Children's Ear, Nose and Throat Associates

And don't forget the bacon!

2012-02-10T20:11:00.000-08:00

One remedy that has gotten significant attention recently is the use of bacon for stopping nosebleeds. This comes from a recent article published in the Annals of Otology, Rhinology, and Laryngology in November of 2011. In a patient with a rare bleeding disorder who had uncontrollable nosebleeds, strips of cured pork, i.e. bacon, were used for control of bleeding in this patient. A wise man once told me about using salt pork for difficult-to-control nosebleeds. Guess the idea wasn't so far fetched.

Digging for gold

2012-02-09T19:20:00.000-08:00

One of the more common reasons to visit a pediatric ENT is fornosebleeds, also known as epistaxis. Nosebleeds are extremely common. These can range in severity from a small amount of blood in the nasalmucus to bleeding like from a faucet. Inany case, particularly when it happens in your child, it can be very scary.

Nosebleeds can happen at any time. One of the most common times is during sleep,where a child will wake up either in the morning, with blood on their pillow,or from sleep in the middle of the night with active bleeding from the nose.

The nose can bleed for many reasons. The anatomy of the nose explains the easewith which the nose seems to bleed. There is an extensive blood supply to the nose coming from all differentdirections. The middle part of the nose,or nasal septum, which divides the left and right side of the nose, has bloodsupply coming from the back of the nose, bottom of the nose and top of thenose. These all meet on the front partof the nasal septum in an area called Kisselbach’s plexus or Little’sarea. This network of vessels is under avery thin lining of mucosa. A smalldisruption of that mucosa, from a sneeze, nose picking, or a simple bump of thenose, can result in an injury to those vessels and a nosebleed.

While children are notorious for picking their noses, thereare many other reasons for this problem. A simple cold, nasal trauma, allergies, or anything that causescongestion can result in engorgement of the vessels increasing their prominenceand making them higher risk for injury. While most nosebleeds come from the front part of the septum, there areother more serious causes of nosebleeds which need to be evaluated by yourpediatric ear, nose and throat doctor. Anytime a nosebleed is associated with headaches, changes in vision,double vision, weight loss, loss of smell, or pain, it raises a concern ofsomething more significant occurring. These symptoms should be brought to the attention of your doctor rightaway.

In general, nosebleeds from the front of the nose are controllable. If the noseis actively bleeding, it is important to encourage your child, and for you, toremain calm. This will help keep bloodpressure low and help facilitate the bleeding vessel to clot. Firmly apply pressure to the soft part of thenose with your thumb and index finger and hold that pressure for 1 minute,watching the clock, without letting go. Youshould not apply pressure to the hard part of the nose or bridge of the nose asthis wont give pressure to the area most likely bleeding. Be sure to have your child’s head tiltedslightly forward so that blood is not running down the back of the throat.

After 1 minute, you should let go, again, trying not to haveyour child get upset and see if the bleeding has stopped. If it has, success, but if you have not, thenit is safe to use oxymetazoline (brand name Afrin) 1-2 sprays on each side,then hold pressure for 2 minutes without letting go. These maneuvers should stop the great majorityof nosebleeds. If this is unsuccessful,you should go to the emergency room or call your pediatric ear, nose and throatdoctor.

Now that we have stopped the nosebleed, we should focus onprevention. Encourage your child not toaggressively rub or pick their nose. Sometimes this is not enough. Ilike to have my children use a small amount of bacitracin ointment in eachnostril each night before bed. Afterapplying a small amount to each nostril, gently squeeze the soft part of thenose together and wipe away the excess. Body heat will melt the ointment, then, the natural function of the nosewill transport that ointment back through the nose. This provides both a low grade antibioticeffect as well as a moisturizing barrier effect to the mucosa of the nose. This should be done only if your child doesnot have an allergy to bacitracin. Youshould stop this after 2 weeks and be reevaluated.

Further workup should be done if this does not solve yourproblems. Your child may requirecauterization of the bleeding area in the nose, which can be done in theoffice. Also, an in office endoscopy tolook at the inside of the nose can provide additional information. Sometimes, blood tests and imaging may needto be ordered. Visit our website at www.childrenentdocs.com, like us on Facebook (www.facebook.com/ChildrensENT), and follow us on Twitter @DrEJ76 and @childrenentdocs.

My child failed his/her newborn hearing screening (part 3)

2012-01-29T18:26:00.000-08:00

We have now talked about the anatomy of the ear and thetests. Now let’s discuss what a failedhearing screening means and what will usually follow. In general, there are 2 types of hearingloss: sensorineural and conductive. Ifyou refer back to part 1 of the series, conductive hearing loss occurs whenthere is a break in the conduction of sound between the outside world and theend of the stapes or 3^rd hearing bone. The second type of hearing loss issensorineural, or nerve related. Thiscan occur within the cochlea or anywhere along the path of thecochlear/auditory nerve and remainder of the pathways from the cochlea to thebrain.

Conductive hearing loss is easy to understand. Something is blocking the sound from gettinginto the inner ear. There things thatcause a conductive hearing loss which result in a failed newborn hearingscreening. The most common of these isfluid in the ear canal or middle ear. The middle ear space is filled with fluid in general up untildelivery. As the baby is delivered, themovement through the birth canal helps push the fluid out of the middle earspace. When this does not happeneffectively, fluid can remain in the middle ear space and cause a conductivehearing loss and a failed newborn screening. This usually goes away after a short time, but it can persist for 4-6 monthsand may necessitate a procedure to drain the fluid from the ears.

A second cause of conductive hearing loss is a malformationof the ear canal called congenital aural atresia. This differs from a malformation of the pinnaor external ear called microtia. Bothcan cause difficulties with hearing but an isolated microtia does not usuallycause enough hearing loss to result in a failed hearing screening. When the ear canal has not developed, soundis unable to be conducted down it, thereby causing a conductive hearing lossand a failed newborn screening. It mayoccur with or without a microtia. Thisshould be evident on physical examination. Other causes of conductive hearing loss resulting in a failed newbornscreening include fixation of the hearing bones, poor development of thehearing bones, and a disconnection between 1 or more of the hearing bones.

Sensorineural hearing loss can also cause a failed newbornscreening. The conductive apparatus maybe fully developed and normal but if the sound pressure wave is not convertedinto electrical signal, sensorineural hearing loss will result. The number of causes of sensorineural hearingloss is vast. There can be infectiousreasons like cytomegalovirus (CMV), herpes simplex virus (HSV), meningitis orcongenital syphilis. There can becongenital malformations of the cochlea or balance system. There can be an error in the development ofthe cochlear/auditory nerve called auditory neuropathy. There can be impaired blood flow to the nerveor cochlea which causes the structure to have impaired function. Prematurity and jaundice are also riskfactors for sensorineural hearing loss.

After a failed hearing screening, your child will requirefollow-up with an audiologist, and, if another failed screening occurs, thenwith a pediatric otolaryngologist (ENT doctor). The second test is usually more thorough than the first and usually isdone when the baby is napping. Sometimesthis limits the amount of testing that can be done, especially if the baby iswaking up during the examination. Follow-upis very important as the earlier we are able to intervene, the less impactthere will be on speech and language development should that be your desiredmode of communication for your child. For more information about hearing loss and the services we offer, visitour website: www.childrenentdocs.com

My child failed his/her hearing screening (part 2)

2012-01-24T17:41:00.000-08:00

Now that we have reviewed how sound makes its way from theoutside world into the brain, today we are going to discuss the different typesof tests which make up a newborn hearing screen. The newborn hearing screening program wassetup as an early intervention program in an attempt to identify children withearly onset hearing loss and facilitate early treatment. Children with even mild hearing loss can havesignificant delays in their speech and language development.

There are 2 main tests which are currently used to perform anewborn hearing screening. The firsttest is called otoacoustic emissions, or OAEs. This test checks the hearing pathway from the outside world to thecochlea. It does not test cochlear/auditorynerve integrity or any of the pathways from the nerve to the brain. In order to have a normal OAE test, thehair cells of the cochlea must be present and healthy. They actually produce a very slight sound,which we cannot routinely hear, in response to a sound administered to the earthrough a very small probe. Thereforethe sound administered by the probe must be funneled to the eardrum, vibratethe eardrum, vibrate the hearing bones, and vibrate the membranes of thecochlea to vibrate these hair cells, which, in turn, produce a sound. The probe that produces the initial stimulussound is able to detect the sound produced by the hair cells, or the otoacousticemission.

OAEs are a good screening test, but have several importantlimitations. First, if there is ablockage of the ear canal, whether from ear wax, fluid or vernix, or adevelopmental malformation of the ear canal, the OAEs will be absent. Similarly, and abnormality in the ear oreardrum that blocks the conduction of sound will impair OAEs. That is because the sound cannot be conductedto the inner ear effectively to vibrate the hair cells. Secondly, one may have a perfectly intactcochlea with normal hair cells and have a profound hearing loss due to a breakin the pathway from the cochlea to the brain, an example of which is auditoryneuropathy where there is abnormal development of the cochlear/auditory nerve.

The second test is called automated auditory brainstemresponse testing, or AABR. This is anewer test which actually checks the integrity of the entire pathway ofhearing, including the area beyond the cochlea up to the brain. During this test, there is a probe which isplaced into the ear which administers a broad-band click stimulus at aconsistent level. This device thenmeasures, with probes that are placed on the head, the passing of that soundfrom the probe, through the ear, into the cochlear/auditory nerve and into thepathway from the brainstem to the brain. This test is very good at ruling out children who do not have hearingloss and ruling in children who do. Eachear is measured independently as in the other test.

While this test evaluates the more of the hearing pathway,it, too, has some limitations. First,this test is a pass/fail test. There isno interpretation possible. Therefore afailed test must be followed up with a formal auditory brainstem response (ABR)test. Second, the click stimulus is notfrequency specific. It generally testsfrom 1000 to 4000 Hz which are the frequencies thought to be most important forspeech and language, but there is much more to our hearing range than is testedwith a click stimulus. Finally, as withthe OAE test, the AABR depends on the conduction of the administered sound intothe inner ear and hearing pathway. Therefore any abnormality in the outer or middle ear could compromisethe result of this test.

Given the relative strengths and weaknesses of these tests,many institutions are using a combination of tests for newborn hearingscreening. Now that we have discussedthese tests and what they measure, in part 3 of our series we will discuss howwe deal with a failed newborn hearing screening and what follow-up is involved.

My child failed his/her hearing screening! (Part 1)

2012-01-23T18:21:00.000-08:00

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Amid all of the excitement of a newborn child, there areseveral tests that are run shortly after birth while your baby is in thenewborn nursery that are mandated by the state. One of those tests is a hearing screen which checks to see if the mostbasic parts of the hearing mechanism are intact. We are going to discuss the newborn hearingscreening, how it works, what the results mean, and what should be done infollow-up of an abnormal test in a 3-part posting. Please be sure to check back for the secondand third parts to follow shortly.

To understand the hearing screening test, we should firsttalk about how sound gets from the outside world into the brain. There are many important pieces which areneeded in order to hear sound. Sound isactually a pressure wave. That wave getsfunneled into the ear canal by the ear which you see on the side of the head,or pinna/auricle. Once in the ear canalthat wave is transmitted down to the ear drum, which it vibrates. The eardrum is connected to 3 of the tiniestbones in the body: the malleus, incus and stapes (or hammer, anvil and stirrupbones). When the sound wave hits theeardrum, the eardrum vibrates, and, as a result, the 3 hearing bones vibrate aswell. The 3^rd hearing bone(stapes) is connected to the inner ear and transmits that wave into the innerear.

Here is where all of the magic happens. The sound wave that is transmitted into theinner ear, or cochlea, vibrates delicate membranes that are within the body of thecochlea. There are cells along thosemembranes which respond to different frequencies of vibration. When that frequency of sound is present,those cells, called hair cells, activate and change that mechanical wave intoan electrical signal. This electricalsignal is then collected by the cochlear, or auditory, nerve which then takesthat information into the brainstem and relays it all the way to the temporallobe of the brain where that signal is perceived as sound.

For a basic animation to understand this process, pleasevisit: http://www.youtube.com/watch?v=tkPj4IGbmQQ

In the next part of this series, we will discuss the types ofnewborn hearing screening tests and what type of information these tests givesus as ear, nose, and throat doctors.

Thank you very much for reading our blog! Please check back again for parts 2 and 3 ofthis series.

Earache after swimming? We can help!

2011-09-05T19:23:00.000-07:00

Vacationing this weekend, I spent many hours in the water,both in the pool and at the beach. Aftermy first day I noticed that my ear was hurting a bit, which has prompted thisblog entry on swimmer’s ear, or otitis externa.

Swimmer’s ear is an infection of the outer ear, primarilywithin the external auditory canal or ear canal. This is a bony and cartilaginous structurewhich extends from the pinna, or ear you can see on the side of the head, downto the eardrum. It is separated from themiddle ear space by the eardrum.

Infections in the ear canal are common. They frequently come after a period of timeat the beach, lake or in the pool. Thefirst presenting signs include pain, fullness in the ear, hearing loss, anddrainage. These infections can be verypainful. Frequently though, theseinfections do not get attention until they are severe. Occasionally, over-the-counter ear remediesare tried. These include medicated paindrops, alcohol, peroxide, and anti-inflammatory pain relievers. These remedies can exacerbate the pain,particularly if the products contain alcohol.

With these infections, the ear canal swells and, as aresult, debris accumulates. This makes theenvironment darker and moister and the infection continues to worsen. The treatment of choice for otitis externa isototopical antibiotic drops. I prefer adrop with a steroid in it to help with the inflammation. Occasionally, the drops are unable to make itinto the ear canal. This is a problem inthat the drops actually have to make it into the ear canal to work.

This is where your otolaryngologist, or ENT, can help yourchild! When the ear canal is too swollento apply the antibiotic drops, sometimes this requires a debridement, orcleaning of the ear canal. If the earcanal is still too swollen, a wick may be placed to help transfer the dropsdown the swollen ear canal. This usuallystays in for 3 days and is then removed for the remainder of the duration ofantibiotic drop treatment. If theinfection is severe enough, with extension onto the face or into the bone ofthe ear, oral or possibly intravenous antibiotics may be required. This is very uncommon.

Remember swimmer’s ear when your child has ear pain afterswimming. This is common and is usuallywell treated with ear drops. Avoidputting cotton swabs in the ears and do not wait too long to seek treatment. Your ENT can help if routine treatment doesnot solve the problem. For more information about this and other ear pathology visit the Children's Ear, Nose and Throat Associates webpage.

I only use it on the outside…

2011-09-01T16:59:00.000-07:00

When I ask parents on their initial visit with me if they use cotton swabs, this is frequently the response I get. They insist that they only use cotton swabs on the outside of the ear and that they NEVER go into the ear canal. I have even heard this and ended up pulling several cotton swab heads out of the ears.

The reason people frequently use cotton swabs is to remove earwax, or cerumen. Cerumen is normal in the appropriate amount. It functions to protect the ear canal as a mechanical barrier and an anti-bacterial layer. Normally, cerumen is worked naturally out of the ear canal with normal movements of the jaw and ear canal.

Occasionally, cerumen gets stuck in the ear canal. This can cause problems on multiple levels. The biggest concern is for resulting hearing loss. A significant cerumen impaction can result in a 30-40 dB hearing loss. Prolonged cerumen impactions can become severe enough to cause erosion of the ear canal. A significant cerumen impaction can also allow water to get trapped in the ear canal. This moist, dark environment is a perfect breeding ground for yeast, mold, and bacteria which can setup a significant infection of the ear canal, or otitis externa.

Cotton swabs frequently facilitate these deeper cerumen impactions as instead of removing the wax, they actually plunge the wax further down the ear canal. Furthermore, they can cause microtrauma to the skin of the ear canal resulting in small injuries which can more easily become infected.

“But how do I clean my child’s ears?” This is one of the more common questions I hear in the office. The truth is, we should not have to do much to clean the ears; they are quite good at cleaning themselves. Occasionally the cerumen will become too thick or dry to work out of the ear canal. In these instances, using a drop or 2 of mineral oil in the ear canal once per week can soften the earwax and help get it out of the ear canal. If this is not enough, your ear, nose and throat doctor can use specialized suctions and instruments to get the cerumen out SAFELY!

“What about over the counter remedies?” There are numerous things sold over the counter that can be used to clean the ears. Beyond mineral oil, I would not recommend any of these. Ear candles, in particular are dangerous, with common injuries including burns and rupture of the eardrum. In fact the FDA has expressed concerns over these as well. However, there are no randomized studies of ear candles in the management cerumen impactions. Other ear drops and remedies are not recommended unless used under the direct supervision of your doctor.

So remember, nothing smaller than your elbow in your ear. Cerumen impactions can cause significant issues for your child, so be aware of this as a source of hearing loss, ear pain, and infections.

You put what...where???

2011-08-30T17:49:00.000-07:00

As September approaches, most of our children have returned to school to begin another year of learning and fun. Younger children tend to have a lot of arts and crafts time and are fascinated with all of the beads, beans, pompoms and foam shapes with which they get to play and craft. Children, for some reason, also have a fascination with placing these things in their ears and nose.

Frequently, objects in the ear will not be noticed until either the child says they put something in their ear, or until they are being seen by their pediatrician for a well-child or sick visit. While objects like beads and erasers and so forth don’t interact with the ear much to cause significant inflammation; other items, like vegetable matter (popcorn kernels, beans), can cause a significant amount of inflammation and swelling. This could result in pain, swelling, and drainage from the ear. Further problems including ear drum perforation or hearing loss can result.

Objects in the nose are more often easier to detect. This is likely secondary to the nature of the lining of the nose being able to produce mucus. When a foreign body is placed in the nose, there is usually an inflammatory response which results in excessive mucus production and may actually be diagnosed as sinusitis. Failure to recognize a foreign body in the nose may result in scarring, bleeding, and potentially, if the object is large enough, an injury to the septum, or cartilage in the middle of the nose.

The treatment for a foreign body in the ear or nose seems simple: just take it out. In reality these can be some of our most challenging cases. For objects in the ear, particularly ones that can swell, they can enlarge enough to get stuck on the bone of the ear canal and become unable to be removed in their entirety. For objects in the nose, they can be stuck between the turbinate and the septum and be quite far back and difficult to see. It is about 3 inches from the tip of the nose to the back of the nose so there is a lot of room for things to hide.

Your ear, nose and throat doctor can use a variety of tools to help remove these objects. Frequently, microscopes, endoscopes, specialized suctions and forceps have to be used. This can require a high level of expertise and experience to be successful and prevent injuries to surrounding structures. Most of the time, though, we are able to get these objects out in the office without a trip to the operating room.

So, keep a foreign body in mind if your child unexpectedly starts complaining of ear pain or having drainage from just one side of the nose. Get your child evaluated and visit an ENT specialist to help solve your problem. Finally, encourage your children to not put things in their ears and noses!

God made dirt…and dirt don’t hurt!

2011-08-28T16:22:00.000-07:00

This popular saying has justified how we have encouraged our children to not be afraid to get dirty. Whether on the little league field sliding for home or scooping out worms to go fishing with grandpa, getting dirty has always been synonymous with growing up.

While exposures to dirt seem harmless enough, as the evidence frequently washes off with a little soap and water, there can be things lurking in the dirt that can cause problems for your kids. Atypical, or nontuberculous, mycobacteria are organisms that live in our water and soil. Younger children are affected most commonly by these organisms, particularly during the teething years. This is felt to be secondary to the amount of time these children spend with their hands in their mouths. Unfortunately, the kids aren’t washing their hands before they put their dirty hands in resulting in potential exposures.

The organisms of concern are from the same family of organisms that cause tuberculosis. Don’t worry! They do not cause the same type of infection as tuberculosis. M. avium has replaced M. scrofulaceum as the leading cause of infections in children. These infections typically cause a swelling of the lymph nodes (glands) in the neck. The typical course of the infection after exposure is a gradual swelling of the lymph nodes of the neck. Other systemic features are rare. In a study from Australia, the incidence of infection was less than 1 in 100,000 children. The route of transmission is thought to be from a cut or break in the skin or mucosa.

These infections typically progress because they do not cause a lot of systemic symptoms. There is usually no fever and, until the neck lymph nodes get really large, they are typically not observed. Some infections present with a discoloration of the skin, and some even present with a wound in the skin with a cottage cheese consistency drainage.

Treatment usually involves multiple components. If the infection is caught early, antibiotics (clarithromycin/Biaxin) may be enough to treat the infection. Frequently, though, surgical intervention is needed. Studies suggest curettage and surgical excision are the 2 primary modes of treatment. The recurrence rate is high with reports as high as 23%. In the literature, surgical excision is preferred if possible to remove the node and not injure important surrounding structures.

Keep this in mind if you see swelling of the lymph nodes which doesn’t go away after a cold. Ask your doctor about the possibility of this, and, if a neck lymph node persists, consider an evaluation by your local pediatric ear, nose, and throat doctor. We work together with our infectious disease doctors to give you a team approach to the care of your child.

While it is impossible to keep your child’s hands out of their mouth, particularly during teething time, fortunately these infections are rare. Try to keep their hands clean, but kids will be kids.

Five little monkeys jumping on the bed...

2011-08-25T19:40:00.000-07:00

In the book Five Little Monkeys Jumping on the Bed by Eileen Christelow, the mischievous monkeys carelessly take to jumping on the bed against their doctor’s orders. While the story is entertaining, and all is well that ends well, when this happens in real life, significant injuries can occur.

Penetrating palate trauma from kids jumping on the bed with an object in their mouth, or even just running around is a common cause for a visit to the emergency department. While the great majority of these cases result in little more than a laceration or contusion (bruise) to the soft palate, significant problems can arise from such an injury.

Because of the shape of the palate and the fact it has both a bony (hard palate) and muscular (soft palate) component, objects tend to be directed to the back of the throat. Here, the soft tissue of the soft palate is easily penetrated by these objects which range from wiffle ball bats to pens and pencils. Obviously, if the object is sharp, it is likely to penetrate into these structures more deeply.

Fortunately, the lining of the back of the throat includes firm layers of fibrous tissue (fascia) in front of bone (spine) and are infrequently significantly injured. Unfortunately, penetrating injuries to the soft palate can result in a defect which goes into the nose. This can, if not treated properly, result in a hole between the 2 cavities (oro-nasal fistula). This can end up causing a change in voice and reflux of things through the nose when eating and drinking. Furthermore, it can be very challenging to repair.

More concerning, however, are the structures which lay to the sides of the throat. Large blood vessels which come from the heart (the carotid arteries) travel right along side the throat. While they do sit a little deeper in the neck, and, as a result, are infrequently penetrated by the object, the carotid arteries can be bruised by the object resulting in the formation of a blood clot. This can alter blood flow and potentially travel to the brain and cause a decrease in blood flow or stroke. While this is very uncommon, with only 32 reported cases through 2006, this injury can be prevented by good supervision of children and early education not to run, jump, or play with objects in their mouths.

The treatment for most injuries involves observation, primarily of the child’s mental status after the injury. If the wound is far enough away from the midline, your doctor may recommend a CT scan to look at the structure of the arteries. Surgery is needed only if the laceration is very large, there is a flap of tissue present, a through-and-through injury is suspected into the nose, or there are retained foreign bodies within the wound.

So while the five little monkeys all ended up at the doctor thanks to quick action by their ‘mama’, everyone survived without significant injury, and fell fast asleep.

Welcome to our blog!

2011-08-21T15:29:00.000-07:00

Children's Ear, Nose and Throat Associates (CENTA) is pleased to announce the development of our first blog, highlighting issues in the care of children with disorders of the ear, nose and throat. The blog will be written by physicians specializing in pediatric otolaryngology (ENT). We will highlight topics that come up in our practice on a day-to-day basis, as each day provides a learning experience for us. Our hope is to turn our experiences into education for parents and families and to heighten awareness of issues facing children with regard to the ears, nose or throat. Please be sure to visit our homepage for more information about our practice. You can also follow us on Facebook and Twitter. We look forward to sharing our experiences and will be posting to you soon!