Common Paediatric Conditions

Hearing loss in children is commonly due to fluid behind the ear drum, or “glue ear” that develops following an upper respiratory tract infection. 50% of the time it resolves spontaneously within 3 months, so a watch and wait policy is initially advised. If the fluid is persistent causing hearing loss, speech delay (good hearing is required for speech development), or predisposing to recurrent infections, then an ENT review would be advised. Treatment options include methods to improve middle ear aeration (such as the Otovent balloon or Valsalva manoeuvre), hearing aids, or grommets (hollow plastic tubes that are surgically inserted into the ear drum). There is good evidence that removal of the adenoids performed at the same time as grommet insertion improves the overall outcome. Topical steroid sprays have been demonstrated by several studies to be ineffective at reducing glue ear.

Recurrent ear infections in children are usually due to infected fluid behind the ear drum following an upper respiratory tract infection. They present as a cold followed by ear pain associated with a high temperature and systemic upset. Occasionally the infected fluid bursts out through the ear drum and is seen as a purulent discharge. This leads to resolution of the pain and infection. If the pus does not burst through the drum, or the infection is treated with a course of oral antibiotics, the now sterile fluid can remain behind the drum and cause ongoing hearing loss (as above). Recurrent middle ear infections may necessitate multiple short courses of oral antibiotics. Alternative treatments include a long-term low-dose course of antibiotics for a few months, or grommet insertion. Grommets aerate the middle ear mucosa and allow it to recover from frequent infections. Any infections that do develop can ooze out through the grommet, rather than bursting out through the ear drum in a painful and traumatic manner. They also allow antibiotic ear drops to be administered close to the source of the infection. There are very serious complications of inadequately treated middle ear infections, including meningitis, mastoiditis, facial palsy, and sigmoid thrombosis, which may require hospital admission for intravenous antibiotics, or even major ear surgery to drain the infection.

Obstructive sleep apnoea (OSA) and sleep disordered breathing (SDB) are terms used to describe abnormal breathing whilst sleeping. In children with OSA they transiently stop breathing, then gasp for breath several times a night. As such their sleep is disturbed and they can wake with headaches, are prone to bed wetting, and are excessively tired throughout the day. They are often found to have a blocked nose and sound hyponasal. SDB is a similar process, but milder. OSA is dangerous as not only does it affect the child’s schooling and development, but the repeated nocturnal micro-arousals strain the lungs and heart. For example, adult OSA can lead to pulmonary hypertension and right heart failure. The cause is usually large tonsils and adenoids. Surgical removal of the tonsils and adenoids usually resolves the issue.

Recurrent tonsillitis in children is extremely common. The (palatine) tonsils are lymphoid tissue visible at the back of the mouth either side of the tongue. Together with the adenoids (hidden at the back of the nose) and the tongue-base tonsils, they form a circle that catches inhaled bugs and mounts your initial immune response. The (palatine) tonsils can become recurrently infected though, causing sore throats, painful eating, temperatures, neck gland enlargement and ear ache. If recurrent, significant time off school may be required, along with multiple courses of antibiotics. Surgical removal of the tonsils stops troublesome tonsillitis. As there remains other tonsillar tissue, tonsillectomy (palatine tonsil removal) does not predispose you to infections – in fact there is evidence it improves your immune system, as it is no longer consumed fighting chronic tonsil infections.

The two main techniques ENT surgeons use to remove tonsils are: Bipolar (which uses an electric current to dissect the tonsils from the surrounding muscles, and stop any bleeding), or a newer technique called Coblation. Bipolar fully removes the tonsil, so the risk of regrowth is neglible, however there is more pain, and the risk of post operative bleeding is slightly more than Coblation. Coblation utilizes a cold plasma field to ablate the tonsils. This causes less pain compared to other techniques, and there is theoretically a lower risk of post-operative bleeding, but there is a significantly higher chance of tonsil regrowth causing recurrent symptoms, and the need for revision surgery. It is predominantly performed for (paediatric) obstructive sleep apnoea, but due to its higher tonsil regrowth/recurrence rates, it is less useful for tonsillitis.