What is otitis media (OM)?
Otitis media is inflammation located in the middle ear. Otitis media can occur as a result of a cold, sore throat, or respiratory infection.

Facts about otitis media:

About 75 percent of children have at least one episode of otitis media by the time they are 3 years of age.
Nearly half of these children have three or more episodes by the time they are 3 years of age.
Otitis media can also affect adults, although it is primarily a condition that occurs in children.
Otitis media is the most common diagnosis for children in the US.
Otitis media occurs more often in the winter and early spring.

Who is at risk for getting ear infections?
While any child may develop an ear infection, the following are some of the factors that may increase your child’s risk of developing ear infections:

being around someone who smokes, whether in or out of the house
family history of ear infections
a poor immune system
spends time in a daycare setting
absence of breastfeeding
having a cold
bottlefed while laying on his/her back

What causes otitis media?
Middle ear infections are usually a result of a malfunction of the eustachian tube, a canal that links the middle ear with the throat area. The eustachian tube helps to equalize the pressure between the outer ear and the middle ear. When this tube is not working properly, it prevents normal drainage of fluid from the middle ear, causing a build up of fluid behind the eardrum. When this fluid cannot drain, it allows for the growth of bacteria and viruses in the ear that can lead to acute otitis media. The following are some of the reasons that the eustachian tube may not work properly:

a cold or allergy which can lead to swelling and congestion of the lining of the nose, throat, and eustachian tube (this swelling prevents the normal flow of fluids)
a malformation of the eustachian tube

What are the different types of otitis media?
Different types of otitis media include the following:

acute otitis media (AOM) - the middle ear infection occurs abruptly causing swelling and redness. Fluid and mucus become trapped inside the ear, causing the child to have a fever, ear pain, and hearing loss.
otitis media with effusion (OME) - fluid (effusion) and mucus continue to accumulate in the middle ear after an initial infection subsides. The child may experience a feeling of fullness in the ear and hearing loss.

What are the symptoms of otitis media?
The following are the most common symptoms of otitis media. However, each child may experience symptoms differently. The symptoms of otitis media may resemble other conditions or medical problems. Always consult your child's physician for a diagnosis.

Symptoms may include:

unusual irritability
difficulty sleeping or staying asleep
tugging or pulling at one or both ears
fever
fluid draining from ear(s)
loss of balance
hearing difficulties
ear pain
nausea and vomiting
diarrhea
decreased appetite
congestion

How is otitis media diagnosed?
In addition to a complete medical history and physical examination, your child’s physician will inspect the outer ear(s) and eardrum(s) using an otoscope. The otoscope is a lighted instrument that allows the physician to see inside the ear. A pneumatic otoscope blows a puff of air into the ear to test eardrum movement. Tympanometry, is a test that can be performed in most physicians' offices to help determine how the middle ear is functioning. It does not tell if the child is hearing or not, but helps to detect any changes in pressure in the middle ear. This is a difficult test to perform in younger children because the child needs to remain still and not cry, talk, or move. A hearing test may be performed for children who have frequent ear infections.

Treatment for otitis media
Specific treatment for otitis media will be determined by your child’s physician based on the following:

your child’s age, overall health, and medical history
extent of the condition
your child’s tolerance for specific medications, procedures, or therapies
expectations for the course of the condition
your opinion or preference

Treatment may include:

antibiotic medication by mouth or ear drops
medication (for pain)

If fluid remains in the ear(s) for longer than three months, your child's physician may suggest that small tubes be placed in the ear(s). This surgical procedure, called myringotomy, involves making a small opening in the eardrum to drain the fluid and relieve the pressure from the middle ear. A small tube is placed in the opening of the eardrum to ventilate the middle ear and to prevent fluid from accumulating. The child's hearing is restored after the fluid is drained. The tubes usually fall out on their own after six to twelve months. Your child's surgeon may also recommend the removal of the adenoids (lymph tissue located in the space above the soft roof of the mouth, also called nasopharynx) if they are infected. Removal of the adenoids has shown to help some children with otitis media. Treatment will depend upon the type of otitis media. Consult your child's physician regarding treatment options.

What are the effects of otitis media?
In addition to the symptoms of otitis media listed above, untreated otitis media can result in any/all of the following:

infection in other parts of the head
permanent hearing loss
problems with speech and language development

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Mastoiditis

What is mastoiditis?
Mastoiditis is an inflammation or infection of the mastoid bone, which is a portion of the temporal bone. The mastoid consists of air cells that drain the middle ear. Mastoiditis can be a mild infection or can develop into life-threatening complications. Mastoiditis is usually a complication of acute otitis media (middle ear infection).

What causes mastoiditis?
Mastoiditis is usually a result of an extension of the inflammation of the middle ear infection into the mastoid air cells. A child with mastoiditis usually has a history of having a recent ear infection or has middle ear infections that continue to reoccur. The risk of mastoiditis is reduced with the use of antibiotics for ear infections. Mastoiditis may be caused by various bacteria.

What are the symptoms of mastoiditis?
The following are the most common symptoms for mastoiditis. However, each child may experience symptoms differently. The symptoms of mastoiditis may resemble other medical conditions or problems. Always consult your child's physician for a diagnosis.

Symptoms may include:

pain behind the ear
swelling of the ear lobe
recent ear infection
fever
irritability
redness or swelling of the bone behind the ear
drainage from an ear infection

How is mastoiditis diagnosed?
In addition to a complete medical history and physical examination, your child’s physician will inspect the outer ear(s) and eardrum(s) using an otoscope. The otoscope is a lighted instrument that allows the physician to see inside of the ear. A pneumatic otoscope blows a puff of air into the ear to test eardrum movement.To help determine how the middle ear is functioning, a tympanometry can be performed in most physician offices. It does not tell if the child is hearing or not, but helps to detect any changes in pressure in the middle ear. This is a difficult test to perform in younger children because the child needs to sit very still and not be crying, talking, or moving. Your child’s physician may also order the following tests to help confirm the diagnosis:

blood work
x-rays of the head a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues and bones of the head onto film.
culture from the infected ear

If your child has symptoms of a brain abscess or other intracranial complication, your child's physician may order the following:

1. computerized tomography scan (also called a CT or CAT scan) - a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called “slices”), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.

2. magnetic resonance imaging ( MRI) - a diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body.

3. If your child has symptoms of meningitis, your child's physician may order a:

lumbar puncture - a special needle is placed into the lower back, into the spinal canal. This is the area around the spinal cord. The pressure in the spinal canal and brain can then be measured. A small amount of cerebral spinal fluid (CSF) can be removed and sent for testing to determine if there is an infection or other problems. CSF is the fluid that bathes your child’s brain and spinal cord.

Treatment for mastoiditis
Specific treatment for mastoiditis will be determined by your child's physician based on:

your child’s age, overall health and medical history
extent of the disease
your child’s tolerance for specific medications, procedures, or therapies
expectations for the course of the condition
your opinion or preference

Treatment of mastoiditis usually requires hospitalization and a complete evaluation by a physician that specializes in the ear, nose, and throat disorders (otolaryngologist). Your child, in most cases, will receive antibiotics through an intravenous (IV) catheter. Surgery is sometimes needed to help drain the fluid from the middle ear.Your child's physician may suggest a myringotomy, a surgical procedure which involves making a small opening in the eardrum to drain the fluid and relieve the pressure from the middle ear. A small tube may be placed in the opening of the eardrum to ventilate the middle ear and to prevent fluid from accumulating. The child's hearing is restored after the fluid is drained. The tubes usually fall out on their own after six to twelve months.

What are the effects of mastoiditis?
If the infection continues to spread, despite antibiotic therapy, the following complications may occur:

meningitis - an infection of the outside of the brain.
brain abscess - a pocket of pus and infection that may develop in the brain.
Early and proper treatment of mastoiditis is necessary to prevent the development of these life-threatening complications.

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Ear Tubes

What are myringotomy tubes (also called ear tubes, tympanostomy tubes, or ventilation tubes)?
Myringotomy tubes are small tubes that are surgically placed into your child’s eardrum by an ear, nose, and throat surgeon. The tubes may be made of plastic, metal, or Teflon®. The tubes are placed to help drain the fluid out of the middle ear in order to reduce the risk of ear infections. During an ear infection, fluid gathers in the middle ear, which can affect your child’s hearing. Sometimes, even after the infection is gone, some fluid may remain in the ear. The tubes help drain this fluid, and prevent it from building up. The most common ages are from 1 to 3 years old. By the age of 5 years, most children have wider and longer eustachian tubes (a canal that links the middle ear with the throat area), thus, allowing better drainage of fluids from the ear.

Who needs ear tubes?
The insertion of ear tubes may be recommended by your child's physician and/or a ear, nose, and throat physician if several of the following conditions are present:

fluid in the ears for more than three or four months following an ear infection
fluid in the ears and more than three months of hearing loss
changes in the actual structure of the eardrum from ear infections
a delay in speaking
repeated ear infections that do not improve with antibiotics over several months

What are the risks and benefits of ear tubes?
The risks and benefits will be different for each child. It is important to discuss this with your child's physician and surgeon. The following are some of the possible benefits that may be discussed:

Ear tubes help to reduce the risk of future ear infections.
Hearing is restored in some children who experience hearing problems.
Speech development is not harmed.
Ear tubes allow time for the child to mature and for the eustachian tube to work more efficiently. (By the age of 5 years, the eustachian tube becomes wider and longer, thus, allowing for better drainage of fluids from the ears.)
Children’s behavior, sleep, and communication may be improved if ear infections were causing problems.

The following are some of the risks that may be discussed:

Some children with ear tubes continue to develop ear infections.

There may be problems with the tubes coming out:

The tubes usually fall out in about one year. After they fall out, if ear infections recur, they may need to be replaced.
If they remain in the ear too long, the surgeon may need to remove them.
After they come out, they may leave a small scar in the eardrum. This may cause some hearing loss.
Some children may develop an infection after the tubes are inserted.
Sometimes, after the tube comes out, a small hole may remain in the eardrum. This hole may need to be repaired with surgery.

How are ear tubes inserted?
Myringotomy is the surgical procedure that is performed to insert ear tubes. Insertion of the tubes is usually an outpatient procedure. This means that your child will have surgery, and then go home that same day. Before the surgery, you will meet with different members of the healthcare team who will be involved in your child’s care. These may include:

nurses - day surgery nurses prepare your child for surgery. Operating room nurses assist the physicians during surgery. Recovery room (also called the Post-Anesthesia Care Unit) nurses care for your child as he emerges from general anesthesia.
surgeon - a physician who specializes in the placement of the tubes.
anesthesiologist - a medical physician with specialized training in anesthesia. He will perform a history and physical examination and formulate a plan of anesthesia for your child. The plan will be discussed with you and your questions will be answered. Insertion of myringotomy tubes requires general anesthesia in children.
Myringotomy involves making a small opening in the eardrum to drain the fluid and relieve the pressure from the middle ear. A small tube is placed in the opening of the eardrum to ventilate the middle ear and to prevent fluid from accumulating. The child's hearing is restored after the fluid is drained. The tubes usually fall out on their own after six to twelve months. Your child's recovery will be monitored closely. Your child must meet all discharge criteria in order to go home. Follow-up care is needed for your child based on the surgeon’s recommendations. Usually, you will return in about two to four weeks, then four to six months after the tubes have been inserted, and then approximately one year later. Your child's physician will help manage the care of your child in-between these visits, in agreement with the surgeon.

Care of the child after the ear tubes are inserted
The following are some of the instructions that may be given to you following the placement of ear tubes in your child:

Your child's surgeon may order antibiotic ear drops to be placed after the initial insertion of the tubes, to prevent infection.
You will be instructed to call your child's physician if your child experiences any of the following symptoms:
- drainage from the ear
- ear pain
- fever
- myringotomy tube displaced (out of ear)

You will be instructed on the use of earplugs while your child is in the water, based on the opinion of your child's physician. Different physicians have different recommendations regarding the use of earplugs.

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Swimmer’s ear

What is otitis externa?
Otitis externa, also called swimmer's ear, is an inflammation of the external ear canal. Swimmer’s ear is caused by fungi or bacteria. Water that remains trapped in the ear canal (when swimming, for example) may provide a source for the growth of bacteria and fungi.

What causes swimmer's ear?
Many different factors can increase your child’s chance of developing swimmer's ear. As the name implies, one of the factors is excessive wetness as with swimming, although it can occur without swimming. Other possible causes of this infection include the following:

being in warm, humid places
harsh cleaning of the ear canal
trauma to the ear canal
dry ear canal skin
foreign body in the ear canal
lack of cerumen (ear wax)
eczema and other forms of dermatitis

What are the symptoms of swimmer's ear?
The following are the most common symptoms of swimmer’s ear. However, each child may experience symptoms differently. Symptoms may include:

redness of the outer ear
itching in the ear
pain, especially when touching or wiggling the ear lobe
drainage from the ear
swollen glands in the neck
swollen ear canal
conductive hearing loss

The symptoms of swimmer's ear may resemble other medical conditions or problems. Always consult your child's physician for a diagnosis.

How is swimmer’s ear diagnosed?
Swimmer’s ear may be diagnosed with a complete medical history and physical examination by your child’s physician. Your child's physician may use an otoscope, a lighted instrument that helps to examine the ear and to aid in the diagnosis of ear disorders. This will help your child's physician know if there is also an infection in the middle ear, called otitis media. Although this infection usually does not occur with swimmer’s ear, some children may have both types of infections.

Treatment of swimmer’s ear
Swimmer’s ear, when properly treated by a physician, usually clears up within seven to 10 days. Specific treatment for swimmer's ear will be determined by your child’s physician based on:

your child’s age, overall health, and medical history
extent of the condition
your child’s tolerance for specific medications, procedures, or therapies
expectations for the course of the condition
your opinion or preference

Treatment may include:

antibiotic ear drops or oral antibiotics
corticosteroid ear drops (to help decrease the swelling)
pain medication
keeping the ear dry, as directed by your child's physician
a wick (a piece of sponge may be placed in your child’s ear if there is a lot of swelling. This wick helps the antibiotic drops work more effectively in the ear canal.)

Preventing swimmer’s ear
The following are some hints to help prevent swimmer’s ear:

Place two to three drops of a mixture of vinegar/isopropyl alcohol/water into your child’s ear after the ears come in contact with water.
Use ear plugs for swimming or bathing.
Do not aggressively clean your child’s ear canal.

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Hearing Loss

What are the different types of hearing loss?
Hearing loss can be categorized by many different types. Two types of hearing loss are sensorineural and conductive. Both types of hearing loss can be congenital (present at birth) or acquired.

SENSORINEURAL - a loss of function within the inner ear or with the connection to the brain. Causes of this type of hearing loss include:

congenital factors - conditions present at birth, such as:
infection by the mother with toxoplasmosis, rubella, cytomegalovirus, herpes, or syphilis
genetic factors and syndromes the child has at birth
low birthweight
hereditary - in the family
acquired
loud noise exposure
trauma
infections
damage from certain medications that can be harmful to the ears

CONDUCTIVE HEARING LOSS - a problem in the outer or middle ear where sound waves are not sent to the inner ear correctly. Conductive hearing loss is the most common type of hearing loss in children and is usually acquired. Factors that may cause this type of hearing loss are:

congenital factors - conditions present at birth, such as:
anomalies of the pinna (the outside of the ear)
anomalies of the tympanic membrane (eardrum)
anomalies of the external ear canal
anomalies of the ossicles (the three tiny bones that deliver the sound waves to the middle ear)
acquired
excessive wax
foreign bodies in the ear canal, such as beads or popcorn kernels
tumors of the middle ear
problems with the eustachian tube
ear infections such as otitis media
chronic ear infections with fluid in the middle ear
perforation of the eardrum

Management of Hearing Loss
Early intervention and detection of hearing loss is necessary to prevent additional problems with speech and language development. A healthcare team approach is normally used when a child is diagnosed with some degree of hearing loss. Team members include the following:

audiologist - a professional who specializes in the evaluation and management of hearing and balance problems in people of all ages. Audiologists are also involved with the fitting and management of hearing aids and other assistive devices.
otolaryngologists - a physician with special training in medical and surgical treatment for children who have disorders of the ear, nose, and throat.
speech pathologist - a professional who helps evaluate and manage speech, language, and hearing problems in your child. Click here to learn about the speech therapists at CHKD.

Specific treatment for hearing loss will be determined by your child's physician based on:

your child’s age, overall health, and medical history
extent of the condition
your child’s tolerance for specific medications, procedures, or therapies
expectations for the course of the condition
your opinion or preference

Management of hearing loss may include one or more of the following:

use of hearing aids - electronic or battery-operated devices that can amplify and change sound. A microphone receives the sound and converts it into sound waves. The sound waves are then converted into electrical signals.
cochlear implants - a surgically placed appliance that helps to transmit electrical stimulation to the inner ear. Only certain children are candidates for this type of device. Consult your child's physician for more information.
training in sign language and lip reading

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Sinusitis

What are sinuses?
The sinuses are cavities, or air-filled pockets, near the nasal passage. Like the nasal passage, the sinuses are lined with mucous membranes. There are four different types of sinuses:

ethmoid sinus - located inside the face, around the area of the bridge of the nose. This sinus is present at birth, and continues to grow.
maxillary sinus - located inside the face, around the area of the cheeks. This sinus is also present at birth, and continues to grow.
frontal sinus - located inside the face, in the area of the forehead. This sinus does not develop until around 7 years of age.
sphenoid sinus - located deep in the face, behind the nose. This sinus does not develop until adolescence.

What is sinusitis?
Sinusitis is an infection of the sinuses near the nose. These infections usually occur after a cold or after an allergic inflammation. There are three types of sinusitis:

acute sinusitis - occurs quickly and improves with the appropriate treatment.
subacute sinusitis - does not improve with treatment initially, and lasts less than three months.
chronic sinusitis - occurs with repeated acute infections or with previous infections that were inadequately treated. The symptoms last longer than three months.

What causes sinusitis?
Sometimes, a sinus infection happens after an upper respiratory infection ( URI) or common cold. The URI causes inflammation of the nasal passages that can block the opening of the paranasal sinuses, and result in a sinus infection. Allergies can also lead to sinusitis because of the swelling of the nasal tissue and increased production of mucus. There are other possible conditions that can block the normal flow of secretions out of the sinuses and can lead to sinusitis including the following:

abnormalities in the structure of the nose
enlarged adenoids
diving and swimming
infections from a tooth
trauma to the nose
foreign objects stuck in the nose
cleft palate

When the flow of secretions from the sinuses is blocked, bacteria may begin to grow. This leads to a sinus infection, or sinusitis. The most common bacteria that cause sinusitis include the following:

Streptococcus pneumonia
Haemophilus influenzae
Moraxella catarrhalis

What are the symptoms of sinusitis?
The symptoms of sinusitis depend greatly on the age of the child. The following are the most common symptoms of sinusitis. However, each child may experience symptoms differently. Symptoms may include:

younger children:
- runny nose
- lasts longer than seven to 10 days
- discharge is usually thick green or yellow, but can be clear
- nighttime cough
- occasional daytime cough
- swelling around the eyes
- usually no headaches younger than 5 years of age
older children and adults:
- runny nose or cold symptoms lasting longer than seven to 10 days
- drip in the throat from the nose
- headaches
- facial discomfort
- bad breath
- cough
- fever
- sore throat
- swelling around the eye, often worse in the morning

The symptoms of sinusitis may resemble other conditions or medical problems. Always consult your child's physician for a diagnosis.

How is sinusitis diagnosed?

In addition to a complete medical history and physical examination, diagnostic procedures for sinusitis may include the following:
cultures from the nose or sinus fluid - laboratory tests that involve the growing of bacteria or other microorganisms to aid in diagnosis.
sinus x-rays - diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film. (X-rays are not typically used, but may help assist in the diagnosis.)
computerized tomography (also called CT or CAT scan.) - a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called “slices”), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.
blood tests

Treatment for sinusitis:

Specific treatment for sinusitis will be determined by your child's physician based on:
your child's age, overall health, and medical history
extent of the infection
your child's tolerance for specific medications, procedures, or therapies
expectations for the course of the infection
your opinion or preference

Treatment of sinusitis may include the following:

antibiotics, as determined by your child's physician (antibiotics are usually given for 10 to 14 days, and sometimes longer)
acetaminophen (for pain or discomfort)
use of a cool mist humidifier in your child's room
nasal drops
Decongestants and antihistamines may not help the symptoms of sinusitis.

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Sinus Surgery

The purpose of endoscopic sinus surgery is to open the passages of the sinuses allowing for proper drainage to the nose. It is called an endoscopic procedure because the physician uses an endoscope a small, flexible tube with a light and a camera lens at the end) to view the inside of the nose. Small incisions or cuts are made to allow the scope to pass. The cuts are usually made inside of the nose. The physician may create new passages or open existing ones by removing polyps, cysts, or thickened mucous membranes.

Endoscopic sinus surgery:

Endoscopic sinus surgery usually takes between one and three hours and is done in the operating room with the child under general anesthesia.
Most young children spend the night in the hospital, but some older children may stay for only a couple of hours after surgery.
Depending on the surgeon's preference and the needs of the child, endoscopic sinus surgery may be performed at the same time as another operation such as septoplasty, tonsillectomy, adenoidectomy, or insertion of ear tubes.

What to expect after surgery:

Your child will have intravenous (IV) fluids until time of discharge. Clear liquids for your child to drink are available in the Post Anesthesia Care Unit (PACU), also called the recovery room.
Your child may complain of a sore nose, not being able to breathe through the nose, and difficulty swallowing.
A pain reliever may be given for pain. An antibiotic is occasionally prescribed to prevent infection.
The head of the bed will be raised in the PACU to help with swelling, breathing, and drainage. At home you should have pillows or a recliner chair available to help your child stay comfortable with his/her head elevated above the level of the chest.
There may be packing in the nose to prevent bleeding. Sometimes, this packing is dissolvable. The physician may remove this packing in one or two weeks or it may dissolve on its own. If the packing needs to be removed, it may be done in the physician's office for older, cooperative children, or may be done in the operation room under anesthesia.
If a septoplasty (straightening of the bone and cartilage in the center of the nose) is performed, then splints will be placed inside the nose at the end of the operation. These will be removed at the physician's office in one to two weeks and may cause some discomfort while they are in place.
If packing is used, your child may be able to feel it in his/her nose. Your child should be told before surgery that they may feel like they have something in their nose when they wake up. If packing is not used, swelling may cause this feeling. Your child should know that he/she will not be allowed to forcefully blow his/her nose for a week or two.
At first, there may be some drainage from the nose. You may see a small piece of gauze taped under your child's nose. This is called a "drip pad." This is usually only needed for the first day, if at all. The drainage from the nose will probably be tinged with blood. Your child may cough or spit up some pink or brown mucus.
Most children are fussy the first few hours after this procedure.
Your child may begin normal play after several days, but may need to stay home from school until the discomfort improves. Consult your child's physician for more specific recommendations.
Your child's physician may recommend the use of nasal ointment, salt water spray, or nasal steroid spray after surgery. Follow instructions carefully.
When to call your child’s physician:

Signs of dehydration:

dry mouth
sunken look around eyes
decreased amount of urine (i.e., fewer wet diapers than usual in an infant)
no tears when crying
skin that, when pinched, forms and holds the shape of a tent

The following are some of the symptoms that may indicate a need for you to promptly contact your child's physician:

bright red bleeding from the nose or mouth
double or impaired vision
a persistent leak of clear fluid from the nose
if your child vomits bright red blood or a coffee ground-like material
if your child develops a croupy (barky) cough/cry or wheezing
if your child's temperature rises greater than 101.5o F rectally or greater than 100.5o F orally
vomiting (or if the vomiting becomes severe)
signs of dehydration (a child can become dehydrated when he/she has prolonged or severe vomiting and is not able to drink enough fluid)

Follow-up: A visit with your child's physician will be scheduled for one to two weeks after surgery and then again several more times in the months after surgery to make sure that the nose is healing properly. Consult your child's physician if you have any questions.

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Sore Throats

What is pharyngitis and tonsillitis?
Pharyngitis and tonsillitis are infections in the throat that cause inflammation. If the tonsils are primarily affected, it is called tonsillitis. If the throat is primarily affected, it is called pharyngitis. A child might even have inflammation and infection of both the tonsils and the throat. This would be called pharyngotonsillitis. These infections are spread by close contact with other individuals. Bacterial infections are more common during the winter. Viral infections are more common in summer and fall.

Facts about pharyngitis and tonsillitis:

Pharyngitis and tonsillitis are most commonly seen in children between the ages of 6 and 8.
Children under age 2 rarely develop group A ß - hemolytic streptococcus (GABHS), or strep throat.

What causes pharyngitis and tonsillitis?
There are many causes of infections in the throat. The following are the most common infectious agents:

viruses:
- adenovirus
- influenza virus
- Epstein-Barr virus
- herpes simplex virus
bacteria:
- group A ß - hemolytic streptococci (GABHS)
- Neisseria gonorrhea
- Haemophilus influenzae Type B
- mycoplasma
- fungal infections
- parasitic infections
- cigarette smoke

What are the symptoms of pharyngitis and tonsillitis?
The symptoms of pharyngitis and tonsillitis depend greatly on the cause of the infection and the person affected. For some children, the onset of symptoms may be quick; for others, symptom onset is slow. The following are the most common symptoms of pharyngitis and tonsillitis. However, each child may experience symptoms differently. Symptoms may include:

sore throat
fever (either low grade or high)
headache
decrease in appetite
not feeling well
nausea
vomiting
stomach aches
painful swallowing
visual redness or drainage in the throat

How are pharyngitis and tonsillitis diagnosed?
In most cases, it is hard to distinguish between a viral sore throat and a strep throat based on physical examination. It is important, though, to know if the sore throat is caused by GABHS, as this requires antibiotic treatment to help prevent the complications associated with these bacteria. As a result, most children, when they have the above symptoms, will receive a strep test and throat culture to determine if it is an infection caused by GABHS. This usually involves a throat swab (called quick test or rapid strep test) in the physician's office. This may immediately become positive for GABHS and antibiotics will be started. If it is negative, part of the throat swab will be kept for a throat culture. This will further identify, in two to three days, if there is any GABHS present. Your child's physician will decide the treatment plan based on the findings.

Treatment for pharyngitis and tonsillitis: Specific treatment for pharyngitis and tonsillitis will be determined by your child's physician based on:

your child's age, overall health, and medical history
extent of the condition
cause of the condition
your child's tolerance for specific medications, procedures, or therapies
expectations for the course of the condition
your opinion or preference

If bacteria do not cause the infection, then the treatment is focused on comfort of your child. Antibiotics will not help treat viral sore throats. Treatment may include:

acetaminophen (for pain)
increased fluid intake
throat lozenges
antibiotics (if the cause of the infection is bacterial, not viral)

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Obstructive Sleep Apnea

What is obstructive sleep apnea?
Obstructive sleep apnea occurs when a child stops breathing during periods of sleep. The cessation of breathing usually occurs because of a blockage (obstruction) in the airway. Tonsils and adenoids may grow to be large relative to the size of a child’s airway (passages through the nose and mouth to the windpipe and lungs). Inflamed and infected glands may grow to be larger than normal, thus, causing more blockage. The enlarged tonsils and adenoids block the airway during sleep, for a period of time. The tonsils and adenoids are made of lymph tissue and are located at the back and to the sides of the throat.During episodes of blockage, the child may look as if he/she is trying to breath (the chest is moving up and down), but no air is being exchanged within the lungs. Often these episodes conclude with a period of awakening and compensation for lack of breathing. Periods of blockage occur regularly throughout the night and result in a poor, interrupted sleep pattern. Sometimes, the inability to circulate air and oxygen in and out of the lungs results in lowered blood oxygen levels. If this pattern continues, the lungs and heart may suffer permanent damage. Obstructive sleep apnea is most commonly found in children between 3 to 6 years of age. It occurs more commonly in children with Down syndrome.

What causes obstructive sleep apnea?
In children, the most common cause of obstructive sleep apnea is enlarged tonsils and adenoids in the upper airway. Infections may cause these glands to enlarge. Large adenoids may completely block the nasal passages and make breathing through the nose difficult or impossible. There are many muscles in the head and neck that help to keep the airway open. When a person (child or adult) falls asleep, muscle tone tends to decrease, thus, allowing tissues to fold closer together. If the airway is partially closed (by enlarged glands) while awake, falling asleep may result in a completely closed passage. Obesity may cause obstructive sleep apnea. While a common cause in adults, obesity is a far less common reason for obstructive sleep apnea in children. A rare cause of obstructive sleep apnea in children is a tumor or growth in the airway.

What are the symptoms of obstructive sleep apnea?
The following are the most common symptoms of obstructive sleep apnea. However, each child may experience symptoms differently. Symptoms may include:

loud snoring or noisy breathing during sleep
periods of not breathing - although the chest wall is moving, no air or oxygen is moving through the nose and mouth into the lungs. The duration of these periods is variable and measured in seconds.
mouth breathing - the passage to the nose may be completely blocked by enlarged tonsils and adenoids.
restlessness during sleep (with or without periods of being awake)
excessive daytime sleepiness or irritability (because the quality of sleep is poor, the child may be sleepy or irritable in the daytime)
hyperactivity during the day
The symptoms of obstructive sleep apnea may resemble other conditions or medical problems. Always consult your child's physician for a diagnosis.

How is obstructive sleep apnea diagnosed?
Your child’s physician should be consulted if noisy breathing during sleep or snoring becomes noticeable. Your child may be referred to an ear, nose, and throat ( ENT) physician (otolaryngologist) for further evaluation.In addition to a complete medical history and physical examination, diagnostic procedures for obstructive sleep apnea may include:

sleep history - report from parents or caretaker
evaluation of the upper airway
Sleep study

The sleep study (also called polysomnography) - the best test available for diagnosing obstructive sleep apnea. The test requires a high level of collaboration on the part of the child and may not be possible in younger and/or uncooperative children. Two types of tests are available. In the first type, the child will sleep in a specialized sleep laboratory. In the second type, the child has on similar monitors but sleeps in his/her own bed.

During the sleep study a variety of testing occurs to evaluate the following:

brain activity
electrical activity of the heart
oxygen content in the blood
chest and abdominal wall movement
muscle activity
amount of air flowing through the nose and mouth

During the sleep study, episodes of apnea and hypopnea will be recorded:

apnea - complete airway obstruction.
hypopnea - the partial airway obstruction combined with a significant decrease in the oxygen content of the blood.
Based on the laboratory test, sleep apnea is generally considered significant in children if more than 10 apnea episodes occur per night, or one or more occur per hour. Some experts define the problem as significant if a combination of one or more episodes of apnea and/or hypopnea occur per hour of sleep.
Symptoms of obstructive sleep apnea may resemble other conditions or medical problems. Consult your child’s physician for more information.

Treatment for obstructive sleep apnea:
Specific treatment for obstructive sleep apnea will be determined by your child’s physician based on:

our child’s age, overall health, and medical history
cause of the condition
your child’s tolerance for specific medications, procedures, or therapies
expectations for the course of the condition
your opinion or preference

The treatment for obstructive sleep apnea is based on the cause. Since enlarged tonsils and adenoids are the most common cause of airway blockage in children, the treatment is surgery and removal of the tonsils (tonsillectomy) and/or adenoids (adenoidectomy). Your child's otolaryngologist will discuss the treatment options, risks, and benefits with you. This surgery requires general anesthesia. Depending on the health of the child, surgery may be performed on an outpatient basis. If the cause of the disorder is obesity, less invasive treatments may be appropriate, including weight loss and wearing a special mask while sleeping to keep the airway open. This mask delivers continuous positive airway pressure (CPAP). The device itself is often clumsy, and it may be difficult to convince a child to wear such a mask. Surgery may be necessary.

What happens during tonsillectomy and adenoidectomy?
Tonsillectomy and adenoidectomy (T&A) surgery is the most common major surgery performed on children in the US. About 400,000 surgeries are performed each year. The need for a T&A will be determined by your child's ear, nose, and throat surgeon and discussed with you. Most T & A surgeries are done on an outpatient basis. This means that your child will have surgery and then go home the same day.

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Tonsillectomy and Adenoidectomy

What are the tonsils?
The tonsils are small, round pieces of tissue that are located in the back of the mouth on the side of the throat. Tonsils are thought to help fight infections by producing antibodies. The tonsils can usually be seen in the throat of your child by using a light. Tonsillitis occurs when the tonsils become inflamed from infection.

What are adenoids?
Adenoids are similar to the tonsils. The adenoids are made up of lymph tissue and are located in the space above the soft roof of the mouth (nasopharynx) and cannot be seen by looking in your child’s nose or throat. Adenoids also help to fight infections. Adenoids may cause problems if they become enlarged or infected. Adenoiditis is when the adenoids become inflamed from infection.

What are the symptoms of tonsillitis?
The symptoms of tonsillitis vary greatly depending on the cause of the infection, and can occur either suddenly or gradually. The following are the most common symptoms of tonsillitis. However, each child may experience symptoms differently. Symptoms may include:

sore throat
fever (either low-grade or high-grade)
headache
decrease in appetite
not feeling well
nausea and vomiting
stomach aches
painful swallowing
visual redness or drainage in the throat
The symptoms of tonsillitis may resemble other conditions or medical problems. Always consult your child’s physician for a diagnosis.

What are the symptoms of adenoiditis, or enlarged adenoids?
The symptoms of adenoiditis vary greatly depending on the cause of the infection, and can occur either suddenly or gradually. The following are the most common symptoms of adenoiditis. However, each child may experience symptoms differently. Symptoms may include:

breathing through the mouth
noisy breathing
snoring
nasal speech
periods at night when breathing stops for a few seconds
The symptoms of adenoiditis may resemble other conditions or medical problems. Always consult your child’s physician for a diagnosis.

Treatment for tonsillitis and adenoiditis:
Specific treatment for tonsillitis and adenoiditis will be determined by your child’s physician based on:

your child’s age, overall health, and medical history
the extent of the infection
the type of infection
your child’s tolerance for specific medications, procedures, or therapies
expectations for the course of the infection
your opinion or preference

Your child’s physician will decide the best treatment for your child. Treatment depends on the cause of the infection, the severity of the infection, and the number of times the child has developed infections. Your child's physician may order antibiotics to help with the infection. Some children may be referred to an ear, nose, and throat surgeon to have the tonsils and adenoids removed. This surgery is called a tonsillectomy and adenoidectomy (T&A). Often, the tonsils and adenoids are removed at the same time, but, sometimes, only one is removed. Your child's physician will discuss this with you.

What are the reasons to have a tonsillectomy and adenoidectomy (T&A)?

The following are some of the more widely accepted reasons for having a T&A:

sleep apnea, or periods at night when your child stops breathing
trouble swallowing
tumor in the throat or nasal passage
bleeding from the tonsils that cannot be stopped
significant blockage of the nasal passage and uncomfortable breathing

The following are T&A Guidelines from the American Academy of Otolaryngology:

seven sore throats in one year
five sore throats in each of two years
three sore throats in each of three years
The sore throats may be associated with the following:
fever above 101o F
discharge on the tonsils
positive strep throat culture

The following are additional reasons that are more controversial regarding the removal of the adenoids and tonsils:

bad snoring
recurrent infections or abscesses in the throat
recurrent ear infections
hearing loss
chronic sinusitis, or infection in the sinuses
constant mouth breathing
frequent colds
cough
bad breath

The following are some situations that DO NOT require removal of the tonsils, although each child will be evaluated on an individual basis:

large tonsils . Some children have large tonsils. The tonsils will decrease in size after the ages of 8 to 12 years. This, in itself, is not a reason to remove the tonsils, in most cases.
school absence If your child seems to miss a lot of school due to different symptoms, such as a sore throat, removing the tonsils will not increase school attendance.
poor appetite, allergies, or seizures A T&A will not help any of these problems.

What happens during tonsillectomy and adenoidectomy?
The need for a tonsillectomy and adenoidectomy (T&A) surgery will be determined by your child's ear, nose, and throat surgeon and discussed with you. Most T & A surgeries are done on an outpatient basis. This means that your child will have surgery and then go home the same day. Some children may be required to stay overnight, such as, but not limited to, children who:

are not drinking well after surgery.
have other chronic diseases or problems with seizures.
have complications after surgery, such as bleeding.
are younger than 3 years of age.

Before the surgery, you will meet with different members of the healthcare team who are going to be involved with your child’s care. These may include:

perioperative nurses - nurses who prepares your child for surgery. Operating room nurses assist the physicians during surgery. Recovery room (also called the Post Anesthesia Care Unit) nurses care for your child as she emerges from general anesthesia.
surgeon - a physician who specializes in surgery of the ear, nose, and throat.
anesthesiologist - a physician with specialized training in anesthesia. She will complete a medical history and physical examination and formulate a plan of anesthesia for your child. The plan will be discussed with you and your questions will be answered. This surgery requires a general anesthesia.

During the surgery, your child will be anesthetized in the operating room. The surgeon will remove your child’s tonsils and adenoids through the mouth. There will be no cut on the skin. In most cases, after the surgery your child will go to a recovery room where she can be monitored closely. Parents may come into the recovery room as soon as the child is stable. After a short stay in the recovery room, usually six hours, you and your child will be able to go home. If your child is going to stay the night in the hospital, the child will be brought from the recovery room to her room. Bleeding is a complication of this surgery and should be addressed immediately by the surgeon. If the bleeding is severe, the child may return to the operating room.

At home after a T&A:
The following are some of the instructions that may be given to you to help care for your child:

increased fluid intake
pain medication, as prescribed
no heavy or rough play for a duration of time recommended by the surgeon

What are the risks of having a T&A?
Any type of surgery poses a risk to a child. About 5 percent of the children begin bleeding from the surgery site about five to eight days after the surgery, and may require additional blood and/or surgery. Some children may have a change in the sound of their speech due to the surgery. The following are some of the other complications that may occur:

bleeding (may happen during surgery, immediately after surgery, or at home)
dehydration (due to decreased fluid intake; if severe, fluids through an intravenous, or IV, catheter in the hospital may be necessary)
fever
difficulty breathing (swelling of the area around the surgery; may be life threatening if not treated immediately)

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Stridor

What is stridor?
Stridor is a high-pitched sound that is usually heard best when a child breaths in (inspiration). It is usually caused by an obstruction or narrowing in your child’s upper airway. The upper airway consists of the following structures in the upper respiratory system:

nose
nasal cavity
ethmoidal air cells - a cavity located near the eyes and the back of the nose.
sinuses - cavities, or air-filled pockets, that are near the nasal passage.
ethmoid sinus - located inside the face, around the area of the bridge of the nose. This sinus is present at birth, and continues to grow.
maxillary sinus - located inside the face, around the area of the cheeks. This sinus is also present at birth, and continues to grow.
frontal sinus - located inside the face, in the area of the forehead. This sinus does not develop until around 7 years of age.
sphenoid sinus - located deep in the face, behind the nose. This sinus does not develop until adolescence.
larynx - also known as the voice box, the larynx is a cylindrical grouping of cartilage, muscles, and soft tissue which contains the vocal cords. The vocal cords are the upper opening into the windpipe (trachea), the passageway to the lungs.
trachea (windpipe) - a tube that reaches from the voice box to the bronchi in the lungs.

The sound of stridor depends on location of the obstruction in the upper respiratory tract. Sometimes, the stridor is heard when the child breathes in (inspiration) and can also be heard when the child breathes out (expiration).

What are the causes of stridor?
There are many different causes of stridor. Some of the causes are diseases, while others are problems with the anatomical structure of the child’s airway. The upper airway in children is shorter and narrower than that of an adult, and, therefore, more likely to lead to problems with obstruction.

The following are some of the more common causes of stridor in children:

Congenital causes (problems present at birth):

laryngomalacia Parts of the larynx are floppy and collapse causing partial airway obstruction. The child will usually outgrow this condition by the time he/she is 18 months old. Some children may need surgery.
subglottic stenosis The larynx (voice box) may become too narrow in a certain spot called the cricoid cartilage. Children with subglottic stenosis are usually not diagnosed at birth, but, more often, a few months after, particularly if the child’s airway becomes stressed by a cold or other virus. The child may eventually outgrow this problem without intervention. Most children will need a surgical procedure if the obstruction is severe.
subglottic hemangioma A type of mass that consists mostly of blood vessels. Subglottic hemangioma grows quickly in the child’s first few months of life. The child will usually shows signs around the age of 3 to 6 months. Some children may outgrow this problem, as the hemangioma will begin to get smaller after the first year of life. Most children will need surgery if the obstruction is severe.
vascular rings The trachea, or windpipe, may be completely enclosed by another structure (an artery or vein) around the outside. Surgery may be required to alleviate this condition.

Infectious causes:

croup Croup is an infection caused by a virus that leads to swelling in the airways and causes breathing problems. Croup is caused by a variety of different viruses, most commonly the parainfluenza virus.
epiglottitis Epiglottitis is an acute life-threatening bacterial infection that results in swelling and inflammation of the epiglottis. (The epiglottis is an elastic cartilage structure at the root of the tongue that prevents food from entering the windpipe when swallowing.) This causes breathing problems that can progressively worsen which may, ultimately, lead to airway obstruction. There is so much swelling that air cannot get in or out of the lungs, resulting in a medical emergency. Epiglottitis is usually caused by the bacteria Haemophilus influenzae, and now is rare because children are routinely vaccinated against this bacteria.
bronchitis Bronchitis is an inflammation of the breathing tubes (airways), called bronchi, which causes increased production of mucus and other changes. Acute bronchitis is usually caused by infectious agents such as bacteria or viruses. It may also be caused by physical or chemical agents dusts, allergens, strong fumes and those from chemical cleaning compounds, or tobacco smoke.
severe tonsillitis The tonsils are small, round pieces of tissue that are located in the back of the mouth on the side of the throat. Tonsils are thought to help fight infections by producing antibodies. The tonsils can usually be seen in the throat of your child by using a light. Tonsillitis is defined as inflammation of the tonsils from infection.
abscess in the throat An abscess in the throat is a collection of cells surrounded by inflamed tissue. If the abscess is large enough, it may narrow the airway to a critically small opening.

Traumatic causes

Foreign bodies in the ear, nose, and breathing tract may cause symptoms to occur. Foreign bodies are any objects placed in the ear, nose, or mouth that do not belong there. For example, a coin in the trachea (windpipe) may close off breathing passages and result in suffocation and death.
fractures in the neck
swallowing a harmful substance which may cause damage to the airways

How is stridor diagnosed?
Stridor is usually diagnosed solely on the medical history and physical examination of your child. It is important to remember that stridor is a symptom of some underlying problem or condition. If your child has stridor, your child's physician may order some of the following tests to help determine the cause of the stridor:

chest x-rays - a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.
blood tests
pulse oximetry - an oximeter is a small machine that measures the amount of oxygen in the blood. To obtain this measurement, a small sensor (like a Band-Aid) is taped onto a finger or toe. When the machine is on, a small red light can be seen in the sensor. The sensor is painless and the red light does not get hot.
sputum culture - a diagnostic test performed on the material that is coughed up from the lungs and into the mouth. A sputum culture is often performed to determine if an infection is present.

Treatment of stridor:
Specific treatment of stridor will be determined by your child's physician based on:

your child's age, overall health, and medical history
cause of the condition
extent of the condition
your child's tolerance for specific medications, procedures, or therapies
expectations for the course of the condition
your opinion or preference

Treatment may include:

referral to an ear, nose, and throat specialist (otolaryngologist) for further evaluation (if your child has a history of stridor)
surgery
medications by mouth or injection (to help decrease the swelling in the airways)
Hospitalization and emergency surgery may be necessary depending on the severity of the stridor.

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Laryngomalacia / Congenital Laryngeal Stridor

What is congenital laryngeal stridor?
Congenital laryngeal stridor (also called laryngomalacia) results from a congenital (present at birth) anomaly of the larynx (voice box). A weakness in the structures in the larynx, can cause stridor. Stridor is a high-pitched sound that is heard best when the child breaths in (inspiration).

What causes congenital laryngeal stridor?
Congenital laryngeal stridor is a defect that is present at birth. During fetal development, the structures in the larynx may not fully develop. As a result, there is a weakness in these structures at birth, causing them to collapse during breathing. In children, congenital laryngeal stridor is the most common cause of chronic stridor. Sixty percent of infants born with congenital laryngeal stridor will have symptoms in the first week of life. Most other infants will show symptoms by 5 weeks old.

What are the symptoms of congenital laryngeal stridor?
The major symptom of this disorder is the stridor that is heard as the infant breathes. The stridor is usually heard when the infant breathes in (inspiration), but can also be heard when the infant breaths out (expiration). Other characteristics of the stridor may include:

The stridor changes with activity.
The stridor is usually less noisy when the child is laying on his/her stomach.
The stridor gets worse if the infant has an upper respiratory infection.

The symptoms of congenital laryngeal stridor may resemble other conditions or medical problems. Always consult your child's physician for a diagnosis.

How is congenital laryngeal stridor diagnosed?
In addition to a complete medical history and physical examination, diagnostic procedures for congenital laryngeal stridor may include a bronchoscopy of the airways - a procedure which involves a tube being passed into the airways to allow your child's physician to observe the airways during breathing.

Treatment for congenital laryngeal stridor:
In most cases, congenital laryngeal stridor is a harmless condition that resolves on its own, without medical intervention. The condition usually improves by the time the infant is 18 months old and has no long-term complications. In some cases, the stridor is apparent until about the age of 5. Each child's case is unique. About 10 to 22 percent develop severe respiratory problems which require medical and surgical interventions.

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Nosebleeds

Nosebleeds can be a scary occurrence, but are usually not dangerous. The medical term for nosebleed is epistaxis. They are fairly common in children, especially in dry climates or during the winter months when dry heat inside homes and buildings can cause drying, cracking, or crusting inside the nose. Many times, children outgrow the tendency for nosebleeds during their teenage years.The front part of the nose contains many fragile blood vessels that can be damaged easily. Most nosebleeds in children occur in the front part of the nose close to the nostrils.

What causes a nosebleed?
Nosebleeds are caused by many factors, but some of the most common causes include the following:

picking the nose
blowing the nose too hard
injury to the nose
over-dry air
colds and allergies
foreign body in the nose
Many times no apparent cause for a nosebleed can be found.

First-aid for nosebleeds:

Calm your child and let him/her know you can help.
Pinch the nostrils together for five to ten minutes without checking to see if bleeding has stopped.
Have your child sit up and lean forward to avoid swallowing blood.
Apply ice or a cold water compress to the bridge of the nose.
If bleeding does not stop, try the above steps one more time.
Do not pack your child’s nose with tissues or gauze.

When should I call my child’s physician?
Specific treatment for nosebleeds, that require more than minor treatment at home, will be determined by your child’s physician. In general, call your child’s physician for nosebleeds if:

you are unable to stop the nosebleed or if it recurs.
your child also has a nose injury that may indicate a more serious problem (such as a fractured nose or other trauma to the head).
there is a large amount or rapid loss of blood.
your child feels faint, weak, ill, or has trouble breathing.
your child has bleeding from other parts of the body (such as in the stool, urine, or gums) or bruises easily.
there is a foreign body stuck in your child’s nose.

Prevention of nosebleeds:

If your child has frequent nosebleeds, some general guidelines to help prevent nosebleeds from occurring include the following:
Use a cool mist humidifier in your child’s room at night if the air in your home is dry. Be sure to follow the manufacturer’s advice for cleaning the humidifier so that germs and mold do not grow in it.
Teach your child not to pick his/her nose or blow it too forcefully.
Apply petroleum jelly inside the nostrils several times a day, especially at bedtime, to help keep the area moist.
Use saline (salt water) drops or a saline nose spray, as directed by your child’s physician.
See your child’s physician for treatment of allergies that may contribute to frequent nosebleeds.

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EXCELLENCE. INTEGRITY. SERVICE. TEAMWORK. The academic advantage for patient-centered quality health care.

Pediatric ENT

Otitis Media (Middle Ear Infection)

Mastoiditis

Ear Tubes

Swimmer’s ear

Hearing Loss

Sinusitis

Sinus Surgery

Sore Throats

Obstructive Sleep Apnea

Tonsillectomy and Adenoidectomy

Stridor

Laryngomalacia / Congenital Laryngeal Stridor

Nosebleeds

EXCELLENCE. INTEGRITY. SERVICE. TEAMWORK.
The academic advantage for patient-centered quality health care.