Mr. Prince Modayil

Glue ear is associated with thick glue like fluid accumulating in the middle ear. This is very common in children. This is due to non-functioning of the eustachian tube which helps to maintain the middle ear pressure and is usually seen in children (also in adults) who get cold very often and also has large adenoids. Treatment is normally only recommended when symptoms last longer than three months and the hearing loss is found to be significant enough to interfere with a child's speech and language development or causes behavioural problems.

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Presentation:

• Deafness (children raising volume of TV, ignoring commands)
• Speech delay
• Behavioural issues because they can't hear what others are talking, lack of concentration, being less interactive, not interested in going to school.
• Constantly rubbing ears
• Unsteadiness

Investigation:

• Hearing assessment (Audiometry)
• Tympanometry

Treatment:

• If deafness persists after 3 months - Grommet insertion (NICE guidelines)
• Informing school to seat them appropriately
• Speech therapy
• Hearing aids (temporary) if surgery is not an option

Outcome:

• Majority of children grow out of it. Some children tend to have more than one set of grommets (3 out of 10).

It is normal to have 3-4 ear infections in a year for a child.If more than this occurs or the ear infections are causing a lot of pain, discharge,school absence or hearing problems, then the child needs intervention. About four out of five cases of otitis media will pass within two to three days without the need for treatment. Antibiotics can be used if symptoms are particularly severe.

Investigation:

• Otoscopy
• Hearing test,Tympanometry
• Blood tests to check immunity

Treatment:

• Medical: Long term of low dose antibiotic
• Surgical: Grommet insertion +- adenoidectomy. This doesn't reduce the number of infections, but it helps the child to get over the infection early and without discomfort

Presentation:

• Sticky smelly discharge from ears (clear, yellow, green, sometimes blood stained)
• Deafness
• Unsteadiness

Causes:

• Hole in the ear drum (Ear drum perforation)
• Inward growth of skin covering ear drum into the middle ear or presence of skin in the middle ear by birth (Congenital & Acquired Cholesteatoma)
• Ear polyps
• Otitis Externa (wax impactions, eczema of ear canal skin)

Investigation:

• Microsuction of ears under microscope
• Ear swab C&S
• Hearing assessment
• CT scans if indicated

Treatment:

• Antibiotic steroid ear drops
• Swimming ear moulds
• Surgery to close ear drum perforation (Myringoplasty) or removal of cholesteatoma (Mastoidectomy operation)
• Hearing reconstruction (Ossiculoplasty)

Outcome:

• Chronic discharging ears can cause deafness due to damage to middle ear bones (Malleus, Incus, Stapes)
• Infection spreading to inner ear (Labyrinthitis) causing nerve deafness and dizziness
• Cholesteatoma causing infection and abscess of brain (meningitis, temporal lobe abscess)

Snoring is a common phenomenon in both children and adults. It is due to breathing through a slightly narrow upper airway. Snoring alone is not an issue in children. But if it is associated with increased work of breathing, disturbed sleep (sweating, waking up) pauses in breathing (sleep apnoeas) it needs medical attention. If not treated it results in poor performance at school, work place, behavioural issues in children, increases risk of heart disease and stroke.

Investigation:

• Sleep study
• ECHO (heart scan if indicated)

Treatment:

• Adenotonsillectomy (commonly performed in children)
• Coblation Tonsillotomy (Tonsil reduction surgery)
• Medical - Weight loss, jaw splints, CPAP
• UPPP (Adults)

Stridor is a type of noisy breathing. The commonest cause of stridor in children is a condition called laryngomalacia (floppy voice box- self resolving before 2 years of age). This type of noisy breathing is more evident during feeding, crying or whenever the child is excited. In 20% of cases there could be other lesions in the airway associated with laryngomalacia and hence it is important to confirm the diagnosis by performing a flexible laryngoscopy in the clinic.

Tonsillitis is associated with sore throat, fever and painful swallow. Mostly it is due to viral infection and hence doesn't require antibiotics. Tonsillectomy is the treatment of choice if a person gets recurrent tonsillitis (refer SIGN guidelines)

Significant tongue ties can cause difficulty in feeding and speech. Release of tongue tie is performed in clinic or theatre depending on the age of the baby. The procedure involves snipping the tongue tie with scissors which is painless and causes very little bleeding. The baby is breast fed after the procedure and the effect is usually noticed immediately. No antibiotics are needed. The snipped area will turn into a whitish spot after one week and heals very well in a few days.

In adults, the above symptoms if persisting for more than 2 weeks, needs an ENT consultation. This involves a fibre optic examination of the throat to rule out any sinister causes. The latter is more in smokers and in people who drink more than recommended amounts of alcohol.

These conditions are usually related to disorders of inner ear or brain. The investigations include hearing tests, balance tests and in some cases MRI scan. The treatment includes medications (in case of meniers's disease, migraine related) , Epley's manoeuvre (BPPV), balance exercises, tinnitus rehabilitation.

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In children, nasal obstruction is usually due to enlarged adenoids, nasal allergy and sometimes due to congenital conditions like choanal atresia, other developmental abnormalities and tumours. In adults it is usually due to deformities of nasal septum, nasal polyps, tumours etc.

Investigations include flexible nasal endoscopy, allergy test and sometimes CT/MRI scans.

Treatment includes medical (treatment of allergy) and surgery (adenoidectomy, functional endoscopic sinus surgery (FESS) for sinusitis, septoplasty, polypectomy etc).

In children it could be due to enlarged lymph nodes, developmental abnormalities (thyroglossal cyst, branchial cysts, branchial sinus & fistulae) and rarely cancers (lymphomas, sarcomas).

In adults, if a neck lump persists for more than 2 weeks, it warrants referral to ENT surgeon.

Investigations include a thorough Ear, nose, throat examination, endoscopic examination of throat and voice box, fine needle aspiration cytology of the lump (FNAC), Ultrasound/CT/MRI scans, open biopsy.

The causes are vocal cord nodule, vocal cord cysts,Papillomas (warts), Vocal cord weakness, Muscle tension dysphonia and cancers (adults)

Investigation includes endoscopic examination of voice box,videostroboscopy (to assess voice characteristics), chest Xray.

Treatment for voice disorders include speech therapy, Microlaryngoscopy procedures, Vocal cord injections etc.

This is very common in children and is usually due to enlarged blood vessels on the nasal septum. This can be cauterised in the clinic. Other causes in children include bleeding disorders (ruled out by blood tests) and angiofibromas. In adults, nose bleeds are seen in people taking blood thinners. It can also be produced by tumours, nasopharyngeal cancers, infected polyps etc.