Tonsillectomy and adenoidectomy

     In followup to our last post, today we are going to talk about tonsillectomy and adenoidectomy.  As we discussed, the indications for this procedure have changed greatly over the last 20+ years.  Formerly, it was a procedure done for infections and now it is much more frequently done for obstructive sleep apnea.  Whatever the indication for surgery, the procedure really is the same. 

     For children, the day before surgery your doctor will generally want them to have nothing to eat or drink after midnight.  This can be variable from center to center so be sure to discuss this with your doctor at your appointment.  It truly depends on the time of day your child will be going to surgery.  Once at the surgery site, your child will be checked in and routinely will go to a preoperative holding area ("PREOP").  There, your child will get a gown, get their vitals taken, meet the operating room team, see your doctor as well as meet and talk with the anesthesiologist.  This is a great time for any last minute questions that have come up since your last appointment.

     Depending on the child and the medical condition, your child may receive some relaxing medicine in the preop area.  Then, it is off to the operating room.  The anesthesia team will put your child to sleep and then the surgery begins.  The surgery time, from the time the patient leaves your side to the time the doctor comes to talk to you is about 30-45 minutes.  Afterwards, the anesthesiologists begin the wake-up process and the children come to the recovery room.  Once safe and awake, you will be called back to be with your child.  Some children will be required to stay overnight in the hospital for observation.  This will be at the discretion of your surgeon.  Usually, most children are able to be discharged the morning after surgery if required to stay. 

     The first 5-7 days are usually the most difficult in the recovery.  Then the children are starting to feel a bit better.  They should maintain a soft diet for 2 weeks after surgery.  This means nothing crunchy to eat.  No chips, crackers, cookies, crusty breads, or pizza crust.  Popsicles, ice cream, macaroni and cheese, mashed potatoes, and things like these are good things with which to start.  We also ask that you keep the child's activity under control for the first 2 weeks after surgery.  This can be difficult, which we understand, particularly during that second week.  We generally recommend a week home from daycare or school and then they may return with the understanding that they will have a reduced activity for the next week.

     There are many different techniques to remove the tonsils and the adenoids.  You may hear about cold dissection, coblation, electrocautery, microdebriding, laser, and others.  Just remember that these are all tools that your doctor can use to accomplish the goal of removing the tissue that needs to be removed.  This will vary from surgeon to surgeon. 

     Even though this procedure is one of the most common procedures done across the United States, there are still risks involved.  In general, we go through the mouth to remove the tonsils and adenoids.  This places the lips, teeth and gums at risk because they are in the path of getting equipment into and out of the mouth during the procedure.  The risk of a severe injury is rare.  Things to consider include dislodging of a loose tooth and a burn to the lips as potential problems. 

     Bleeding is the risk we tend to worry about the most.  The risk of bleeding from the nose or mouth after removing the tonsils and adenoids is around 1-3%.  That risk has been stable in the literature throughout the years.  Fortunately the chance of severe bleeding is rare, and the chance of needing a blood transfusion or something worse happening is very uncommon.  If there is any bleeding from the nose or mouth after surgery, be sure to contact your doctor.

     Removing the tonsils and adenoids is a painful procedure.  This is likely related to the fact that the tonsils sit in a bed of muscle, and, in addition to that, we are creating a large open wound like a big ulcer in the back of the throat.  Your doctors will give you an appropriate pain regimen for after surgery but you have to encourage your kids to take it.  It is also important that the throat stay well hydrated during this time.  A dry throat after surgery is very painful and can lead to not wanting to drink and more pain until one ends up back at the hospital with dehydration. 

     When the tonsils and adenoids are removed, we are increasing the space in the back of the throat.  Sometimes, it is too much space and the body is not able to compensate for that.  Particularly, the palate can have a difficult time closing the gap between the throat and the nose.  This may result in a change in the voice to a hypernasal quality.  You might think that your child already has a nasal voice from this tissue, but in general, that is a hyponasal voice: an obstructed voice from too much tissue in the back of the throat and nose.  If this happens, it frequently will resolve on its own.  If not, about 1:1,000 children will require speech therapy or potentially even surgery to correct this.

     There are small risks of the adenoids regrowing or scarring in the back of the nose.  These happening to any significant degree is rare, but may mean an additional surgery or medication down the line. 

     For these reasons, we as surgeons try to make sure you as parents are well informed prior to making a decision to go to surgery.  Be sure to ask any questions that you have so that you are able to make the best decision.  After surgery, be sure to contact your doctor after for a fever over 101.5, pain uncontrolled by medication, bleeding, poor oral intake, decreased urination, or any other concerns. Please check out Dr. EJ on Twitter @DrEJ76 and @childrenentdocs and like us on Facebook:www.facebook.com/ChildrensENT.

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

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

There are 2 main tests which are currently used to perform a newborn hearing screening.  The first test is called otoacoustic emissions, or OAEs.  This test checks the hearing pathway from the outside world to the cochlea.  It does not test cochlear/auditory nerve integrity or any of the pathways from the nerve to the brain.    In order to have a normal OAE test, the hair 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 ear through a very small probe.  Therefore the sound administered by the probe must be funneled to the eardrum, vibrate the eardrum, vibrate the hearing bones, and vibrate the membranes of the cochlea to vibrate these hair cells, which, in turn, produce a sound.  The probe that produces the initial stimulus sound is able to detect the sound produced by the hair cells, or the otoacoustic emission. 

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

The second test is called automated auditory brainstem response testing, or AABR.  This is a newer test which actually checks the integrity of the entire pathway of hearing, including the area beyond the cochlea up to the brain.  During this test, there is a probe which is placed into the ear which administers a broad-band click stimulus at a consistent level.  This device then measures, with probes that are placed on the head, the passing of that sound from the probe, through the ear, into the cochlear/auditory nerve and into the pathway from the brainstem to the brain.  This test is very good at ruling out children who do not have hearing loss and ruling in children who do.  Each ear 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 is no interpretation possible.  Therefore a failed test must be followed up with a formal auditory brainstem response (ABR) test.  Second, the click stimulus is not frequency specific.  It generally tests from 1000 to 4000 Hz which are the frequencies thought to be most important for speech and language, but there is much more to our hearing range than is tested with a click stimulus.  Finally, as with the OAE test, the AABR depends on the conduction of the administered sound into the inner ear and hearing pathway.  Therefore any abnormality in the outer or middle ear could compromise the result of this test.

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

Earache after swimming? We can help!

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

Swimmer’s ear is an infection of the outer ear, primarily within the external auditory canal or ear canal.  This is a bony and cartilaginous structure which extends from the pinna, or ear you can see on the side of the head, down to the eardrum.  It is separated from the middle ear space by the eardrum. 

Infections in the ear canal are common.  They frequently come after a period of time at the beach, lake or in the pool.  The first presenting signs include pain, fullness in the ear, hearing loss, and drainage.  These infections can be very painful.  Frequently though, these infections do not get attention until they are severe.  Occasionally, over-the-counter ear remedies are tried.  These include medicated pain drops, 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 a result, debris accumulates.  This makes the environment darker and moister and the infection continues to worsen.  The treatment of choice for otitis externa is ototopical antibiotic drops.  I prefer a drop with a steroid in it to help with the inflammation.  Occasionally, the drops are unable to make it into the ear canal.  This is a problem in that the drops actually have to make it into the ear canal to work.

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

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