Pediatric ENT

Children are particularly susceptible to recurrent or chronic ear infections compared to adults. The Eustachian tubes, which equalize pressure behind the eardrums, are narrower and more horizontal in children. This makes it harder for pressure and/or fluid to drain from behind the eardrum, which can then turn more easily into an ear infection.

Sleep apnea is a condition in which the upper airway (nose and throat generally) becomes obstructed frequently during sleep. This can lead to daytime fatigue, morning headaches, and difficulty focusing on school/work. In children, potential consequences include hyperactivity, behavior issues (often mis-diagnosed as ADHD), and delayed cognitive development. Both medical and surgical options exist to treat sleep apnea, but evaluation by an ENT is critical to determining the proper treatment plan. Typically, a sleep study will be ordered, which is performed at a sleep medicine facility.

Tongue tie is a condition characterized by shortened or tight frenulum (thin band of tissue under the tongue). This can interfere with feeding early in life, and can also present problems with speech articulation later in childhood. Frenulectomy can be safely performed in the office during infancy to help address this issue. In older children, this is usually done under general anesthesia, as it is generally too painful after 6 months of age.

There are a multitude of reasons for speech delay in children. This can range from hearing loss to delays in cognitive/neurologic development. Occasionally, some children have anatomic problems with the tongue or throat that can impact articulation. A pediatric ENT can perform a complete examination to help ascertain what the underlying issue may be. Depending on the root cause, the solution may involve surgeries (ear tube placement, cleft palate repair) and/or speech therapy.

Hearing loss can be congenital or acquired in children. Congenital hearing loss is usually assessed with a newborn hearing screen. A failed screen does not always indicate irreversible hearing loss, but follow up hearing testing is always indicated. Acquired hearing loss can be caused by conditions such as chronic otitis media, meningitis, and cholesteatoma. Regardless of the cause, objective hearing testing (audiograms) are of the utmost importance. We have the capability of performing hearing testing in children over the age of 6 months.

Neck masses in children are usually benign in nature. The most common diagnoses include enlarged lymph nodes, or infected congenital cysts in the face/neck (e.g branchial cleft cysts, thyroglossal duct cysts, preauricular pits and fistulas). However, head and neck masses in children have a moderately higher risk for harboring malignancy compared to adults, so it is always worthwhile to have an ENT examine your child if a mass has been present for longer than 3-4 weeks. If indicated, these can be surgically removed with minimal risk to the child.

Vocal cord and voice box (larynx) problems are fairly common in children, and are usually present shortly after birth. Noisy breathing on its own is usually self-limiting and resolves over a matter of weeks to months. However, when breathing difficulties start to impact growth or weight gain, or cause increased respiratory effort to the point of causing fatigue of the breathing muscles, a pediatric ENT can help diagnose the issue at hand and possibly correct it through surgery.

Swallowing is a complex process that involves multiple levels of the upper airway, from the lips and tongue all the way to the esophagus and stomach. Newborns are not born with the innate ability to feed, and it takes time to properly coordinate all the muscles of swallowing. However, when poor feeding persists to the point of impacting growth and weight gain, a pediatric ENT can help diagnose at which point the swallowing difficulty is occurring. Supplemental testing may include flexible endoscopy in the office, as well as a video fluoroscopic swallow study (a type of live-action X-ray), which is typically performed at a children’s hospital.

Kids are naturally curious, and younger children in particular are exploring their surroundings by any means possible. Sometimes, however, this means they will put objects in their mouths, noses, or ears. Occasionally, these objects will get stuck! This can cause pain, bleeding, or difficulty swallowing or breathing. An ENT is trained to remove all manner of foreign bodies, both in the office and in the operating room.

Dr. Tsang is a member of the craniofacial team at Inova Fairfax Children’s Hospital. He sees children with cleft lips and/or palates, as well as congenital malformations of the ears, such as microtia (malformed outer ear) and aural atresia (narrowing or complete lack of the ear canal). These children can require specialized care involving multiple different specialties.

Placement of pressure equalizing tubes is the most common pediatric outpatient surgery in the US. This is most commonly performed to remove fluid or pressure behind the eardrum in children to reduce the risk of recurrent infections. Additional indications include hearing loss and speech delay. The ear tubes stay in place for about a year on average. Most children only ever need one set of tubes, but some children may need a second or even third set of tubes, depending on whether there are other medical conditions in play, such as enlarged adenoids or allergies.

Removal of the tonsils and adenoids is a very routine and safe procedure in children. The most common indication currently is snoring and sleep apnea. However, this procedure can also be performed for recurrent strep throat and upper respiratory infections. Dr. Tsang typically performs this procedure using the intracapsular technique, which has been shown to significantly reduce postoperative pain and bleeding risk.

Dr. Tsang has a significant amount of experience with tongue tie release (frenulectomy). At our office, this procedure is performed with cold technique (scissors) rather than with laser or powered instruments. This reduces the risk to the child of injury to neighboring structures, such as the tongue, floor of mouth, and lips. This typically a painless procedure in newborns, and children are able to feed normally within 1-2 hours after the procedure.

The vast majority of airway surgery in children can be performed endoscopically, using small cameras through the mouth to examine the vocal cords, larynx, and the windpipe (trachea). This is commonly known as a microdirect laryngoscopy and bronchoscopy. Dr. Tsang regularly performs this procedure on children of all ages, including infants.

A tracheostomy can be a life-changing procedure for many children and their families. It is typically performed for chronic respiratory failure, in which a child has persistent difficulty breathing or keeping oxygen levels normal. This can be due to prematurity, weakness of the airway structures, or airway obstruction. Dr. Tsang regularly performs this procedure in the hospital, and sees these patients regularly in the office afterwards to monitor for when they might eventually not need the tracheostomy anymore (decannulation).

Children with severe hearing loss may be eligible for implantable hearing devices when traditional hearing aids may not be effective. This includes bone anchored hearing aids and cochlear implants. Cochlear implants can be implanted at any age, even infants (usually around 10 months), with the goal of rehabilitating the hearing so children can develop speech and language normally. Bone anchored hearing aids can be an option for children with congenital deficiencies of the ear, such as lack of an ear canal or missing middle ear bones behind the eardrum (ossicles).

It is not uncommon for children to be born with malformed ears. This can range from complete lack of an outer ear to abnormal folding patterns of the normal/existing ear tissue. Traditionally, these have been treated with cosmetic ear surgery around age 6. However, there are newer technologies (e.g EarWell) in which the infant’s ear(s) can be molded using non-surgical devices to correct ear deformities and negate any future need for surgery. The window to perform this is fairly small though, and must be completed before 6 weeks of life. After this point, the ear cartilage stiffens and does not respond well to the molding process. Please see Dr. Tsang within the first 2-3 weeks after birth to see if your child’s ears would benefit from EarWell.