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What is facial trauma?

The term facial trauma means any injury to the face or upper jaw bone. Facial traumas include injuries to the skin, underlying skeleton, neck, nose and sinuses, eye socket, or teeth and other parts of the mouth. Sometimes these types of injuries are called maxillofacial injury. Facial trauma is often recognized by swelling or lacerations (breaks in the skin). Signs of broken bones include bruising around the eyes, widening of the distance between the eyes, movement of the upper jaw when the head is stabilized, abnormal sensations on the face, and bleeding from the nose, mouth or ear.

In the U.S., about three million people are treated in emergency departments for facial trauma injuries each year. Of the pediatric patients, 5 percent have suffered facial fractures. In children under three years old, the primary cause of these fractures is falls. In children more than five years old, the primary cause for facial trauma is motor vehicle accidents. Fortunately, the correct use of seat belts, boosters and car seats can dramatically reduce the risk of facial trauma in children.

A number of activities put children at risk for facial injury, such as contact sports, cheerleading, gymnastics and cycling. Proper supervision and appropriate protective gear, such as bicycle helmets, shin guards, helmets, etc., should always be employed during these activities. But when accidents do happen, children’s facial injuries require special attention, as a child’s future growth plays a big role in treatment for facial trauma. So one of the most important issues for a caregiver is to follow a physician’s treatment plan as closely as possible until your child is fully recovered.

Why is facial trauma different in children than adults?

Facial trauma can range between minor injury to disfigurement that lasts a lifetime. The face is critical in communicating with others, so it is important to get the best treatment possible. Pediatric facial trauma differs from adult injury because the face is not fully formed and future growth will be a factor in how the child heals and recovers. Certain types of trauma may cause a delay in growth or further complicate recovery. Difficult cases require doctors or a team of doctors with special skills to make a repair that will grow with your child.

Types of facial trauma

New technology, such as advanced CT scans that can provide three-dimensional anatomic detail, has improved physicians’ ability to evaluate and manage facial trauma. In some cases, immediate surgery is needed to realign fractures before they heal incorrectly. Other injuries will have better outcomes if repairs are done after cuts and swelling have improved. Research has shown that even when an injury does not require surgery, it is important to a child’s health and welfare to continue to follow up with a physician’s care.

Soft tissue injuries

Injuries such as cuts (lacerations) may occur on the soft tissue of the face. In combination with suturing the wound, the provider should take care to inspect and treat any injures to the facial nerves, glands or ducts. In younger children, many lacerations require sedation or general anesthesia to achieve the best repair.

Bone injuries

When facial bone fractures occur, the treatment is similar to that of a fracture in other parts of the body. Some injuries may not need treatment, and others may require stabilization and fixation using wires, plates and screws. Factors influencing these treatment decisions are the location of the fracture, the severity of the fracture, and the age and general health of the patient. It is important during treatment of facial fractures to be careful that the patient’s facial appearance is minimally affected.

Injuries to the teeth and surrounding dental structures

Isolated injuries to teeth are quite common and may require the expertise of various dental specialists. Because of the specific needs of the dental structures, certain actions and precautions should be taken if a child has received an injury to his or her teeth or surrounding dental structures.

  • If a tooth is “knocked out” it should be placed in salt water or milk. The sooner the tooth is re-inserted into the dental socket, the better the chance it will survive, so the patient should see a dentist or oral surgeon as soon as possible.
  • Never attempt to “wipe the tooth off” since remnants of the ligament which hold the tooth in the jaw are attached and are vital to the success of replanting the tooth.

References:
Stewart MG, Chen AY. Factors predictive of poor compliance with follow-up after Facial trauma: A prospective study. Otolaryngology Head & Neck Surgery 1997: 117:72-75

Kim MK, Buchman R, Szeremeta. Penetrating neck trauma in children: An urban hospital’s experience. Otolaryngology Head & Neck Surgery 2000: 123: 439-43

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

Does your child have allergies? Allergies can cause many ear, nose and throat symptoms in children, but allergies can be difficult to separate from other causes. Here are some clues that allergies may be affecting your child.

Children with nasal allergies often have a history of other allergic tendencies (or atopy). These may include early food allergies or atopic dermatitis in infancy. Children with nasal allergies are at higher risk for developing asthma.

Nasal allergies can cause sneezing, itching, nasal rubbing, nasal congestion and nasal drainage. Usually, allergies are not the primary cause of these symptoms in children under four years old. In allergic children, these symptoms are caused by exposure to allergens (mostly pollens, dust, mold and dander). Observing which time of year or in which environments the symptoms are worse can be important clues to share with your doctor.

Ear infections:

One of childrens’ most common medical problems is otitis media, or middle ear infection. In most cases, allergies are not the main cause of ear infections in children under two years old. But in older children, allergies may play role in ear infections, fluid behind the eardrum, or problems with uncomfortable ear pressure. Diagnosing and treating allergies may be an important part of healthy ears.

Sore throats:

Allergies may lead to the formation of too much mucus which can make the nose run or drip down the back of the throat, leading to “post-nasal drip.” It can lead to cough, sore throats and a husky voice.

Sleep disorders:

Chronic nasal obstruction is a frequent symptom of seasonal allergic rhinitis and perennial (year-round) allergic rhinitis. Nasal congestion can contribute to sleep disorders such as snoring and obstructive sleep apnea, because the nasal airway is the normal breathing route during sleep. Fatigue is one of the most common, and most debilitating, allergic symptoms. Fatigue not only affects children’s quality of life, but has been shown to affect school performance.

Pediatric sinusitis:

Allergies should be considered in children who have persistent or recurrent sinus disease. Depending on the age of your child, their individual history and an exam, your doctor should be able to help you decide if allergies are likely. Some studies suggest that large adenoids (a tonsil-like tissue in the back of the nose) are more common in allergic children.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

The thyroid is a butterfly-shaped gland located at the base of the throat. It has two lobes joined in the middle by a strip of tissue (the isthmus). The thyroid secretes three main hormones: 1) Thyroxine, that contains iodine, needed for growth and metabolism; 2) Triiodothyronine, also contains iodine and similar in function to Thyroxine; and 3) Calcitonin, which decreases the concentration of calcium in the blood and increases calcium in the bones. All three of these hormones have an important role in your child’s growth.

Thyroid cancer is the third most common solid tumor malignancy and the most common endocrine malignancy in children. It occurs four times more often in females than males and has similar characteristics as adult thyroid cancer. Surgery is the preferred treatment for this cancer. Although the procedure is often uncomplicated, risks of thyroid surgery include vocal cord paralysis and hypocalcemia (low blood calcium). Consequently, an otolaryngologist – head and neck surgeon, one experienced with head and neck issues, should be consulted.

Types of thyroid cancer in children:

Papillary: This form of thyroid cancer occurs in cells that produce thyroid hormones containing iodine. This type, the most common form of thyroid cancer in children, grows very slowly. This form can spread to the lymph nodes via lymphatics in the neck and occasionally spreads to more distant sites.

Follicular: This type of thyroid cancer also develops in cells that produce thyroid hormones containing iodine. The disease afflicts a slightly older age group and is less common in children. This type of thyroid cancer is more likely to spread to the neck via blood vessels, causing the cancer to spread to other parts of the body, making the disease more difficult to control.

Medullary: This rare form of thyroid cancer develops in cells that produce calcitonin, a hormone that does not contain iodine. This cancer tends to spread to other parts of the body and constitutes about 5-10 percent of all thyroid malignancies. Medullary thyroid carcinoma (MTC) in the pediatric population is usually associated with specific inherited genetic conditions, such as multiple endocrine neoplasia type 2 (MEN2)

Anaplastic: This is the fastest growing of the thyroid cancers, with abnormal cells that grow and spread rapidly, especially locally in the neck. This form of cancer is not seen in children.

Symptoms: Symptoms of this disease vary. Your child may have a lump in the neck, persistent swollen lymph nodes, a tight or full feeling in the neck, trouble with breathing or swallowing, or hoarseness.

Diagnosis: If any of these symptoms occur, consult your child’s physician for an evaluation. The evaluation should consist of a head and neck examination to determine if unusual lumps are present. A blood test may be ordered to determine how the thyroid is functioning. Ultrasonography uses sound waves and a computer to create an image of the thyroid gland and neck contents such as lymph nodes. Other tests that may be warranted include a radioactive iodine scan, which provides information about the thyroid shape and function, identifying areas in the thyroid that do not absorb iodine in the normal way, or a fine needle biopsy of any abnormal lump in the thyroid or neck. Sometimes it is necessary to remove a part of the tumor or one of the lobes of the thyroid gland, known as a thyroid lobectomy, for analysis to help establish a diagnosis and plan for management.

Treatments for thyroid cancer:

If the tumor is found to be malignant, then surgery is recommended. Surgery may consist of a lobectomy, subtotal thyroidectomy (removal of at least one lobe and up to near-total removal of the thyroid gland), or a total thyroidectomy. In children with papillary or follicular thyroid cancer, total or near-total thyroidectomy is currently the standard of practice, as children typically have more extensive disease at presentation, have higher rates of spread, and it reduces the risk of recurrence. In children, there is an increased need for repeat surgery when less than a total thyroidectomy is performed. Lymph nodes in the neck may need to be removed as part of the treatment for thyroid cancer if there is suspicion of spread of cancer to the lymph nodes.

Surgery may be followed by radioactive iodine therapy, to destroy cancer cells that are left after surgery. Thyroid hormone therapy may need to be administered throughout your child’s life to replace normal hormones and slow the growth of any residual cancer cells.

If cancer has spread to other parts of the body, chemotherapy (treatment by chemical substances or drugs) may be given. This therapy interferes with the cancer cell’s ability to grow or reproduce. Different groups of drugs work in different ways to fight cancer cells and shrink tumors. Radiation treatment may also be required for treatment of some forms of thyroid cancer.

In general, treatment outcomes for this type of cancer in children tend to be excellent. The best outcomes are seen in teenage girls, papillary type cancer, and tumors localized to the thyroid gland.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

Overview of Sleep Disordered Breathing

Sleep-disordered breathing (SDB) is a general term for breathing difficulties occurring during sleep. SDB can range from frequent loud snoring to Obstructive Sleep Apnea (OSA) a condition involving repeated episodes of partial or complete blockage of the airway during sleep. When a child’s breathing is disrupted during sleep, the body perceives this as a choking phenomenon. The heart rate slows, blood pressure rises, the brain is aroused and sleep is disrupted. Oxygen levels in the blood can also drop.

Approximately 10 percent of children snore regularly and about 2-4 % of the pediatric population has OSA. Recent studies indicate that mild SDB or snoring may cause many of the same problems as OSA in children.

Could my child have Obstructive Sleep Apnea?

The most obvious symptom of sleep disordered breathing is loud snoring that is present on most nights. The snoring can be interrupted by complete blockage of breathing with gasping and snorting noises and associated with awakenings from sleep. Due to a lack of good quality sleep, a child with sleep disordered breathing may be irritable, sleepy during the day or have difficulty concentrating in school. Busy or hyperactive behavior may also be observed. Bed-wetting is also frequently seen in children with sleep apnea.

A common physical cause of airway narrowing contributing to SDB is enlarged tonsils and adenoids. Overweight children are at increased risk for SDB because fat deposits around the neck and throat can also narrow the airway. Children with abnormalities involving the lower jaw or tongue or neuromuscular deficits such or cerebral palsy have a higher risk of developing sleep disordered breathing.

Potential consequences of untreated pediatric sleep disordered breathing

  • Social: Loud snoring can become a significant social problem if a child shares a room with siblings or at sleepovers and summer camp.
  • Behavior and learning: Children with SDB may become moody, inattentive and disruptive both at home and at school. Sleep disordered breathing can also be a contributing factor to attention deficit disorders in some children.
  • Enuresis: SDB can cause increased nighttime urine production, which may lead to bedwetting.
  • Growth: Children with SDB may not produce enough growth hormone, resulting in abnormally slow growth and development.
  • Obesity: SBD may cause the body to have increased resistance to insulin or daytime fatigue with decreases in physical activity. These factors can contribute to obesity.
  • Cardiovascular: OSA can be associated with an increased risk of high blood pressure or other heart and lung problems.

How is sleep apnea diagnosed?

Sleep disordered breathing in children should be considered if frequent loud snoring, gasping, snorting and thrashing in bed or unexplained bedwetting is observed. Behavioral symptoms can include changes in mood, misbehavior and poor school performance. Not every child with academic or behavioral issues will have SDB, but if a child snores loudly on a regular basis and is experiencing mood, behavior or school performance problems, sleep disordered breathing should be considered. If you notice that your child has any of those symptoms, have them checked by an otolaryngologist (ear, nose and throat doctor). Sometimes physicians will make a diagnosis of sleep disordered breathing based on history and physical examination. In other cases, such as in children suspected of having severe OSA due to craniofacial syndromes, morbid obesity or neuromuscular disorders or for children less than 3 years of age, additional testing such as a sleep test may be recommended.

The sleep study or polysomnography (PSG) is an objective test for sleep disordered breathing. Wires are attached to the head and body to monitor brain waves, muscle tension, eye movement, breathing and the level of oxygen in the blood. The test is not painful and is generally performed in a sleep laboratory or hospital. Sleep tests can occasionally produce inaccurate results, especially in children. Borderline or normal sleep test results may still result in a diagnosis of SDB based on parental observations and clinical evaluation.

Treatment for sleep disordered breathing

Enlarged tonsils and adenoids are a common cause for SDB. Surgical removal of the tonsils and adenoids (T&A) is generally considered the first line treatment for pediatric sleep disordered breathing if the symptoms are significant and the tonsils and adenoids are enlarged. Of the over 500,000 pediatric T&A procedures performed in the U.S. each year, the majority are currently being done to treat sleep disordered breathing. Many children with sleep apnea show both short and long-term improvement in their sleep and behavior after T&A.

Not every child with snoring should undergo T&A as the procedure does have risks. Potential problems can include anesthesia or airway complications, bleeding, infection and problems with speech and swallowing. If the SDB symptoms are mild or intermittent, academic performance and behavior is not an issue, the tonsils are small, or the child is near puberty (tonsils and adenoids often shrink at puberty), it may be recommended that a child with SDB be watched conservatively and treated surgically only if symptoms worsen.

Recent studies have shown that some children have persistent sleep disordered breathing after T&A. A post-operative PSG may be necessary after surgical intervention, especially in children with persistent symptoms or increased risk factors for persistent apnea after T&A such as obesity, craniofacial anomalies or neuromuscular problems. Additional treatments such as weight loss, the use of Continuous Positive Airway Pressure (CPAP) or additional surgical procedures may sometimes be required.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

Today in the United States, studies estimate that 34% of U.S. adults are overweight and an additional 31% (approximately 60 million) are obese. Combined, approximately 127 million Americans are overweight or obese. Some 42 years ago, 13% of Americans were obese, and in 1980 15% were considered obese.

Alarmingly, the number of children who are overweight or obese has doubled in the last two decades as well. Currently, more than 15% of 6- to 11-year-olds and more than 15% of 12- to 19-year-olds are considered overweight or obese.

What is the difference between designated “obese” versus “overweight”?

Unfortunately, the words overweight and obese are often interchanged. There is a difference:

  • Overweight: Anyone with a body mass index (BMI) (a ratio between your height and weight) of 25 or above (e.g., someone who is 5-foot-4 and 145 pounds) is considered overweight.
  • Obesity: Anyone with a BMI of 30 or above (e.g., someone who is 5-foot-4 and 175 pounds) is considered obese.
  • Morbid obesity: Anyone with a BMI of 40 or above (e.g., someone who is 5-foot-4 and 233 pounds) is considered morbidly obese. “Morbid” is a medical term indicating that the risk of obesity related illness is increased dramatically at this degree of obesity.

Obesity can present significant health risks to the young child. Diseases are being seen in obese children that were once thought to be adult diseases. Many experts in the study of children’s health suggest that a dysfunctional metabolism, or failure of the body to change food calories to energy, precedes the onset of disease. Consequently, these children are at risk for Type II diabetes, fatty liver, elevated cholesterol, SCFE (a major hip disorder), menstrual irregularities, sleep apnea and irregular metabolism. Additionally, there are psychological consequences; obese children are subject to depression, loss of self-esteem and isolation from their peers.

Pediatric obesity and otolaryngic problems

Otolaryngologists, or ear, nose and throat specialists, diagnose and treat some of the most common children’s disorders. They also treat ear, nose and throat conditions that are common in obese children, such as:

Sleep apnea

Children with sleep apnea literally stop breathing repeatedly during their sleep, often for a minute or longer, usually ten to 60 times during a single night. Sleep apnea can be caused by either complete obstruction of the airway (obstructive apnea) or partial obstruction (obstructive hypopnea – or slow, shallow breathing), both of which can wake one up. There are three types of sleep apnea – obstructive, central and mixed. Of these, obstructive sleep apnea (OSA) is the most common. Otolaryngologists have pioneered the treatment for sleep apnea; research shows that one to three percent of children have this disorder, often between the age of two-to-five years old.

Enlarged tonsils, which block the airway, are usually the key factor leading to this condition. Extra weight in obese children and adults can also interfere with the ability of the chest and abdomen to fully expand during breathing, hindering the intake of air and increasing the risk of sleep apnea.

The American Academy of Pediatrics has identified obstructive sleep apnea syndrome (OSAS) as a common condition in childhood that results in severe complications if left untreated. Among the potential consequences of untreated pediatric sleep apnea are growth failure; learning, attention, and behavior problems; and cardio-vascular complications. Because sleep apnea is rarely diagnosed, pediatricians now recommend that all children be regularly screened for snoring.

Middle ear infections

Acute otitis media (AOM) and chronic ear infections account for 15 to 30 million visits to the doctor each year in the U.S. In fact, ear infections are the most common reason why an American child sees a doctor. Furthermore, the incidence of AOM has been rising over the past decades. Although there is no proven medical link between middle ear infections and pediatric obesity there may be a behavioral association between the two conditions. Some studies have found that when a child is rubbing or massaging the infected ear the parent often responds by offering the child food or snacks for comfort.

When a child does have an ear infection the first line of treatment is often a regimen of antibiotics. When antibiotics are not effective, the ear, nose and throat specialist might recommend a bilateral myringotomy with pressure equalizing tube placement (BMT), a minor surgical procedure. This surgery involves the placement of small tubes in the eardrum of both ears. The benefit is to drain the fluid buildup behind the eardrum and to keep the pressure in the ear the same as it is in the exterior of the ear. This will reduce the chances of any new infections and may correct any hearing loss caused by the fluid buildup.

Postoperative vomiting (POV) is a common problem after bilateral myringotomy surgery. The overall incidence is 35 percent, and usually occurs on the first postoperative day, but can occur up to seven days later. Several factors are known to affect the incidence of POV, including age, type of surgery, postoperative care, medications, co-existing diseases, past history of POV, and anesthetic management. Obesity, gastroparesis, female gender, motion sickness, pre-op anxiety, opioid analgesics and the duration of anesthetic all increase the incidence of POV. POV interferes with oral medication and intake, delays return to normal activity and increases length of hospital stay. It remains one of the most common causes of unplanned postoperative hospital admissions.

Tonsillectomies

A child’s tonsils are removed because they are either chronically infected or, as in most cases, enlarged, leading to obstructive sleep apnea. There are several surgical procedures utilized by ear, nose and throat specialists to remove the tonsils, ranging from use of a scalpel to a wand that emits energy that shrinks the tonsils.

Research conducted by otolaryngologists found that morbid obesity was a contributing factor for requiring an overnight hospital admission for a child undergoing removal of enlarged tonsils. Most children who were diagnosed as obese with sleep apnea required a next-day physician follow-up.

A study from the University of Texas found that morbidly obese patients have a significant increase of additional medical disorders following tonsillectomy and adenoidectomy for obstructive sleep apnea or sleep-disordered breathing when compared to moderately obese or overweight patients undergoing this procedure for the same diagnosis. On average they have longer hospital stays, a greater need for intensive care and a higher incidence of the need for apnea treatment of continuous positive airway pressure upon discharge from the hospital. The study found that although the morbidly obese group had a greater degree of sleep apnea, they did benefit from the procedure in regards to snoring, apneic spells and daytime somnolence.

What you can do

If your child has a weight problem, contract your pediatrician or family physician to discuss the weight’s effect on your child’s health, especially prior to treatment decisions. Second, ask your physician about lifestyle and diet changes that will reduce your child’s weight to a healthy standard.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

Everyone has gastroesophageal reflux (GER), the backward movement (reflux) of gastric contents into the esophagus. Extraesophageal Reflux (EER) is the reflux of gastric contents from the stomach into the esophagus with further extension into the throat and other upper aerodigestive regions. In infants, more than 50 percent of children three months or younger have at least one episode of regurgitation a day. This rate peaks at 67 percent at four months old. But an infant’s improved muscle control and the ability to sit up will lead to a spontaneous resolution of significant GER in more than half of infants by 10 months old, and four out of five at age 18 months. Researchers have found that 10 percent of infants younger than 12 months with GER develop significant complications.

The diseases associated with reflux are known collectively as Gastro-Esophageal Reflux Disease (GERD). Physically, GERD occurs when a valve at the lower end of the esophagus malfunctions. Normally, this muscle closes to keep acid in the stomach and out of the esophagus. The continuous entry of acid or refluxed materials into areas outside the stomach can result in significant injury to those areas. It is estimated that some 5 to 8 percent of adolescent children have GERD.

What symptoms are displayed by a child with GERD?

While GER and EER in children often cause relatively few symptoms, the most common initial symptom of GERD is heartburn. Heartburn is more common in adults, and children have a harder time describing this sensation. They usually will complain of a stomach ache or chest discomfort, particularly after meals.

More frequent or severe GER and EER can cause other problems in the stomach, esophagus, pharynx, larynx, lungs, sinuses, ears, and even the teeth. Consequently, other typical symptoms can include crying/irritability, poor appetite/feeding and swallowing difficulties, failure to thrive/weight loss, regurgitation (“wet burps” or outright vomiting), stomach aches (dyspepsia), abdominal/chest pain (heartburn), sore throat, hoarseness, apnea, laryngeal and tracheal stenosis, asthma/wheezing, chronic cough and throat clearing, chronic sinusitis, ear infections/fluid, and dental caries. Effortless regurgitation is very suggestive of GER. However, recurrent vomiting (which is not the same) does not necessarily mean a child has GER.

If your child displays the typical symptoms of GERD, a visit to a pediatrician is warranted. However, in some circumstances, the disorder may cause significant ear, nose and throat disorders. When this occurs, an evaluation by an otolaryngologist is recommended.

How is GERD diagnosed?

Most of the time, the physician can make a diagnosis by interviewing the caregiver and examining the child. There are occasions when testing is recommended, and each test has advantages and shortcomings. Those most commonly used to diagnose GERD include:

  • pH probe: A small wire with an acid sensor is placed through the nose down to the bottom of the esophagus, and usually left in place between 12-24 hours. The sensor detects when acid from the stomach is “refluxed” into the esophagus.
  • Barium swallow or upper GI series: The child is fed barium, a white, chalky, liquid. A video x-ray machine follows the barium through the upper intestinal tract and lets doctors see if there are any abnormal twists, kinks or narrowing of the tract.
  • Technetium gastric emptying study: The child is fed milk mixed with technetium, a very weak radioactive chemical, which is then followed through the intestinal tract using a special camera. This test helps determine whether some of the milk/technetium ends up in the lungs, and how long milk sits in the stomach.
  • Endoscopy with biopsies: This most comprehensive test involves passing a flexible endoscope with lights and lenses through the mouth into the esophagus, stomach and duodenum. This allows the doctor to see any irritation or inflammation present. In some children with GERD, repeated exposure of the esophagus to stomach acid causes some inflammation (esophagitis). Endoscopy in children usually requires a general anesthetic.

What treatments are available for GERD?

Treatment of reflux in infants is intended to lessen symptoms, not to relieve the underlying problem, as this will often resolve on its own with time. A simple treatment is to thicken a baby’s milk or formula with rice cereal, making it less likely to be refluxed.

Several steps can be taken to assist the older child with GERD:

  • Lifestyle changes: Raise the head of the child’s bed about 30 degrees and have the child eat smaller, more frequent meals instead of large amounts of food at one sitting. Avoid eating right before they go to bed or lie down; let two or three hours pass. Try a walk or warm bath or even a few minutes on the toilet. Some researchers believe that certain lifestyle changes such as losing weight or dressing in loose clothing may assist in alleviating GERD.
  • Dietary changes: Avoid chocolate, carbonated drinks, caffeine, tomato products, peppermint, and other acidic foods like citrus juices. Fried foods and spicy foods are also known to aggravate symptoms. Pay attention to what your child eats.
  • Medical treatment: Most medications prescribed to treat GERD break down or lessen intestinal gas, decrease or neutralize stomach acid or improve intestinal coordination. Your physician will prescribe the most appropriate medication for your child. It is rare for children with GERD to require surgery.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

Dust, mites, pet dander and ragweed are not the only allergic threats to your child. Food allergies and sensitivities may cause a wide range of adverse reactions to the skin, respiratory system, stomach and other physiological functions of the body.

Determining what foods are the cause of an allergic reaction is key to treatment. Before you identify the ingestible culprit you must consider what type of food allergy your child has. There are two types, classified as:

  • Fixed (immediate) food allergies: A fixed food allergy may be very apparent, such as the child whose lips swell and throat itches immediately in response to eating peanuts. The cause for this type of food allergy is similar to that of inhalant allergies, so the diagnosis is more easily reached. Blood testing (i.e., RAST test) is typically used to verify fixed food allergies. Approximately 5 to 15 percent of food allergies are of the fixed variety.
  • Cyclic (delayed) food allergies: These allergies are far more common but less understood. Delayed food allergy symptoms can take up to three days to appear. This type of reaction is associated with the body’s immunoglobulin G (IgG) or antibodies. Unlike fixed food allergies, this allergic response is cyclical in nature. As an example, a child may be IgG sensitive to milk. Consequently, symptoms might appear if the child increases the intake and/or frequency of milk consumption.

Both children and adults are susceptible to food allergies. The bad news for children is that they often have more skin reactions, such as eczema, to foods than do adults. But the good news for the young patient is that a child often outgrows his or her food sensitivities over time, even those that are positive on a RAST test. Food allergies may fade, and then inhalant (e.g, dust, ragweed) allergies may begin to manifest themselves.

Diagnosing and treating the cyclic food allergy

If your child is experiencing allergic reactions to food of unknown origin, you should ask yourself, “Are there any foods that my child craves or any food that I avoid offering?” These foods may be the ones that are causing difficulties for the young patient.

Your physician may also suggest the Elimination and Challenge Diet. This dietary test consists of the following steps:

  1. Keep a detailed food diary, tracking what was eaten (including ingredients), when it was eaten, medications taken, and any symptoms that developed. Be honest! Some well-meaning parents or caregivers often create a food diary that looks healthier than it really is. Your child can receive the best diagnosis if the diet records are accurate, timed precisely and truthful. The diet diary can be evaluated by the doctor to identify food items that may be the culprits.
  2. Conduct an elimination and challenge diet at home based upon your physician’s assessment of your child’s diet diary. It is best if you carefully maintain a new diet diary for your child during this period. During this diet, your child must abstain from one, and only one, of the possible food culprits at a time for a period of four days. This can be difficult to carry out if the food is very common, such eggs or cereal, so you need to pay strict attention to your child’s diet during the elimination phase. Any cheating will invalidate the results. On the fifth day, you will be asked to feed your child the suspected culprit food item. This is the challenge! Provide your child an average-sized portion of the food in question to be eaten in five minutes. In one hour the child should eat another half portion if no symptoms have developed. Any symptoms that develop are then timed and recorded. With a true cyclic food allergy, you would expect a significant worsening of the symptoms described in the original diet diary, although the challenge symptoms may vary as well.
  3. If the Elimination and Challenge Diet confirms a cyclic food allergy, then you will be asked to abstain from feeding your child this food for a period of three to six months. After this time you can slowly reintroduce the food on a rotary basis; it is not to be eaten more frequently than every four days (once or twice a week).

For minor, moderate discomfort from the testing, the caregiver may choose to offer one of the following: 1) a child’s laxative to decrease the transit time through the digestive system; 2) Alka Seltzer® Gold; 3) buffered Vitamin C (one gram).

Fixed food allergies should never be deliberately challenged unless under the direct supervision of a physician.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

The National Institute on Deafness and Other Communication Disorders reports approximately 28 million Americans have lost some or all of their hearing, including 17 in 1,000 children under age 18. Noise exposure is increasingly common in the age of iPods and other personal music players. Overexposure to noise can cause both temporary and permanent hearing loss.

Loudness of common sounds

30 decibels (dBa)         Whisper
60 decibels                    Normal Conversation
60 – 80 decibels            Cars to a close observer
Above 85 decibels        Can cause permanent hearing loss

Although 10 million Americans suffer irreversible noise-induced hearing loss, with 30 million more exposed to dangerous noise levels each day, very little has been reported on the risk of such hearing loss in children.

How does noise exposure cause hearing loss?

Very loud sounds damage the inner ear by damaging the hair cells of the cochlea. When loud sounds are exposed to the ear for a short time, one may experience what’s called a temporary threshold shift, or a temporary hearing loss. This hearing loss may be accompanied by tinnitus (a ringing in the ears). One may recover from the temporary loss. But if the ear is exposed to loud sounds over longer periods of time, the hair cells can be permanently damaged, causing permanent sensorineural hearing loss.

Should MP3 player use be limited?

The maximum sound from an iPod Shuffle has been measured at 115 decibels, a level that can cause hearing loss to listeners of all ages. A survey sponsored by the Australian government found that about 25 percent of people using portable stereos had daily noise exposures high enough to cause hearing damage. Further research from the Netherlands reports that 90 percent of adolescents listened to music through earphones on MP3 players, almost half used high-volume settings, and only 7 percent used a noise limiter. Researchers at Boston Children’s Hospital determined that listening to a portable music player with headphones at 60 percent of their potential volume for one hour a day is relatively safe. The maximum volume limit is adjustable on many current MP3 players.

Why earplugs are important at concerts

Parents should be aware that various medical studies have found sound levels at rock concerts often to be significantly higher than 85 dBA, with some reports suggesting that sound intensity may reach 90 dBA to as high as 122 dBA.

To experience 85 dBA, listen to an electric shaver or a busy urban street. If levels are maintained at values greater than 85 dBA for long periods of time, this may lead to a significant noise exposure. Frequent concertgoers may experience some potentially irreversible hearing loss from their experience.

A research study, “Incidence of spontaneous hearing threshold shifts during modern concert performances” (Opperman, Reifman, Schlauch, Levine; Otol-HNS 2006, 134:4: 667-673), examined sound intensity throughout a well known concert venue, and the effectiveness of earplugs. The findings stated that sound pressure levels appeared equally hazardous in all parts of the concert hall, regardless of the type of music played. Accordingly, you should use earplugs at every type of musical concert, regardless of your distance to the stage.

A good rule of thumb: When a child accompanies a parent to any activity or location with excessive noise, ear protection should be worn by the entire family.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

What is laryngopharyngeal reflux (LPR)?

Food or liquids that are swallowed travel through the esophagus and into the stomach where acids help digestion. Each end of the esophagus has a sphincter, a ring of muscle, that helps keep the acidic contents of the stomach in the stomach or out of the throat. When these rings of muscle do not work properly, you may get heartburn or gastroesophageal reflux (GER). Chronic GER is often diagnosed as gastroesophageal reflux disease or GERD.

Sometimes, acidic stomach contents will reflux all the way up to the esophagus, past the ring of muscle at the top (upper esophageal sphincter or UES) and into the throat. When this happens, acidic material contacts the sensitive tissue at back of the throat and even the back of the nasal airway. This is known as laryngopharyngeal reflux or LPR.

During the first year, infants frequently spit up. This is essentially LPR because the stomach contents are refluxing into the back of the throat. However, in most infants, it is a normal occurrence caused by the immaturity of both the upper and lower esophageal sphincters, the shorter distance from the stomach to the throat, and the greater amount of time infants spend in the horizontal position. Only infants who have associated airway (breathing) or feeding problems require evaluation by a specialist. This is most critical when breathing-related symptoms are present.

What are symptoms of LPR?

There are various symptoms of LPR. Adults may be able to identify LPR as a bitter taste in the back of the throat, more commonly in the morning upon awakening, and the sensation of a “lump” or something “stuck” in the throat, which does not go away despite multiple swallowing attempts to clear the lump. Some adults may also experience a burning sensation in the throat. A more uncommon symptom is difficulty breathing, which occurs because the acidic, refluxed material comes in contact with the voice box (larynx) and causes the vocal cords to close to prevent aspiration of the material into the windpipe (trachea). This event is known as laryngospasm.

Infants and children are unable to describe sensations like adults can. Therefore, LPR is only successfully diagnosed if parents are suspicious and the child undergoes a full evaluation by a specialist such as an otolaryngologist. Airway or breathing-related problems are the most commonly seen symptoms of LPR in infants and children and can be serious. If your infant or child experiences any of the following symptoms, timely evaluation is critical.

  • Chronic cough
  • Hoarseness
  • Noisy breathing (stridor)
  • Croup
  • Reactive airway disease (asthma)
  • Sleep disordered breathing (SDB)
  • Spit up
  • Feeding difficulty
  • Turning blue (cyanosis)
  • Aspiration
  • Pauses in breathing (apnea)
  • Apparent life threatening event (ALTE)
  • Failure to thrive (a severe deficiency in growth such that an
  • infant or child is less than five percentile compared to the expected norm)

What are the complications of LPR?

In infants and children, chronic exposure of the laryngeal structures to acidic contents may cause long term airway problems such as a narrowing of the area below the vocal cords (subglottic stenosis), hoarseness, and possibly eustachian tube dysfunction causing recurrent ear infections, or persistent middle ear fluid, and even symptoms of “sinusitis’. The direct relationship between LPR and the latter mentioned problems are currently under research investigation.

How is LPR diagnosed?

Currently, there is no good standardized test to identify LPR. If parents notice any symptoms of LPR in their child, they may wish to discuss with their pediatrician a referral to see an otolaryngologist for evaluation. An otolaryngologist may perform a flexible fiber-optic nasopharyngoscopy/laryngoscopy, which involves sliding a 2 mm scope through the infant or child’s nostril, to look directly at the voice box and related structures or a 24-hour pH monitoring of the esophagus. He or she may also decide to perform further evaluation of the child under general anesthesia. This would include looking directly at the voice box and related structures (direct laryngoscopy), a full endoscopic look at the trachea and bronchi (bronchoscopy), and an endoscopic look at the esophagus (esophagoscopy) with a possible biopsy of the esophagus to determine if esophagitis is present. LPR in infants and children remains a diagnosis of clinical judgment based on history given by the parents, the physical exam and endoscopic evaluations.

How is LPR treated?

Since LPR is an extension of GER, successful treatment of LPR is based on successful treatment of GER. In infants and children, basic recommendations may include smaller and more frequent feedings and keeping an infant in a vertical position after feeding for at least 30 minutes. A trial of medications including H2 blockers or proton pump inhibitors may be necessary. Similar to adults, those who fail medical treatment, or have diagnostic evaluations demonstrating anatomical abnormalities may require surgical intervention.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

Tinnitus is a condition where the patient hears a ringing or other noise that is not produced by an external source. This disorder can occur in one or both ears, range in pitch from a low roar to a high squeal, and may be continuous or sporadic. This often debilitating condition has been linked to ear injuries, circulatory system problems, noise-induced hearing loss, wax build-up in the ear canal, medications harmful to the ear, ear or sinus infections, misaligned jaw joints, head and neck trauma, Ménière’s disease, or an abnormal growth of bone of the middle ear. In rare cases, slow-growing tumors on auditory, vestibular or facial nerves can cause tinnitus as well as deafness, facial paralysis and balance problems. The American Tinnitus Association estimates that more than 50 million Americans have tinnitus problems to some degree, with approximately 12 million people having symptoms severe enough to seek medical care.

Tinnitus is not uncommon in children. Although it is as common as in adults, children generally do not complain of tinnitus. Researchers believe that a child with tinnitus considers the noise in the ear to be normal, as it has usually been present for a long time. A second explanation of the discrepancy is that the child may not distinguish between the psychological impact of tinnitus and its medical significance.

Continuous tinnitus can be annoying and distracting, and in severe cases can cause psychological distress and interfere with your child’s ability to lead a normal life. The good news is that most children with tinnitus seem to eventually outgrow the symptom. It is unusual to see a child carry the problem into adulthood.

If you think your child has tinnitus, first arrange an appointment with your family physician or pediatrician. If the child does not have a specific problem with the ears such as middle ear inflammation with thick discharge, then it may be necessary to have your child referred to an otolaryngologist (ear, nose and throat specialist).

What treatment may be offered

Most people, including children, who are diagnosed with tinnitus find that there is no specific problem underlying their tinnitus. Consequently, there is no specific medicine or operation to “cure” the problem. However, experts suggest that the following steps be taken with the child diagnosed with tinnitus:

  1. Reassure the child: Explain that this condition is common and they are not alone. Ask your physician to describe the condition to the child in terms and images that they can understand. Depending on the nature of the tinnitus, the doctor may order further testing, such as a hearing test, a CT scan or MRI.
  2. Explain that he/she may feel less distressed by their tinnitus in the future: Many children find it helpful to have their tinnitus explained carefully and to know about ways to manage it. This is partly due to a medical concept known as “neural plasticity”, where children are more able to change their response to all kinds of stimulation. If carefully managed, childhood tinnitus may not be a serious problem.
  3. Use sound generators or provide background noise. Sound therapy, which makes tinnitus less noticeable, has been used to treat adults for some time, and can also be used with children. If tinnitus occurs on a regular basis, with sound therapy the child’s nervous system can adapt to the condition. The sound can be environmental, such as a fan or quiet background music.
  4. Have hearing-impaired children wear hearing aids. A child with tinnitus and hearing loss may find that hearing aids can help improve the tinnitus. Hearing aids can pick up sounds children may not normally hear, which in turn will help their brains filter out their tinnitus. It may also help them by taking the strain out of listening. Straining to hear can make your child’s brain focus on the tinnitus noises.
  5. Help your child to sleep with debilitating tinnitus. Severe tinnitus may lead to sleep difficulties for the young patient. Ask your otolaryngologist the best strategy to adopt if your child cannot sleep.
  6. Finally, help your child relax. Some children believe their tinnitus gets worse when they are under stress. Discuss appropriate stress-relieving techniques with your pediatrician or family physician.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery