Category: Children’s ENT

Snoring and OSA

Snoring occurs when air flowing through the narrow throat passage makes the tissues vibrate and the breathing becomes audible. Sometimes it can be very loud.

Simple snoring is common amongst both children and adults, but it is important to recognise that it can sometimes be harmful. Particularly if sleeping is very restless and disturbed, or more severe when there are some pauses in breathing with the gasping restarts of breathing after an apnoea.

If your child suffers from OSA they may not be having any restful sleep and this can have a negative effect on growth and development in general, their energy levels, their concentration and their ability to learn. A poor nights sleep can make anyone grumpy and irritable in the morning.

What can be done about Obstructive sleep anoea?

There is a large body of evidence that supports removing obstructive tissue from the throat (tonsils) and the back of the nose (adenoids) in children with obstructive sleep apnoea. Of course, not all children who snore require surgery and it is important that parents observe their children closely (and even make video recordings) before making an appointment to see a surgeon.

With a thorough history and comprehensive examination, Dr Phillips can assess the presence and severity of snoring or OSA, and discuss treatment options. Then he will discuss and make a treatment plan. If this involves any surgical procedures this will be fully discussed including the benefits and the risks to the parents so they can make an informed decision.

Sleep studies will occasionally be used to assess the severity of obstructive sleep apnoea, though this investigation is usually reserved for children with more complex medical issues.

Adenoids

These are lymphoid tissue at the back of the nose and are usually present between early childhood and adolescence. They are probably a useful part of the immune system in early infancy but there is no evidence they possess any useful immunological role beyond that time.

If they become too large or infected, adenoids can be quite a burden – leading to nasal obstruction, nasal discharge and snoring. Infected adenoids are a common cause of recurrent childhood sinusitis and post-nasal drip. Longstanding nasal obstruction due to enlarge adenoids can also effect growth of the upper teeth and lead to orthodontic issues.

Adenoidectomy

This may be done on its own, or combined with tonsillectomy, grommets or other nasal surgery. If the enlarged adenoids block the openings to the drainage tubes from the ears (Eustachian tubes), ear infections and hearing loss can sometimes happen (see grommets above). Adenoidectomy is performed with a curved surgical instrument (through the mouth) or with a precision coblation device. Recovery is usually a day or two and the procedure is usually done as a day procedure.

Tonsillectomy

This common operation is performed for kids or adults who suffer many bouts of tonsillitis or in those where the tonsils get so large they block the throat and cause difficulty with eating, breathing and sleeping. Tonsillectomy used to be done very routinely but we are more selective nowadays, and take many different factors in the history and examination into account before recommending surgery. Most tonsillectomies are done because of OSA in children aged 3-7, and in young adults aged 16-20, because of  recurrent tonsillitis. Occasionally people outside these age groups may also need tonsillectomy surgery. The surgery is done using very precise coblation instrumentation to perform the most modern technique of intracapsular coblation tonsillectomy. This is a very safe proceedure and research papers conclude there is a better and faster recovery with less complications. Blood loss is usually less than a routine blood test. Local anaesthetic put in during surgery makes the initial recovery very easy. Dr Phillips has  been using coblation techniques of tonsillectomy for 17 years now is performed well over 4,000 tonsillectomies.

Most kids under 4 years old and adults stay overnight after surgery but most children over 5 years old do very well going home on the same day as the operation. Prior to planning any surgery the risks and the expected course of recovery will be explained to the patient and/or their parents.

What is tonsillitis?

Tonsillitis is an infection affecting the tonsils, which are located on either side of the throat. This condition can be caused by either bacteria or viruses.

What are the symptoms of tonsillitis?

Tonsillitis commonly causes a sore throat on both sides and a general feeling of being unwell. Other symptoms can include bad breath and tenderness or swelling of the lymph nodes in the neck. Symptoms can usually last for up to a week.

What is the treatment of tonsillitis?

During an episode of tonsillitis, it is important to manage your child’s discomfort with appropriate pain relief and maintain good fluid intake. Antibiotics may be prescribed if a bacterial infection is suspected or if symptoms are not improving.

When are tonsils removed for tonsillitis?

Tonsil removal (tonsillectomy) may be considered when infections occur frequently or cause significant problems. 

The usual criteria include:

• 7 episodes of tonsillitis within one year
• 5 episodes per year over two consecutive years
• 3 episodes per year over three consecutive years
• 2 episodes of quinsy (a type of tonsil abscess)

Obstructive sleep apnoea [OSA]

Obstructive sleep apnoea (OSA) in children is often first noticed by parents who observe pauses in their child’s breathing during sleep. These pauses are typically followed by a gasp or snort as breathing resumes. 

OSA can be classified as mild, moderate, or severe. Regardless of how severe it is, treatment is generally recommended, as the condition suggests that a child may not be getting enough oxygen Nore a very restful nights sleeping.

Bringing a video of the child sleeping can be helpful during assessment. Treatment varies from child to child, but an adenotonsillectomy (removal of the adenoids and tonsils) is recommended in many cases.

Snoring

Regular disturbed snoring in children, especially every night, is not considered normal. 

The more restless the sleeping pattern is the more abnormal it is and should be evaluated. Occasional snoring, such as during a cold, is common and usually not a concern; however, consistent nightly snoring may indicate disrupted breathing during sleep and reduced oxygen levels.

Providing a video of your child’s snoring can assist with assessment and diagnosis.

Tonsillitis

Tonsillitis can lead to repeated illness, discomfort and reduced appetite. It may also result in frequent school absences. When episodes become frequent or significantly impact daily life, removal of the tonsils (tonsillectomy) may be considered as an option.

General if there are more than 4-5 episodes of tonsillitis in a year evaluation by an ENT surgeon should be considered.

Acute otitis media [Middle ear infections]

Acute otitis media (AOM) is an infection of the middle ear, with pain usually as the main symptom. Children may become unsettled, have difficulty sleeping and appear more irritable. It is also common for children to pull or tug at their ears during these episodes. Hearing may also be temporarily reduced.

If these infections occur repeatedly, insertion of grommets may be considered.

Otitis media with effusion [Glue ear]

Otitis media with effusion (OME), often referred to as “glue ear,” is a condition where fluid remains in the middle ear for an extended period. It is usually noticed when hearing difficulties become apparent.

If the fluid does not clear with medical treatment, grommet insertion may be recommended.

Nasal obstruction

Nasal blockage in children can appear in different ways. Symptoms may range from a constantly runny nose to disturbed sleep. The underlying cause can vary depending on your child’s age and specific symptoms.

Hearing loss

Hearing loss in children can have a range of causes. Early management focuses on identifying the reason for the hearing loss while also ensuring that speech and language development continue to progress normally.

About the procedure

Grommets are small ventilation tubes placed into the tympanic membrane (ear drum) to allow air to flow into the middle ear and help middle ear fluid or glue ear dissipate. 

They are commonly recommended in the following situations:

• Recurrent acute otitis media (middle ear infections), such as more than 4 episodes in a year or 3 within 6 months
• Otitis media with effusion with poor hearing (fluid behind the ear drum) affecting both ears for three months, or one ear for six months
• Delayed speech development because of persistent middle ear effusions
• There are also some rare indications such as severe tympanic membrane retractions from severe eustachian tube dysfunction or needing to provide pressure relief for hyperbaric chamber treatments.

After grommet insertion, it is common for children to show a noticeable improvement in how they respond to sounds. Speech clarity may also improve as hearing becomes clearer.

Grommet insertion is considered a safe and routine procedure. In children, it is performed under general anaesthetic, and discharge home is usually possible about one hour after surgery. In adults, grommets are much more rarely required and are also  often inserted in the operating theatre, although sometimes under local anaesthesia.

Grommets are designed to remain in place for around 9–24 months. They usually fall out naturally on their own, often without being noticed. The small opening in the ear drum typically heals by itself once the grommet has come out.

Surveillance checks will usually be recommended on a 6 monthly basis until the grommets naturally extrude on their own. At least 2 in 3 children who need grommets never need another set inserted.

An appointment can be made with Dr Phillips for further discussion about grommet insertion.

Grommets post-operative instructions

What to expect

Immediately post op:

Your child may experience some brief discomfort after the procedure. This is generally short-lived and often related to the effects of the anaesthetic. Discharge home usually occurs about one hour after surgery.

Day 1 – 7:

You will not usually notice any discharge. Occasionally a small amount of discharge from your child’s ear, which may include blood or pus can occur during the first few days and part of the normal healing process. Ear drops are sometimes recommended and should be used if they have been prescribed in your post op orders. If your child is in pain, paracetamol (Panadol) or ibuprofen (Nurofen) is usually sufficient. Showering is permitted, but swimming should be avoided during this time until after the first post operative visit which is usually at 2-3 weeks after the procedure.

After day 7:  

Return to Swimming is usually restricted until after the first post operative visit and then can resume often without the need for any er plugs in most cases.

It is recommended to avoid submerging the head under soapy water in the bath, and also in dirty water like dams or low flowing rivers.

If you noticed discharge from your child’s ears, this is often associated with a cold or other upper respiratory infection. If discharge continues for more than 24 hours, antibiotic ear drops (such as Ciloxan 3 drops twice per day)) may be required and can be prescribed by a GP or by your Ent surgeon.

If discharge persists for longer than one week following treatment, it is important to contact the clinic, as review by your child’s surgeon may be needed. In some cases, gentle suctioning of the ears may be required or arranging to send a swab of the discharge to a lab for microscopy and culture.

Frequently asked questions