Tonsils and adenoids: not just there to take out!

After a long hiatus, I have returned with anticipation to the blogging arena.  I wish I had a great excuse for being absent for so long.  As time has gone by, however, I realized just how quickly that time has faded into a memory.   

In reflecting on the last 8 months...yes...it has been 8 months since I last wrote... I was trying to think about a topic that I have really needed to address during that time.  Something that I have seen frequently.  Something where trends have changed and new guidelines have been published.  Ah, yes, I know it...we will discuss tonsils and adenoids.

First, let's discuss a little anatomy (click link for picture).  The tonsils and adenoids are part of a surveillance system for the upper airway.  The tonsils sit on either side of the throat at the level of the soft palate and the adenoids sit above the palate at the back of the nose.  Things (antigens) that are recognized as foreign coming into the nose or mouth are identified in these tissues and antibodies (defenses) are made to fight them.  The greatest contributions of tonsils and adenoids to immunity are made in the early years before age 10.  After that, their function decreases, perhaps secondary to the fact that these tissues have seen most of these antigens and do not have to work hard to produce antibodies against them.  This is why the tonsils and adenoids decrease in size, when kids get older, to nearly nothing in most adults.

So one might ask...if the tonsils and adenoids go away eventually, why do they have to be taken out?  That is an excellent question.  By the numbers, tonsillectomy and adenoidectomy procedures have actually decreased over the years due to changes in the criteria for candidacy for the procedure.  Back in the old days, tonsils were frequently taken out because they looked big or for just a few infections.  The current recommendations from the American Academy of Otolaryngology are for tonsils to be removed for infectious reasons for 7 infections in 1 year; 5 infections per year for 2 consecutive years; or 3 infections per year for 3 consecutive years.  These are strict criteria, but they do not indicate that each of these infections has to be strep throat.  Other infectious reasons for surgery could include recurrent peritonsillar abscess.

Nearly 80% of tonsillectomies done today are done for sleep disordered breathing or obstructive sleep apnea.  This is a disease of too much tissue in the back of the throat.  When the tonsils are enlarged, they occupy space in the throat, sometimes creating a blockage when the muscles of the throat relax during sleep.  This can present as snoring, restless sleep, frequent awakenings, and even pauses, choking and gasping during sleep.  This does not mean that all sleep apnea in children is caused by enlarged tonsils, but they are frequently contributing. 

Frequently parents will come into the office with a presumption that the tonsils need to be removed purely because they are big, or for 1 or 2 infections.  Your ENT physician will work with you to get a history of exactly how those big tonsils are affecting your child and what other options are available for treatment.  During your evaluation, some additional workup may be required including a sleep study, a neck x-ray, or potentially laboratory studies.  In our next installment, we will discuss the  procedure including potential risks, surgical considerations, and post-operative expectations.  Please check out Dr. EJ on Twitter @DrEJ76 and like us on Facebook: www.facebook.com/ChildrensENT.  

And don't forget the bacon!

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

One of the more common reasons to visit a pediatric ENT is for nosebleeds, also known as epistaxis.  Nosebleeds are extremely common.  These can range in severity from a small amount of blood in the nasal mucus to bleeding like from a faucet.  In any 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 ease with which the nose seems to bleed.  There is an extensive blood supply to the nose coming from all different directions.  The middle part of the nose, or nasal septum, which divides the left and right side of the nose, has blood supply coming from the back of the nose, bottom of the nose and top of the nose.  These all meet on the front part of the nasal septum in an area called Kisselbach’s plexus or Little’s area.  This network of vessels is under a very thin lining of mucosa.  A small disruption of that mucosa, from a sneeze, nose picking, or a simple bump of the nose, can result in an injury to those vessels and a nosebleed.

While children are notorious for picking their noses, there are many other reasons for this problem.  A simple cold, nasal trauma, allergies, or anything that causes congestion can result in engorgement of the vessels increasing their prominence and making them higher risk for injury.  While most nosebleeds come from the front part of the septum, there are other more serious causes of nosebleeds which need to be evaluated by your pediatric 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 of something more significant occurring.  These symptoms should be brought to the attention of your doctor right away.

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

After 1 minute, you should let go, again, trying not to have your child get upset and see if the bleeding has stopped.  If it has, success, but if you have not, then it 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 majority of nosebleeds.  If this is unsuccessful, you should go to the emergency room or call your pediatric ear, nose and throat doctor.

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

Further workup should be done if this does not solve your problems.  Your child may require cauterization of the bleeding area in the nose, which can be done in the office.  Also, an in office endoscopy to look at the inside of the nose can provide additional information.  Sometimes, blood tests and imaging may need to 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.  

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.