Health problems from diseases of the tonsils and adenoids are among the most common problems in the pediatric population. Sore throats, upper respiratory infections and associated diseases of the ear account for the greatest number of visits in most pediatric practices.
Tonsils are collections of lymphoid tissue located on each side of the back of the throat. Though the exact function of tonsils is still being studied, it is thought that they play a role in fighting disease and the development of immunity early in life. Tonsils trap bacteria and viruses and help produce antibodies and "killer cells" to fight infection. This action diminishes rapidly with age. Studies have shown that children without their tonsils do not suffer more frequent infections than children with tonsils.
WHAT IS TONSILLITIS?
Tonsillitis occurs when the tonsils become infected. This may be caused by bacteria or viruses. Generally under preschool age children develop viral tonsillitis while older children and adults are affected by bacterial infections. Viruses can also lead to bacterial infections secondarily. Common symptoms your child may experience with tonsillitis are:
If you looked at your child's throat with a flashlight during an episode of tonsillitis, the tonsils would be red, swollen, and sometimes have a white-yellow exudate on the surface. A throat culture is necessary to diagnose bacterial tonsillitis.
HOW IS TONSILLITIS TREATED?
Tonsillitis is treated by a combination of relieving a child's symptoms as well as eliminating the infection. Supportive measures which make a child feel better include:
Antibiotics have been highly successful in treating tonsillitis and are the standard of care at this time. Penicillin is still an effective agent which treats most bacteria causing tonsillitis. Viral infections, however, do not respond to antibiotics and are treated by supportive measures alone.
Tonsillectomy is the surgical removal of the tonsils. A tonsillectomy is done when medical and supportive measures are not effective. This may be done both for recurrent infections or for chronically enlarged tonsils. Studies have shown that those with a history of bacterial infections which occur more than five to six times per year, or at least two to three times per year for several years, benefit from tonsillectomy. If your child has had persistent or recurrent sore throats, they should be checked by a physician to determine whether or not the episode was a case of tonsillitis.
Enlarged or swollen tonsils can be normal for many children. If left alone, tonsils may shrink on their own over time, or the child may outgrow them. However, they can become so large that they block a child's breathing. This shows up most prominently at night as a child struggles to breathe as he relaxes with sleep. The child may develop respiratory pauses in breathing called sleep apnea. Sleep apnea is now one of the more common indications for tonsillectomy.
HOW IS A TONSILLECTOMY DONE?
Removal of tonsils is generally done under general anesthesia. An anesthesiologist will monitor your child during the procedure. The tonsil is surrounded by a capsule and is dissected from adjacent throat tissue with special instruments. The procedure takes approximately 20-30 minutes to perform and for most children this can be done on an outpatient basis. Often we use a device called a Coblator to remove the tonsil. This seems to result in a bit less postoperative pain for most children. Surgery is often a frightening experience for both parent and child. Talking about the procedure and even taking a tour of the operating room or hospital will do much to relieve anxieties of both child and parents.
RISKS OF TONSILLECTOMY
Any anesthetic carries a small risk. However, the major risk after tonsillectomy is bleeding. This may occur right after or, more commonly, up to 7-14 days after the operation was performed. This occurs if the scab in the operative area falls off prematurely. Bleeding may occur in about 1-4% of patients and seems to be more frequent with age. Some of these may need to return to the operating room or hospital for the bleeding to be controlled.
Tonsillectomy produces a very sore throat. This usually will last until the scab has disappeared from the operative site. Throat pain makes it extremely difficult to swallow. It is very important for your child to drink adequate amounts of liquid to prevent postoperative dehydration, which could lead to further complications. Your doctor will prescribe pain medications and an antibiotic to minimize the discomfort after tonsillectomy.
WHAT ARE ADENOIDS?
Adenoids are collections of lymph tissue very similar to tonsils, found in back of the nose. As they are located near the entrance to the breathing passages, it is thought that their function is to sample or catch inhaled bacteria or viruses. In early childhood this process is important in the formation of the body's immune system to fight infection. This function diminishes with age and is probably of minimal importance after 2 or 3 years of age. Adenoids shrink or atrophy as children enter adolescence or young adulthood. Long-term investigations have shown no loss of ability to fight infection or disease in children who have had their adenoids removed.
WHAT ARE THE SYMPTOMS OF ENLARGED OR INFECTED ADENOIDS?
WHY ARE ADENOIDS IMPORTANT?
Adenoids are important because, when enlarged, they may obstruct air flow through the nose, forcing children to breathe through the mouth, or snore. In addition, the adenoid is located near the opening of the eustachian tube which drains the middle ear. Enlarged and infected adenoids may serve as a source of infection or bacteria to travel up the eustachian tube into the middle ear. This results in an ear infection.
WHEN DO ADENOIDS REQUIRE TREATMENT?
In cases where enlarged adenoids are chronically infected, significantly obstruct nasal breathing, or contribute to ear infections, removal of the adenoids has been found to be beneficial. This may be done in conjunction with a tonsillectomy for severe breathing difficulty during sleep (sleep apnea) or, along with ventilation tube placement in cases of chronic ear infections.
WHAT HAPPENS DURING ADENOID SURGERY?
Ear infections (otitis media) occur when fluid accumulates behind the eardrum and becomes infected. This area is called the middle ear. Ear infections are the most common illness affecting children. About 70% of children have at least one bout of otitis media before their third birthday. It is estimated over 24.5 million episodes of otitis media occur per year in the United States.
WHY DO EAR INFECTIONS OCCUR?
Most investigators feel that an immature eustachian tube predisposes children to otitis media. The eustachian tube is a narrow tube running from the air pocket behind the tympanic membrane to the back of the nose. In children the eustachian tube is shorter than in adults and allows bacteria and viruses to enter the middle ear. In young children, the eustachian tube is almost horizontal. This positioning interferes with drainage. In addition, the muscles of the palate which open the eustachian tube with swallowing or jaw movement are less well developed. The eustachian tube is also physically small in young children. All these factors may lead to eustachian tube blockage. As a child grows, the eustachian tube enlarges, angles down, and reaches adult development at approximately age six.
WHAT CAUSES OTITIS MEDIA?
Many ear infections may begin with a cold. The nasal membranes and eustachian tube become swollen and congested. This results in obstruction of the eustachian tube. Fluid accumulates in the middle ear space. Bacteria then contaminate the fluid in the middle ear, causing the infection. Factors that may predispose some children to otitis media are:
Presently there is debate as to how often bacteria are responsible for middle ear infections. Recent studies of fluid obtained from the middle ear space during an acute infection have shown the fluid to contain bacteria in approximately 75%, viruses in 15%, and to be sterile in 10%.
WHAT SYMPTOMS ARE PRESENT WITH EAR INFECTIONS?
Children suffering from an ear infection may display some or many of a constellation of these symptoms:
Older children may explain ear pain, ear fullness or hearing loss while younger children may be irritable, fussy, sleep poorly or have trouble hearing. After treatment of an ear infection, if the middle ear fluid does not clear and the fluid remains, a sensation of plugging or fullness as well as hearing loss may be the only symptoms that your child experiences.
HOW ARE EAR INFECTIONS TREATED?
Therapy for otitis media is centered around antibiotic therapy as well as relief of ear pain and fever. There is some debate as to how often antibiotics are needed as many ear infections resolve spontaneously, and viral infections are not improved by antibiotic treatment. In bacterial infections, antibiotics are highly effective with response seen usually within 48 hours. Although the antibiotic may help the earache resolve rapidly, it is important to finish the entire 10-14 day course of medication as it may take longer for the infection to resolve completely. In as many as 40% of children, the antibiotic may kill the bacteria, but the eustachian tube does not open and fluid is retained behind the eardrum. This fluid may persist for three to six weeks after completion of antibiotics, resulting in hearing loss as the eardrum is unable to vibrate normally. In most cases the fluid finally drains spontaneously. Other medications which may be prescribed for otitis media are analgesics to relieve pain and fever, or antibiotic ear drops.
ARE EAR INFECTIONS CONTAGIOUS?
No, but the preceding upper respiratory infection is usually contagious. The incubation time for otitis media is variable, but usually occurs several days after a cold.
WHEN ANTIBIOTICS FAIL
In a certain number of children, ear infections become chronic. Either the infections occur with very little well time between flares (back-to-back) or the middle ear fluid never clears, resulting in prolonged hearing impairment. In these instances, your doctor may recommend "ventilation tubes." A ventilation tube is a hollow tube placed in the eardrum via a surgical opening. This prevents the accumulation of fluid behind the ear drum and equalizes air pressure. Placement of a ventilation tube usually restores a child's hearing to normal.
The decision as to when an ear tube is necessary is complex and beyond the scope of this discussion. It depends on a child's frequency of infection, severity of symptoms, response to medication and level of hearing. It is crucial to discuss these factors with your pediatrician and otolaryngologist as therapy for otitis media must be individual for each patient.
Early diagnosis and therapy for hearing loss in infancy is extremely important. To illustrate this, consider the following facts:
In considering these facts regarding hearing impairment, it is extremely important to have your child's hearing evaluated shortly after birth and definitely before six months of age. Several technologies are now available to assess hearing in children. These include OAE (Otoacoustic Emissions) and ABR (Auditory Brainstem Responses).
Otoacoustic emissions are an important new tool in the early detection of hearing loss in infants. The major advantages of this new testing modality are:
Otoacoustic emissions were discovered in 1978 and became widely accepted as an accurate measurement of hearing in the mid 1990s. Basically, the cells of the inner ear generate sounds which are recordable in the ear canal. The presence of emissions indicates normal inner ear function (i.e., hearing). Absence of emissions, on the other hand, indicate hearing impairment.
The test is done with the infant sitting on the other's lap. A small probe (recording device) is lightly placed in the ear canal and sounds are recorded from the ear over a short period of time. This is done for each ear. Testing can be performed from frequencies 500 Hz to 8,000 Hz, which exactly overlaps the frequencies of speech.
Otoacoustic emissions are also used as a tool in the evaluation and management of speech, language and learning disorders. The presence of normal emissions can assure parents that hearing loss is not a component of their child's language or learning difficulties.
In summary, otoacoustic emissions allow physicians to assess hearing as early as birth. It is a quick, painless, accurate, and objective measure of inner ear hearing in all ages. It is an easy means of assuring parents that their babies hear normally and is performed in our office.
WHY IS NORMAL HEARING IMPORTANT FOR MY BABY?
Normal hearing in infancy and early childhood is critical for your child's development. A baby needs to hear to learn how to speak. This process begins at or shortly after birth as a baby starts to mimic the sounds of speech. Without adequate stimulation, language development may be delayed. As most learning in early childhood is based on auditory (speech) rather than visual (reading) methods, a child's ability to learn may also suffer. Therefore, it is imperative to know how well your baby can hear.
WHAT CAUSES INFANT HEARING LOSS?
Hearing loss occurs in two general types.
IS IT HARD TO ASSESS MY BABY'S HEARING?
Determining a baby's ability to hear is more difficult than it initially seems. Parents are generally very sensitive to the way a child responds to verbal stimulation and may become suspicious of a hearing problem. General developmental "landmarks" have also been established and used by physicians to monitor hearing and language development.
Until recently these behavioral assessments were the only way to evaluate a baby's hearing. These methods often picked up hearing loss late, missed subtle degrees of hearing loss, and were frequently inaccurate. Infant hearing loss is often a subtle problem-- it has no obvious symptoms and can easily be confused with other developmental problems. Unilateral (one ear) hearing loss, for example, may be impossible to detect by behavioral methods. Late treatment of hearing loss may not allow a child to fully compensate and develop normal language and learning skills. What is needed is an accurate, objective test of infant hearing.
HOW CAN MY BABY'S HEARING BE TESTED?
In the past, newborn hearing screening was restricted to "high risk" infants whose medical problems or family history suggested a high possibility of hearing impairment. In about 1980, accurate, automated means of newborn and infant hearing assessment were developed. These tests have been refined and now are widely available. These tests, delivered by audiologists or trained technicians are:
Both tests are painless, rapid methods to effectively screen an infant's hearing. As they are reliable and inexpensive, a larger number of infants can be screened. Using "high risk" criteria, only 5% of newborns were screened for hearing loss in 1993. The goal of hearing specialists is to screen every baby's hearing.
Allergic rhinitis is an extremely common childhood problem. The exact incidence of this disorder is unknown, but is probably enormous, considering that over 20% of the population is allergic. Nasal allergy also seems to be highly correlated with recurring sinus infection, otitis media (ear infections), asthma, and possibly facial growth abnormalities.
MECHANISM OF ALLERGY
Initially, sensitization to allergens occurs with exposure to airborne or food molecules which initiate IgE (an antibody) production. The antibodies are directed at the specific antigen (i.e., pollen, dust mites, etc.).
Repeat exposure to allergens causes continued IgE release, and the IgE then binds mast cells and eventually causes a release of Histamine. Histamine is the chemical that makes the nasal membranes swell, increases mucous secretion in the nose, and causes neural reflexes (sneezing). The mostly common allergens causing allergic rhinitis are house dust mites, molds, animal proteins, and pollens. It is uncommon to see pollen allergy in the first few years of life, as sensitization seems to take several years. Isolated food allergy without concomitant airborne allergies are also uncommon.
SIGNS AND SYMPTOMS
The most common signs and symptoms of allergic rhinitis in children are nasal congestion, runny nose, sneezing, nasal itching, and palate itching. In many children, the symptoms often make a cold. Children are prone to rubbing their nose and may have allergic shiners, which are not specific only to allergy, but are frequently seen with allergic rhinitis. Other allergic diseases, such as asthma, dermatitis, and food allergies commonly occur along with nasal allergic rhinitis.
HOW IS ALLERGY DIAGNOSED?
A careful history is even more important. The differentiation between exposures which are year-round or seasonal may help isolate allergy. For example: younger children are more prone to perennial (year-round) sensitizers, such as dust mites, and take longer to develop sensitivity to seasonal antigens, such as pollen. This sometimes makes diagnosis via history difficult because exposures may not be immediate, but delayed for a period of time after a patient comes in contact with an allergen.
Physical examination in diagnosing allergic rhinitis can be dramatic or unimpressive. Typically, the nasal membranes are pale pink and swollen. Other associated allergic diseases such as a contact dermatitis or asthma may correlate with flares of allergic symptoms.
Whether to use skin tests or not depends upon the severity of an individual's allergy and are appropriate after failure of medical treatment. Skin scratch or injection of extracts reproduce the allergic reaction in the patient's skin. There is a good correlation between skin tests and inhaled allergens as well as clinical symptoms. Occasionally people are not sensitized enough to react to prick-type allergy testing, and if a high degree of suspicion still remains, then allergen is actually injected into the skin with a small needle. This technique is called subdermal skin testing.
Total IgE: A measurement of the total amount of IgE circulating in a patient's blood can be helpful but is elevated in only one-half of allergic patients. RAST testing is a more specific blood test for allergy. This is a radio-immune assay where a patient's serum is incubated with different allergens and antigen/antibody complexes are then measured. This is not as sensitive as skin testing and certainly more costly, and cannot therefore be used as a screening tool. A smear of nasal mucus, checked for eosinophils (allergy mediating cells), can be helpful if the percentage of eosinophils is over 5%. An adenoid x-ray to assess how large the airway is at the back of the nose is also helpful. Physical examination can sometimes distinguish allergy from viral upper respiratory infections, but this is often quite difficult.
Treatment of allergic rhinitis falls into four major categories:
Environmental controls are the best form of allergy management as avoidance of the inciting allergens is the most effective way to prevent an allergic reaction. However, this is often impossible. For example, dust mites are a common antigenic sensitizer in childhood and it is impossible to eliminate dust mites from a normal household environment. They feed on sloughed skin, need a fairly high humidity of 50% or more, and typically are found in carpets, stuffed animals, furniture, toys, mattresses, etc.
It is more feasible to control mold in a house. Diminishing the humidity in a house with a dehumidifier is very helpful. Bleach also kills and removes mold. In the Central Valley, mold can be a significant problem as, due to the lack of basements, concrete slabs over moist ground serve as a wick and may act as a conduit for moisture to promote mold growth in carpet or carpet padding.
Pollen avoidance is impossible as exposure occurs whenever a patient is outside. HEPA filters (High Efficiency Particulate Air Filters) are quite helpful as a means of controlling particulates such as pollen when in a house.
Antihistamines are the first line of therapy in most cases for the treatment of allergic rhinitis. Antihistamines are best at diminishing nasal itch and reflex sneezing as well as diminishing the hypersecretion of mucus from the nose. They are less effective in diminishing nasal membrane swelling. Antihistamines come in two basic types: (a) First generation, or older medications, some of which are now sold over-the-counter. These are quite effective but tend to be sedating and over time patients typically develop a tolerance to these medications. (b) Second generation antihistamines are non-sedating medications. They are newer prescription medications, typically more expensive, and as yet, none have been FDA approved to less than six years of age. However, in special instances these medications have been used at younger ages. Examples of non-sedating second-generation antihistamines would be Claritin, Zyrtec, and Allegra.
Decongestants, such as Sudafed, are helpful to diminish the swelling of nasal membranes as they cause contraction of blood vessels within the nasal turbinates. They are complementary to antihistamines but have the side effects of hyperactivity, irritability, and occasionally insomnia. Frequently they are combined with an antihistamine in a single tablet or liquid. These combined medications are convenient, but do not allow dose adjustment of either component. Topical over-the-counter decongestants, such as Afrin nasal spray or Neo-Synephrine nasal spray, are not recommended as overuse can cause dependency on these drugs and over time, they significantly irritate the nasal membranes.
Topical Nasal Medications
Topical steroids applied as an intranasal spray are extremely effective in helping control allergy. These are prescription medications and generally safe and efficacious for finite periods of time. Steroids work by diminishing inflammation. They are active topically in the nose and generally very poorly absorbed, so significant amounts of the drug do not get into the bloodstream or the rest of the body. The portion that is swallowed and not absorbed by the nose is rapidly inactivated in the gastrointestinal tract. Usually these medications are convenient, needing to be used only once or twice per day, and are quite complementary to the antihistamines. Nasal sprays can be used in children, in some cases as young as 2 years old. In general, one tries to use the least potent, lowest dose steroid to obtain the desired outcome. Oral steroids are generally not used due to significant side effects. Generally, side effects of intranasal steroids are mild, but they do include nasal crusting and occasional bleeding. They can make chicken pox worse when used during an active chicken pox infection.
Astelin and Nasalcrom are topically applied antihistamine medications. They offer a high degree of safety and are an important complement to other medical therapies in the treatment of nasal allergy.
Immunotherapy (Desensitization Therapy) = Allergy Shots
Immunotherapy consists of injecting dilute antigen into the skin of the patient to build up tolerance to that allergen. Immunotherapy is indicated for those patients who fail environmental controls and medical therapy, or patients with extremely severe allergy. Which antigens are used are determined by skin testing. Immunotherapy is rarely done in children less than six years of age, as allergic sensitivity is rapidly changing up to that age. Allergy shots are usually initiated at one or two times per week, and the allergen extract is increased in concentration up to maintenance dose, and at maintenance, injections are delivered about every two to four weeks. There are many variations of both allergy extract and technique in immunotherapy. Generally, benefit is achieved within the first year, and the majority of patients continue therapy for three to five years. Side effects are fairly unusual but can be quite severe. Anaphylaxis is a rare, extremely severe, life-threatening allergic response to allergen contact. In light of this, allergy shots should be delivered only by physicians and staff trained in allergy and the management of its potential complications.
WHAT ARE SINUSES?
The sinuses are paired, air-filled spaces within the bones of the face. They are connected to and drain into either side of the nose.
The ethmoid and maxillary sinuses are present at birth and enlarge as a child grows.
WHAT IS SINUSITIS?
Sinusitis means inflammation or infection of the sinuses. It is most commonly the result of viral infections (i.e. colds) or nasal allergy. These disorders cause membrane swelling within the sinuses, inhibit flow of mucus out of the sinuses, and weaken the sinuses' defenses. As a result, bacteria may invade the sinus cavity, causing an acute sinusitis (sinus infection). Your child may have symptoms similar to a bad cold, but may also develop fever, headache, tooth pain, and a pus-like drainage from the nose. With proper treatment, i.e., antibiotics, most acute sinus infections resolve.
Chronic sinusitis is also a fairly common disorder in childhood. In this case, symptoms may be more subtle but prolonged- like a cold that just won't go away. Frequently, these children have a stuffy nose, chronic drainage from the nose or down the throat, bad breath, and often a persistent cough. Chronic sinusitis may require prolonged medical therapy. In rare cases of medical failure, procedures to drain the sinuses may be required.
HOW DO I KNOW IF MY CHILD HAS SINUSITIS?
The diagnosis of childhood sinusitis is difficult. A child's symptoms often are not much different from a common cold. Testing can also be equivocal. X-rays and CT scans are not always helpful due to age-dependent differences in sinus development. An x--ray or CT scan may also look abnormal when a child simply has a viral upper respiratory infection. Cultures of the nose can be misleading as he bacteria obtained from the front of the nose are usually different from those infecting the sinus. The character of nasal drainage may also be misleading. Clear drainage is most commonly associated with allergy, but can occur with viral or bacterial infection. If the mucus dries out, it will not only be thicker, but may turn white, yellow, or green, regardless of cause. There doesn't seem to be a reliable way to determine the cause of nasal drainage simply by its color.
It is presumed that a child has acute sinusitis if the child has cold-like symptoms, lasting more than ten days. If the child has chronic symptoms, lasting more than a few months, the presumption is that the child has chronic sinusitis.
HOW IS SINUSITIS TREATED?
Antibiotics are the primary therapy for acute sinusitis. Usually a course of therapy lasts about two or three weeks. The choice of antibiotic agent is becoming more difficult for your doctor as bacteria resistant to commonly used antibiotics are becoming more prevalent. In addition to antibiotics, gently washing the nose with saline (salt and water) to promote flow out of the sinuses, or a topical decongestant nasal spray (used no more than three consecutive days) are also helpful. Tylenol or other analgesics are important to lower fever and diminish discomfort.
In chronic sinusitis, determination and elimination of contributing factors is imperative. If allergy is present, specific allergy therapies such as antihistamines are warranted. Some children are affected by non-allergic airborne irritants, i.e., cigarette smoke, pollution, etc. In these cases, as in viral infections, antihistamines are not helpful. They may even make the condition worse by thickening nasal mucus, which impairs drainage. In these cases, elimination of tobacco smoke exposure and air filters/cleaners may significantly help your child.
Nasal steroid sprays are commonly used and are helpful in chronic sinusitis. They reduce membrane swelling and diminish inflammation. They are fairly safe to use in children as they are not absorbed in significant amounts. As a result, the side-effects associated with steroids taken by mouth are avoided.
Antibiotics are also necessary in most cases of chronic sinusitis. The duration of therapy is much longer-- usually more than a month. Choice of antibiotics is critical as usually bacteria or bacteria with some pattern of resistance are more commonly present within the sinuses.
Supportive measures such as humidifiers and saline nasal rinses are also beneficial. Oral decongestants (Sudafed) and mucolytics (mucus thinners) are useful in selected cases.
WILL SURGERY HELP MY CHILD'S SINUSITIS?
Sinus surgery is generally not necessary in young children. This is primarily due to the large number of factors that use or contribute to chronic sinusitis. For example, allergy, frequent exposure to colds, an immature immune system, and enlarged adenoids may all be causative factors in a child's propensity for sinusitis. If these factors are controlled, a child's sinusitis typically improves. In rare cases refractory to prolonged treatment, or in children where a structured deformity within the nose obstructs sinus drainage, surgery may be an appropriate and necessary treatment. However, in children it certainly is the treatment of "last resort."
Kids with asthma don’t have to miss out on the fun of summer camp. All that’s needed for a safe, enjoyable, asthma-free camp experience is some planning. The American Lung Association recommends the following summer camp tips for children with asthma:
1) Furnish equipment to measure your child’s pulmonary functions
3) You and your child can:
For more information, call 1-800-LUNG-USA (1-800-586-4872)