain words and speaks louder than normal. Essentially, a child experiencing hearing loss from middle ear infections will hear muffled sounds and misunderstand speech rather than incur a complete hearing loss. Even so, the consequences can be significant – the young patient could permanently lose the ability to consistently understand speech in a noisy environment (such as a classroom) leading to a delay in learning important speech and language skills.

Do children lose their hearing for reasons other than chronic otitis media?

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

• Cerumen impaction: The buildup of layers of earwax within the ear canal to the point of blocking the canal and putting pressure on the eardrum. Ironically, cerumen impaction is often caused by misguided attempts to remove earwax.
• Swimmer’s Ear: An Inflammation of the external auditory canal.
• Cholesteatoma: Also called pearl tumor.
• Otosclerosis: The primary form of hearing loss in otosclerosis is conductive hearing loss (CHL) whereby sounds reach the ear drum but are incompletely transferred via the ossicular chain in the middle ear, and thus partly fail to reach the inner ear (cochlea).
• Trauma: A serious shock to the ear or head may cause temporary or permanent hearing loss.

Ear Tubes

Painful ear infections are a rite of passage for children—by the age of five, nearly every child has experienced at least one episode. Most ear infections either resolve on their own (viral) or are effectively treated by antibiotics (bacterial). But sometimes ear infections and/or fluid in the middle ear may become a chronic problem leading to other issues, such as hearing loss, or behavior and speech problems. In these cases, insertion of an ear tube by an otolaryngologist (ear, nose, and throat specialist) may be considered.

What are ear tubes?

Ear tubes are tiny cylinders placed through the ear drum {tip The membrane separating the external from the middle ear. Also known as eardrum; tympanum.}(tympanic membrane){/tip} to allow air into the middle ear. They also may be called tympanostomy tubes, myringotomy tubes, ventilation tubes, or PE (pressure equalization) tubes.

These tubes can be made out of various materials and may have a coating intended to reduce the possibility of infection. There are two basic types of ear tubes: short-term and long-term. Short- term tubes are smaller and typically stay in place for six months to a year before falling out on their own. Long-term tubes are larger and have flanges that secure them in place for a longer period of time. Long-term tubes may fall out on their own, but removal by an otolaryngologist may be necessary.

Who needs ear tubes and why?

Ear tubes are often recommended when a person experiences repeated middle ear infection (acute otitis media) or has hearing loss caused by the persistent presence of middle ear fluid (otitis media with effusion). These conditions most commonly occur in children, but can also be present in teens and adults and can lead to speech and balance problems, hearing loss, or changes in the structure of the ear drum. Other less common conditions that may warrant the placement of ear tubes are malformation of the ear drum or eustachian tube, Down Syndrome, cleft palate, and barotrauma (injury to the middle ear caused by a reduction of air pressure, usually seen with altitude changes as in flying and scuba diving).

Each year, more than half a million ear tube surgeries are performed on children, making it the most common childhood surgery performed with anesthesia. The average age for ear tube insertion is one to three years old. Inserting ear tubes may:

• Reduce the risk of future ear infection;
• Restore hearing loss caused by middle ear fluid;
• Improve speech problems and balance problems; and
• Improve behavior and sleep problems caused by chronic ear infections.

How are ear tubes inserted in the ear?

Ear tubes are inserted through an outpatient surgical procedure called a myringotomy. A myringotomy refers to an incision (small hole) in the ear drum or tympanic membrane. This is most often done under a surgical microscope with a small scalpel, but it can also be accomplished with a laser. If an ear tube is not inserted, the hole would heal and close within a few days. To prevent this, an ear tube is placed in the hole to keep it open and allow air to reach the middle ear space (ventilation).

Tonsils and Adenoids

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

The procedure to remove the tonsils is called a tonsillectomy; excision of the adenoids is an adenoidectomy. Both procedures are often performed at the same time; hence the surgery is known as a tonsillectomy and adenoidectomy, or T&A.

T&A is an outpatient surgical procedure lasting between 30 and 45 minutes and performed under general anesthesia. Normally, the young patient will remain at the hospital or clinic for several hours after surgery for observation. Children with severe obstructive sleep apnea and very young children are usually admitted overnight to the hospital for close monitoring of respiratory status. An overnight stay may also be required if there are complications such as excessive bleeding, severe vomiting, or low oxygen saturation.

Allergy Testing and Treatment

Allergic rhinitis (hay fever) is an especially common chronic nasal problem in adolescents and young adults. Allergies to inhalants like pollen, dust, and animal dander begin to cause sinus and nasal symptoms in early childhood. Infants and young children are especially susceptible to allergic sensitivity to foods and indoor allergens.

What causes allergic rhinitis?

Allergic rhinitis typically results from two conditions: family history/genetic predisposition to allergic disease and exposure to allergens. Allergens are substances that produce an allergic response. Children are not born with allergies but develop symptoms upon repeated exposure to environmental allergens. The earliest exposure is through food—and infants may develop eczema, nasal congestion, nasal discharge, and wheezing caused by one or more allergens (milk protein is the most common). Allergies can also contribute to repeated ear infections in children. In early childhood, indoor exposure to dust mites, animal dander, and mold spores may cause an allergic reaction, often lasting throughout the year. Outdoor allergens including pollen from trees, grasses, and weeds primarily cause seasonal symptoms.

The number of patients with allergic rhinitis has increased in the past decade, especially in urban areas. Before adolescence, twice as many boys as girls are affected; however, after adolescence, females are slightly more affected than males. Researchers have found that children born to a large family with several older siblings and day care attendance seem to have less likelihood of developing allergic disease later in life.

What are allergic rhinitis symptoms?

Symptoms can vary with the season and type of allergen and include sneezing, runny nose, nasal congestion, and itchy eyes and nose. A year-long exposure usually produces nasal congestion (chronic stuffy nose).

In children, allergen exposure and subsequent inflammation in the upper respiratory system cause nasal obstruction. This obstruction becomes worse with the gradual enlargement of the adenoid tissue and the tonsils inherent with age. Consequently, the young patient may have mouth-breathing, snoring, and sleep-disordered breathing such as obstructive sleep apnea. Sleep problems such as insomnia, bed-wetting, and sleepwalking may accompany these symptoms along with behavioral changes including short attention span, irritability, poor school performance, and excessive daytime sleepiness.

In these patients, upper respiratory infections such as colds and ear infections are more frequent and last longer. A child’s symptoms after exposure to pollutants such as tobacco smoke are usually amplified in the presence of ongoing allergic inflammation.

Eye Allergies

People who have allergies are often quick to seek help for symptoms like sneezing, sniffling, and nasal congestion. But allergies can affect the eyes as well as the nose, causing red, itchy, burning, and watery eyes and swollen eyelids. The good news is that the same treatments and self-help strategies that ease nasal allergy symptoms work against eye allergies, too.

Like all allergies, eye allergies are caused by a glitch in the body’s immune system. The trouble starts when the conjunctiva (the mucous membrane that lines the eyelids and covers the whites of the eyes) comes into contact with something that, while actually harmless, is seen as a threat. In a mistaken attempt to fight off the threat, the immune system makes antibodies that cause your eyes to release histamine and other substances. That, in turn, makes eyes red, itchy, and watery. Eye allergy symptoms can happen alone or along with nasal allergy symptoms.

Breathing Problems and Apnea

Pediatric Obstructive Sleep Apnea

Sleep disordered breathing (SDB) in children, from infancy through puberty, is in some ways a similar condition but has different causes, consequences, and treatments. A child with SDB does not necessarily have this condition as an adult. The premiere symptom of sleep disordered breathing is snoring that is loud, present every night regardless of sleep position, and is ultimately interrupted by complete obstruction of breathing with gasping and snorting noises. Approximately 10 percent of children are reported to snore. Ten percent of these children (one percent of the total pediatric population) have obstructive sleep apnea.

When an individual, young or old, obstructs breathing during sleep, the body perceives this as a choking phenomenon. The heart rate slows, the sympathetic nervous system is stimulated, blood pressure rises, the brain is aroused, and sleep is disrupted. In most cases a child’s vascular system can tolerate the changes in blood pressure and heart rate. However, a child’s brain does not tolerate the repeated interruptions to sleep, leading to a child that is sleep deprived, cranky, and ill behaved.

Consequences of untreated pediatric sleep disordered breathing

• Snoring: A problem if a child shares a room with a sibling and during sleepovers.
• Sleep deprivation: The child may become moody, inattentive, and disruptive both at home and at school. Classroom and athletic performance may decrease along with overall happiness. The child will lack energy, often preferring to sit in front of the television rather than participate in school and other activities. This may contribute to obesity.
• Abnormal urine production: SDB also causes increased nighttime urine production, and in children, this may lead to bedwetting.
• Growth: Growth hormone is secreted at night. Those with SDB may suffer interruptions in hormone secretion, resulting in slow growth or development.
• Attention deficit disorder (ADD) / attention deficit hyperactivity disorder (ADHD): There are research findings that identify sleep disordered breathing as a contributing factor to attention deficit disorders.

Diagnosis of sleep disordered breathing

The first diagnosis of sleep disordered breathing in children is made by the parent’s observation of snoring. Other observations may include obstructions to breathing, gasping, snorting, and thrashing in bed as well as unexplained bedwetting. Social symptoms are difficult to diagnose but include alteration in mood, misbehavior, and poor school performance. (Note: Every child who has sub par academic and social skills may not have SDB, but if a child is a serious snorer and is experiencing mood, behavior, and performance problems, sleep disordered breathing should be considered.)

A child with suspected SDB should be evaluated by an otolaryngologist – head and neck surgeon. If the symptoms are significant and the tonsils are enlarged, the child is strongly recommended for T&A, or tonsillectomy and adenoidectomy (removal of the tonsils and adenoids). Conversely, if the symptoms are mild, academic performance remains excellent, the tonsils are small, and puberty is eminent (tonsils and adenoids shrink at puberty), it may be recommended that SDB be treated only if matters worsen. The majority of cases fall somewhere in between, and physicians must evaluate each child on a case-by-case basis.

There are other pediatric sleep disorder diagnoses. Sudden infant death syndrome (SIDS) and apparent life threatening episode (ALTE) are considered forms of sleep disordered breathing. Children with these conditions warrant thorough evaluation by a pediatric sleep specialist. Children with craniofacial abnormalities, primarily abnormalities of the jaw bones, tongue, and associated structures, often have sleep disordered breathing. This must be managed and the deformities treated as the child grows.

The sleep test is the standard diagnostic test for sleep disordered breathing. This test can be performed in a sleep laboratory or at home. Sleep tests can produce inaccurate results, especially in children. Borderline or normal sleep test results may still result in a diagnosis of SDB based on parental observation and clinical evaluation.

Treatment for sleep disordered breathing

Enlarged tonsils are the most common cause for SDB, thus tonsillectomy/adenoidectomy is the most effective treatment for pediatric sleep disordered breathing. T&A achieves a 90 percent success rate for childhood SDB. Of the nearly 400,000 T&As performed in the U.S. each year, 75 percent are performed to treat sleep disordered breathing.

Not every child with snoring should undergo T&A. The procedure does have risks and possible complications. Aside from the mental anguish experienced by the parent and child, potential problems include: anesthesia risks, bleeding, and infection.

Custom Fit Ear Plugs and iPod Earbuds

Mack’s Earplugs: Drug stores, about $6 for 6 pairs

Material: Non-toxic hypoallergenic silicone putty.

How to use: Shape whole plug into a ball. Place over ear opening and flatten to form airtight seal. To loosen and remove, press up behind ear.

When to use: Bathing, surface (non-vigorous) swimming, noise reduction (up to 22 decibels).

What our patients say: Good for occasional use by adults. Difficult and messy to get into childrens’ ears.

Doc’s ProPlugs: Available in our offices for $15 per pair

Material: Hypoallergenic Kraton with memory.

How to use: Qualified staff will recommend correct size from 8 options designed for infants, children, teens, and adults. Semi-custom ear plugs easily insert into the ear. Clean with mild soap and water, air dry.

When to use: Bathing, surface (non-vigorous) swimming, noise reduction (up to 25 decibels).

What our patients say: Great for occasional use by adults. Easy to insert and remove in young children. Cost effective option for fast-growing kids.

Ear Band-it: Available in our offices for $20

Material: Soft neoprene.

How to use: Wear over water-safe earplugs such as Mack’s or Doc’s ProPlugs, fastening around the head, over the ears.

When to use: To safeguard children from choking on plugs that could be removed by the child or fall out during vigorous water play.

What our patients say: Cost effective option if used in conjunction with Doc’s ProPlugs or Mack’s plugs for growing kids.

Custom Swim Plugs: Available in our offices for $100 per pair

Material: Medical grade silicone. Will not shrink or harden. They float!

How to use: Audiologist will take a custom impression of your ears. You select the color and the lab creates them just for you. Easily inserted into the ears. To loosen and remove, press up behind ear. Clean with mild soap and water, air dry.

When to use: Kids & adults for bathing, swimming, noise reduction (up to 26 decibels)

What our patients say: Custom ear plugs are the best for frequent swimming. Extremely comfortable! Very easy to insert! Kids love the bright color options, swirls, and glitter! I ordered before my child’s ear tube surgery and picked up at his post-op visit – very convenient!

Ask about custom iPod and MP3 player molds! Personal fit ensures consistent sound quality and volume while exercising, and helps teens keep the volume lower to reduce damaging noise exposure. Offering quality custom hearing protection especially for pilots, musicians, construction/landscaping workers, and police officers.

Protect yourself from occupational and recreational noise exposure today!