Children’s ENT

Rhinitis (Sensitive nose)

What is Rhinitis (Sensitive nose)?

Frequent clear runny nose, blocked nose, sneezing and itchy eyes? Chances are your child is likely suffering from Rhinitis (sensitive nose) Rhinitis is inflammation of the nasal cavity. Majority of the time, Rhinitis is allergic when it is triggered by exposure to a substance known as allergen (most commonly House Dust Mites). Sometimes, Rhinitis is non-allergic and can be triggered by cigarette smoke, temperature changes, strong odors, hormonal changes and dietary factors.

 

Rhinitis is diagnosed based on a combination of clinical history, physical examination and occasionally in children, a flexbile nasoendoscopy. In some children, a skin prick test or blood tests may be performed to better understand the reason for the sensitive nose.

 

Majority of the time, Rhinitis can be treated medically with a combination of allergen or “trigger avoidance” (if possible), nasal steroid sprays (Figure 1) and antihistamines. In suitable children with Allergic Rhinitis, immunotherapy (often called “Allergy Shots”) to desensitize the patient to the allergen may be indicated. If your child continues to suffer from persistent or troublesome blocked nose despite maximal medical treatment, procedures to reduce the size of the inferior turbinate may be indicated (see section on “Inferior Turbinate Hypertrophy”)

Impacted earwax

What is an Impacted earwax?

Earwax in small amounts is good for the ear. It protects the ear by gathering dead skin, hair and dirt as it moves from the inside of the ear outwards. Hence it is a natural cleanser for the ear. It also has antibacterial and antifungal properties. Earwax will move out of the ear on its own as we chew or talk. The jaw is located below the ear canal and movement of the jaw will help move the wax outwards.

 

However, sometimes, earwax can block up the ear canal. Earwax buildup (Figure 1a-d) that fails to clear on its own is usually due to these reasons:

  1. Ear digging with a cotton bud or an ear pick
  2. Excessive earwax production
  3. Dry skin in the ear canal
  4. Small ear canal
  5. Frequent wearing of hearing aid or ear plugs

 

Many people have the habit of cleaning the ear canal with a cotton bud. This should not be done. The cotton bud is designed to clean or dry up fluid outside the ear canal (Figure 2a). It is not meant to be inserted into the ear canal (Figure 2b). The cotton bud is too big for the ear canal and insertion into the ear canal will only push the earwax and debris deeper against the ear drum. When this happen, the earwax will be jam-packed against the ear drum (Figure 3a) and the self-cleansing mechanism of the ear will fail. In some cases, patients may scratch the lining of the ear canal resulting in an ear infection, puncture the ear drum (Figure 3b) or even have the tip of the cotton bud stuck in the ear canal.

Cotton Bud

 

Ear Wax Removal

 

Earwax, or cerumen, is a mixture of fatty secretions from a number of glands in the walls of your ear canal. They combine with other debris such as dead skin and hair, and will generally remove themselves from our ear canal when there is a movement of our jaws during chewing or talking. Earwax lowers the risk of ear infections and prevents discomfort in your ear canal. However, there are times where your body may overproduce earwax and cause it to block the ear canal, requiring professional earwax removal. Earwax that picks up a lot of debris, sits in the ear canal for too long, or is pushed inwards by foreign objects such as earbuds, are also likely to cause a blockage.

 

If you or your child is suffering from an impacted earwax, you can either seek medical help for earwax removal, or do it yourself. Some symptoms of earwax blockage can include hearing loss, pain in the ear, tinnitus, dizziness, cough, or a feeling of fullness in the ear. Without earwax removal, infection can occur and result in serious symptoms such as drainage from the ear canal, itching, odour, and/or fever.

 

Many people make use of cotton swabs or other foreign objects for earwax removal, but it does not clean your ears and will only push the earwax deeper inside, causing damage to your middle and/or inner ear. This can lead to serious injuries and even cause hearing loss. For a safer earwax removal method, you can soak a cotton ball with water or saline solution and drip it into your ear with your head tilted to the side. Remain in the position to allow the liquid to flow through the earwax. Then, tilt your head the other way to let the fluid and earwax drain out before wiping the outer parts of your ears. Read on for other earwax removal treatment methods.

 

Microsuction for Ear Wax Removal

 

Earwax removal, when performed on your own, can be dangerous. If you or your child are experiencing earwax blockage, you may seek medical intervention for a safer earwax removal procedure.

 

Microsuction is one method of removal. It is a safe, painless, and no-mess process that utilises a small, long and thin suction device to gently dislodge the earwax and vacuum it out of your ears. It uses a device with an attached camera to give the doctor a clear view of your ear and the amount of wax inside. This allows your doctor to thoroughly remove earwax blockages while also inspecting your ear for any problems. The entire procedure will only last a few minutes. You may feel some suction inside your ear, a slight tickling sensation, and/or some crackling or squeaking sounds during the procedure.

 

Using microsuction for earwax removal is extremely safe as it is gentle on the ears, fast, effective, and does not damage the inner ear lining. No solution will be flushed through your ear. Hence, people who suffer from a ruptured eardrum, a history of ear surgery, have foreign matter in the ear, or mild ear infection can also rely on microsuction for earwax removal. However, do speak to your doctor about your current and previous conditions, and your allergies to determine whether you are a suitable candidate for microsuction.

 

Microsuction can be administered once every four to six months. Some may require more sessions of earwax removal if they are prone to blockages or are wearing hearing aids.

 

As with every procedure, microsuction also comes with its risks and side effects. Most side effects are mild and temporary. They include:

  • Dizziness
  • Discomfort
  • Reduced hearing

 

In more serious cases, which rarely occur, side effects may include:

  • Infection
  • Temporary or permanent hearing loss
  • Injury to the eardrum
  • Tinnitus

 

Other Ear Wax Removal Methods

 

Apart from microsuction for earwax removal, there are several other earwax removal treatments available in Singapore. Depending on your condition, some methods may not be suitable for you. Do speak to your doctor for medical advice. Here are other alternative methods to removal:

  • Earwax Softener: Also known as ear drops, doctors may prescribe medicated solutions such as carbamide peroxide to soften the earwax in your ear to help it dislodge and fall out naturally. If buildup continues, your doctor may schedule an earwax removal procedure to manually remove the blockage.
  • Ear Irrigation: A ear cleansing method used to remove a buildup of earwax, ear irrigation involves flushing liquid into your ears to dislodge and remove any earwax. This procedure is not recommended for people with certain medical conditions or who have gone through ear surgery as it can cause more damage to the ears.
  • Manual Earwax Removal: Your doctor will use a flexible plastic loop, a cerumen curette, forceps, or a small hook to manually remove the earwax from your ear canal.

 

Some patients may attempt to remove earwax via ear candling, which involves lighting one end of a candle and placing the unlit end into the ear to create a vacuum seal that will draw the wax up. This method is not recommended as it does not work and may even burn or damage your ears.

 

If you have an impacted ear wax, you may have decreased hearing level in that ear, ear discomfort or pain or a secondary ear infection. You should get your ear examined by a doctor and you may benefit from removal of ear wax under microscope guidance.

Hearing loss

What is Hearing loss?

Normal hearing is especially important in children for normal speech and language development. Hence, if there is any suspicion of hearing loss or signs of speech and language delay in children, early assessment and intervention is of paramount importance.

 

The ear can be divided into outer, middle and inner ear. The cause of hearing loss can be broadly divided into conductive or sensorineural causes (Figure 1).

 

Conductive hearing loss is due to a problem with sound reaching the inner ear. Most of the time, conductive hearing loss is reversible. Hearing is usually restored when the cause is successfully treated. Some of the common causes of conductive hearing loss include:

 

  1. Impacted ear wax
  2. Ear infections
  3. Fluid in the middle ear (Figure 2)
  4. Foreign body in the ear canal
  5. Hardening or stiffening of the hearing bones

 

Sensorineural hearing loss is due to a problem with the inner ear structures (cochlea – which is the hearing organ or vestibular nerve – which is the hearing nerve). Unfortunately, most of the time, sensorineural hearing loss is permanent or irreversible. If the hearing loss is significant, these children usually require a hearing aid (conventional or implantable). Some of the common cause of sensorineural hearing loss include:

 

  1. Genetic causes
  2. Regular and prolonged exposure to loud noises
  3. Viral infection of the inner ear structures (labyrinthitis)
  4. Certain medications (ototoxic drugs)
  5. Trauma

 

For assessment of hearing loss, your ENT Specialist will take a full clinical history, conduct a physical examination and likely perform a hearing test (audiometry). The management of hearing loss depends on the cause of hearing loss.

Ear infections

What are Ear infections?

Otitis externa is infection and inflammation of the ear canal (Figure 1a&b) . This occurs more often in patients who dig their ears frequently and in regular swimmers. These patients usually experience ear pain, ear discharge and sometimes hearing loss. Treatment includes cleaning of the ear (aural toilet under microscope guidance), antibiotics ear drops and keeping the ear dry till the infection resolves. Sometimes, the infection may start off from an infected hair follicle, like a pimple or boil on the skin (Figure 2a&b) .

Fungal Infection Ear Canal

 

Middle ear infections (Otitis media) are more common in children due to their immature Eustachian tube (the tube that connects the middle ear to the back of the nose) and in adults with Eustachian tube dysfunction. Eustachian tube dysfunction results in inadequate ventilation of the middle ear. Patients with middle ear infection usually experience ear blockage, ear pain and occasionally, ear discharge (if there is a hole in the ear drum). In children, they may also have fever, become restless or agitated and have significant hearing loss that may affect their speech and language development. The hearing loss is usually due to accumulation of fluid behind the ear drum (otitis media with effusion – Figure 3a). Most middle ear infections settle with a course of antibiotics and treatment of the nose if required. In patients with fluid behind the ear drum that does not resolve after a period of watchful waiting or after a course of antibiotics, a grommet tube can be placed in the ear drum to drain the fluid (Figure 3b).

Frequent tonsil Infections (Recurrent tonsillitis)

What is Frequent tonsil Infections (Recurrent tonsillitis)?

Tonsils are two oval-shaped cluster of tissues located at the back of your throat (left tonsil and right tonsil)(Figure 1).They are part of your immune system that protects you against infection and illness. Although the tonsils are part of your immune system, they play a very small part. Other parts of the immune system such as the lymphatic system, bone marrow, spleen and thymus are the main parts of the immune system.

 

Tonsillitis is an infection of the tonsils (Figure 2). Children with tonsillitis will experience severe sorethroat, painful swallowing and fever. During an active infection, the tonsils are swollen, inflamed and may have patches of white pus. The treatment of tonsillitis involves adequate rest, hydration, antibiotics (in cases of bacterial tonsillitis), pain relievers and mouth gargle and lozenges.

 

Some children are prone to getting frequent tonsil infections. The reason for this is unknown. If your child experiences frequent severe tonsil infections requiring significant amount of time from school or requiring frequent hospitalization, you should consider having your child’s tonsils removed (procedure is known as Tonsillectomy). Removal of the tonsils does not weaken your child’s immune system nor does it make your child more susceptible to infections. There are many studies that have shown that tonsillectomy has no clinically significant negative effect on the immune system

Enlarged lymph nodes (Cervical lymphadenopathy)

What are Enlarged lymph nodes (Cervical lymphadenopathy) ?

Lymph nodes in the neck are part of your immune system and can be enlarged when your immune system is fighting a threat in the body (e.g. by infection, inflammation or cancer). Majority of the time, lymph nodes in the neck are enlarged due to an infection. They usually resolve or become smaller after the infection settles.

 

Assessment of a child with enlarged lymph nodes in the neck includes a thorough clinical history and physical examination. If the lymph node does not resolve or has worrisome signs (e.g. hard consistency, does not move easily, is in a location just above the collar bone in the neck or is bigger than usual inflammatory or infective lymph node) or is present in other parts of the body, your doctor may perform a fine needle aspiration and cytology (FNAC). FNAC involves sticking a needle into the lump (like a b to collect some cells from the lymph node for testing. If the result of the test is inconclusive, a biopsy of the lymph node (either removal of some tissue or the whole lymph node) may be required.In some instances, further investigations such as blood tests and imaging (Chest X-ray & Ultrasound or CT scan of the neck) may be required.

Differences Between Sinus, Rhinitis and Sinusitis

When Should You See An ENT Specialist In Singapore?

  • Any Ear, Nose or Throat symptoms that you are troubled with or concerned of
  • Persistent blocked nose with mouth breathing or snoring

Dr Gan provides a comprehensive management in a broad array of Ear, Nose and Throat as well as Head & Neck conditions. He has a special interest in treating various nose and sinus conditions including snoring and Obstructive Sleep Apnea (OSA)

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