Common ENT Problems in Children

Glue ear (Also known as otitis media with effusion/OME) is a common childhood condition characterized by the accumulation of fluid within the middle ear without signs of acute infection.
The presence of fluid behind the eardrum (tympanic membrane) adversely affects the efficiency of movement of the 3 bones (ossicles) of hearing in the middle ear. The sound signal is not carried as well to the sensory organ in the inner ear (cochlea) and as a result the sound is heard as a quieter noise than it ought to be.

There are 2 peaks in the incidence of glue ear around 3 and 5 years of age. Glue ear is very common and 80% of children have been affected by 10 years. Hearing loss is the commonest presenting feature but sometimes the hearing difficulty can go unnoticed.

Less frequently glue ear may present with poor educational progress, clumsiness, ‘the wobbly child’, abnormal noises in the ears (tinnitus) and intolerance of loud noise (hyperacusis). Glue ear may resolve naturally and therefore a period of 3 months of ‘active monitoring’ following diagnosis is recommended. If the glue ear persists for over 3 months with accompanying hearing difficulty then intervention should be offered. Medicinal treatments have not been shown to be effective in the management of glue ear.

This intervention can take the form of surgically draining the fluid and inserting grommets (ventilation tubes) to ventilate the middle ear. Grommets prevent the development of the negative pressure in the middle ear that is thought to lead to the development of glue ear. Hearing aids are an option to amplify the sounds sent into the ear to counter-act the inefficient sound transfer. They allow the child to hear better, whilst waiting for the natural resolution of the glue ear, that can take months to a few years.

Infection involving the middle ear (Acute Otitis Media (AOM)) is the commonest bacterial disease occurring in infants and children. All children are likely to experience 1 episode, with 1/3 experiencing 2+ episodes in first 3 years of life. Children aged 3-7 years are most commonly affected. AOM causes pain, reduced hearing and fever. Sometimes the eardrum will perforate and pus will leak out of the ear.

Severe cases, those with leakage of pus (otorrhoea) and when both ears are infected in children under 2 years of age, require antibiotic treatment. Other cases can often be managed without antibiotic treatment providing they are seen to be improving over 2-3 days. If a child is having regular, or persistent ear infections, then it is necessary to check that the eardrum is normal and in some cases to ensure that ‘booster’ vaccinations are not needed. Grommets (ventilation tubes) are sometimes required if the infections are very regular.

Serious complications of AOM are very rare, but the infection can occassionally spread to involve the bone behind the ear (mastoiditis) and extremely rarely spread inside the skull (intracranial sepsis).

Acute tonsillitis is the term used to describe viral or bacterial infections of the tonsils in the back of the throat. Tonsillitis is a very common infection in childhood. It presents with a sore throat, fever, earache, tiredness and lack of appetite. Some children may also have stomach (abdominal) pain.

Mild to moderate severity cases may not require treatment except for painkillers (analgesia). However, more severe cases and those lasting over 5-7 days may benefit from antibiotic treatment. When a child is suffering from regular severe tonsillitis then they may benefit from surgical removal of their tonsils (tonsillectomy).

Many children will snore at some point during childhood. Snoring results from partial obstruction of the upper airway during sleep. In every child the muscles of the throat relax during sleep, but in some children this ‘normal’ airway collapse is exacerbated by large tonsils and adenoids or nasal obstruction, causing the child to snore. The airway obstruction in primary snoring rarely causes significant alteration in the bodies ability to effectively transfer oxygen from the air we breath to the blood system. Therefore, primary snoring does not usually require surgical treatment, but may respond to medical treatment to reduce nasal obstruction.

In obstructive sleep apnoea (OSA) the collapse in the upper airway can be complete and the child may stop breathing for several seconds. As a result, in OSA the levels of oxygen in the blood stream drop, leading to stress on the heart and lungs. The brain then detects that breathing has stopped and wakes the child briefly, thereby opening up the airway again. This cycle of breath holding and waking can significantly affect the quality of sleep, leaving the child sleepy during the day. OSA may also result in a deterioration in behaviour and school performance, and regular ‘napping’ during the day in preschool and school aged children. Very rarely, untreated OSA may lead to significant heart and lung problems (pulmonary hypertension).

A tongue tie occurs when the band of tissue beneath the tongue (frenulum) is abnormally formed (short or tight), which can result in restriction of tongue movements. This may lead to difficulties breastfeeding, in particular poor latch (attachment to the nipple) or maternal discomfort during breastfeeding. Not all tongue ties need dividing and advice regarding breast feeding technique can make a significant difference to beast feeding success.

Troublesome tongue ties can be divided surgically in the clinic setting for infants below 9 months of age, but a general anesthetic is required for older children. The main aim of dividing tongue ties is to allow mothers to continue to breastfeed. In addition, to making the diagnosis, it is important to make the distinction from other causes of difficult breast feeding, such as nasal obstruction, palatal abnormalities and reflux.