• How early should I have my baby’s hearing screened?

• How is Hearing screening in newborn done?

• What are the advantages of OAE screening?

• What does ‘REFER’ or ‘FAIL’ mean?

• What is the Hearing Screening Protocol at Audicco Gliriaa?

• What are some of the warning signs of hearing loss in an infant?

Why Newborn Hearing  Screening?

Newborn babies learn to recognize the familiar sounds in their home in their first few months of life.  Baby if can’t hear the sound, can’t speak, profound hearing loss can lead to dumbness.  Even partial Hearing loss in children can impair normal development of speech & language, his emotional balance, academic & intellectual skills and it affects individual for the rest of his life.

Subjective methods, such as ringing bells and hand clapping have not proven to be reliable for screening. Prior to Objective hearing tests such as OAE, infants with hearing loss typically remained unidentified until 2 ½ years of age. – far too late for optimal language development.

How early should I have my baby’s hearing screened?

  Your baby should have a hearing screening at birth or within the first month of life. If hearing loss is confirmed, it’s important to consider the use of hearing Aids or Cochlear Implant by 6 months of age. Hearing should be tested as child grows at any time on slightest suspicion of hearing deficit by Parents, care givers, teachers and family doctors.

How is Hearing screening in newborn done?

The procedure is performed with a portable hand held screening unit.

OAE screening–A small probe is placed in the child’s ear canal. This probe delivers a low-volume sound stimulus into the ear.

Tone or click stimuli are delivered, which travels from middle ear to inner ear where OAE is generated by the outer hair cells of the cochlea. This travels back and is measured with a microphone.

In approximately 30 seconds, the result is displayed on the screening unit as a “pass” or “refer.”

Automated ABR screening – Disposable surface electrodes are placed high on the forehead, on the mastoid, and on the nape of the neck.

The click stimulus (usually set at 35 dB hearing level [HL]) is delivered to the infant’s ear via small disposable earphones designed to attenuate background noise.

As with OAE screening, the sound travels through the outer, middle, and inner ear. However, in ABR, the sound continues along the eighth nerve to the brain.

An electrical response from that nerve is picked up by electrodes strategically placed on the infant’s head. This response is recorded and analyzed.

However, it lacks frequency-specific information and requires increased preparation time prior to testing.

What are the advantages of OAE screening?

Handheld otoacoustic emissions (OAE) screening is the most practical method for screening infants and toddlers because it :

• objective and not dependent on a behavioral response from the child
• Reliable and efficient
• Help to detect sensorineural hearing loss and wide range of hearing-health concerns.
• Is quick and painless
• Simple and portable

What does ‘REFER’ or ‘FAIL’ mean?

Refer, an absent response to a click, does not always mean total deafness, but it does mean that your baby needs his/her hearing looking at more carefully.

The ear will not pass the screening if there is –

(a)  Blockage in the ear canal by wax or  amniotic,

(b) Structural problem or excess fluid in the middle ear

(c) Impaired cochlea that is not responding normally to sound.

What is the Hearing Screening Protocol ?

 All newborn should be screened at birth, or, within a month’s time.

Visual inspection – Outer ear abnormalities, foreign objects or blockage in the ear canal, any fluids draining from the ear, or noticeable odor; if any abnormal conditions are present, medical management should be done by ENT specialist.

Ist OAE screening – If both Ears Pass the test, the child’s hearing screening is considered complete

Those who have high-risk for hearing loss should be followed up at intervals of 6 months even if they are cleared at the screening. (As per Joint Committee on Infant Hearing 2000 position statement)

If the child does not pass the screening on any ear child is evaluated and managed by ENT specialist for a possible middle ear disorder within 3 months of age.

Repeat OAE screening- After treatment and/or medical clearance is obtained, the OAE screening is repeated.

If the ear passes the test, no further screening

However, if the ear dues not pass the Repeat test child is referred to a pediatric audiologist for complete Hearing evaluation like BERA (ABR), ASSR and Impedance.

Appropriate measures such as hearing aid fitting initiated before 6 months.

What are some of the warning signs of hearing loss in an infant?

If your child does not startle to loud noises or awaken from sleep by very loud noises in the house.

If your child is not babbling repetitively (ba ba, da da, etc.) by 8-10 months or

if your child doesn’t turn to localize the source of your voice by 7-8 months, you should be suspicious.

Ask for an objective set of tests. 

A teenage girl visited ENT clinic with her mother with ringing in the ear and felt like cotton in the ear. Previous night,  Diwali Night she had spent several hours setting off the fire crackers.

Her ear were normal on video otoscopy and Audiogram showed  35 db at 4000 and 8000 hertz, Several days later, her hearing had returned to normal.

This patient is an example of a “temporary threshold shift.” Or Reversible Hearing Loss by exposure to an intense “impulse” sound such as fireworks or loud rock concert.

If sound is too loud or duration of exposure is long enough, such as noise generated in a woodworking shop it may lead to permanent threshold shift.  This condition is called Noise Induced Hearing Loss which has no cure.

Acoustic trauma occurs when excessive sound energy strikes inner ear. When we are exposed sounds that are too loud or loud sounds that last a long time—small sensitive structures in our inner ear, called hair cells, can be damaged, Hair cells convert sound energy into electrical signals that travel to the brain. The louder the sound, the shorter the time period before NIHL can occur.

Sound is measured in units called decibels. Continual exposure to more than 85 decibels (dB) is dangerous to the ears. Firecrackers emit sounds from 120 to 160 decibels. Sound with 140dB can cause ear ache. A very high intensity sound (above 160 dB) may also damage the ear drum and can cause dislocation of middle ear ossicles.

An even higher intensity may cause leakage of inner ear fluid leading to permanent hearing loss associated with dizziness.

Symptoms

• Hearing loss
• Sense of fullness  the ear
• Noises, ringing in the ear
• Earache
• Bleeding from the are
• Dizziness,

Signs and tests

Acoustic trauma is suspected if hearing loss occurs after noise exposure. Audiometry may determine how much hearing has been lost. Audiogram has typical “notch” at 4000 hz, with better hearing at both lower and higher frequencies. Otoacoustic Emisson (OAE) testing is very sensitive to noise induced hearing loss.

Treatment

The hearing loss may not be treatable. The goal of treatment is to protect the ear from further damage. Hearing aid is prescribed for communication needs. If ear Drum is ruptured, surgery to repair ear drum may be needed.

Ear protection using noise protector ear plugs or ear muffs may prevent the hearing loss from getting worse.

Noise exposure, whether occupational or recreational, is the leading preventable cause of hearing loss. It can be prevented by avoiding “too loud” or “too long” Noise exposure and use of hearing protection when necessary.

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It’s a Noisy Planet. Protect Their Hearing campaign, a program of the National Institute on Deafness and Other Communication Disorders (NIDCD).

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Different people with autism can have very different symptoms hence term “Autism Spectrum Disorder” (ASD).

Early signs of autism spectrum disorder are usually present before 18 months and parents usually know that there is something wrong with their kid. Family members and health care providers should value parent’s instinct and give importance to concern relating to child’s development.

Health care provider should know the fine line between typical and atypical development and should be able to recognize the Red Flags which indicates that a child should be evaluated and screened.

New born hearing screening and developmental screening should be done on slightest doubt.

Treatment should begin as early as possible by validated screening tools and should be tailored for every child to meet his needs.

Early intervention and educational approach may help in improving quality of life for autistic kid & family members.

Possible Red Flags for Autism

Social Interaction:

• The child does not respond to his/her name.
• The child doesn’t smile when smiled at.
• The child has poor eye contact.
• The child seems to be in his/her “own world.”
• The child seems to tune people out.
• The child is not interested in other children
• The child seems to prefer to play alone
• The child throws intense or violent tantrums.
• The child is overly active, uncooperative, or resistant.
• The child doesn’t know how to play with toys.
• Child does not play ‘pretend’ games.
• The child gets things for him/herself only.
• The child is very independent for his/her age.
• The child does things “early” compared to other children.
• Have trouble understanding other’s feeling or talking about their own feeling

Communication:

• Not speak as well as other children his/her age?
• The child cannot explain what he/she wants.
• The child’s language skills are slow to develop or speech is delayed.
• The child doesn’t follow simple directions.
• At times, the child seems to be deaf
• unusual voice quality

Repetitive Behaviors & Restricted Interests:

• Repetitive movements with objects
• Repetitive movements or posturing of body, arms, hands, or fingers
• The child gets “stuck” doing the same things over and over and can’t move on to other things.
• Repeat words or phrases said to them
• Child spends a lot of time lining things up or putting things in a certain order. Have trouble adapting when routine changes.

Screening should also be done If the child…

• Does not babble or gesture by 12 months of age
• Does not say single words by 16 months of age
• Does not say two-word phrases on his or her own (rather than just repeating what someone says to him or her) by 24 months of age
• Has ANY loss of ANY language or social skill at any age.

Source- Center for Disease Control and Prevention (CDC)

On Autism Awareness Day aim should be to educate parents, health care providers, and child educators to identify and act early.

Sleep problems affect quality of life for up to 45% of world’s population and is a major public health concern.

Most sleep disorders are preventable or treatable, yet because of lack of awareness only few seek professional help. Awareness about health effects of lack or disturbed sleep should be raised in general public especially students, BPO industry workers, transport services. Medical practitioners should be trained for diagnosis of sleep related disorders.

Poor sleep may be due to obstructive sleep apnea, poor life style, anxiety, depression etc. Snoring could be an indication of sleep apneas but usually ignored or discussed as a fun.

Watching television and using computers and mobile phones at night can prevent getting enough sleep.

WSD (World Sleep Day) 2011 is being held on March 18th, under the slogan ‘Sleep Well, Grow Healthy’. This year’s theme highlights the importance of sleep for all ages.

Sleep Hygiene: Healthy Sleeping Practices (How to sleep Well?)

1. Set up biological clock, Fix time to sleep and time to get up.  Follow age old saying “early to bed and early to rise makes a man healthy, wealthy and wise”.  It holds true scientifically.
2. Exercise regularly and follow a healthy diet
3. Limit daytime naps to 30-45 minutes.
4. Avoid tea, coffee, chocolates and smoking 6 hours before bed time.
5. Avoid heavy and spicy food, sweets and alcohol 4 hours before bedtime
6. Avoid watching horror or action movies before going to bed.
7. Avoid exercising just before bed.
8. Wear loose comfortable clean cloths
9. Use comfortable clean bedding.
10. Keep the room well ventilated,  free from noise.
11. Go to bed when you feel like sleeping.
12. Reserve bed for sleeping, avoid working or studying in bed.

Sleep related problems and sleep apnea apnea can have serious significant complications yet vast majority remain undiagnosed and untreated because of lack of awareness by the parents and health care providers.

Snorer with excessive daytime sleepiness or lack of concentration,  and all children with ADHD, behavioral problems & poor academic performances should be assessed for sleep problems.

People having minor itching in the ear to the people hearing less- everybody want to quick fix the things with magical ear drop. If I mildly, jokingly or sometimes with force refuse the request to write the ear drops for relatives there is always a helping chemist to amuse them with the one perfect for the need.

So there are things which really don’t need an ear drops but at times it is absolutely necessary to talk about ear drops not to just prescribe the one.

Almost every one will agree that to be effective medicine should reach to the site of infection, so ear drops must also be delivered to the site of infection which is external ear canal in case of otitis externa & wax and middle ear in case of otitis media. Almost all cases of ototopical therapy failure are due to inadequate drug delivery.

Topical drug delivery can be improved in a number of ways–

Steps followed by the ENT professionals-

Hands should be cleaned with disinfectant.

Careful cleaning of ear (aural toilet) is prerequisite. The external auditory canal should be mopped dry prior to instillation of ear drops.

If too much of thick secretion is present irrigation of the external auditory canal with a small bulb syringe can be done before instillation of ear drop.

In case of refractory acute otitis media with tympanostomy tube fenestrated otowicks may be used to allow drainage and ventilation of the middle ear. Ear wicks of ribbon gauze may also be used in case of otitis externa.

In cases of failure to respond to drug health care provider should always keep in mind the possibility of diabetes, mastoiditis, cholesteatoma or MRSA ( methcillin resistant ) or immunocompromized status.

Steps to be explained to the patients

1. Wash hands with soap and water.

2. Clean outer part of the ear very gently ( do not use cotton buds inside the canal)

3. Shake the bottle well for 10 seconds to thoroughly mix

4. The patient should preferably be lying down with the affected ear up

5. Ear should be gently pulled backward and upward to straighten the canal to provide a linear path into middle ear (child younger than 3 years of age, pull backward )

6. Instill the number of drops in the ear as recommended.

7. Shake the ear and by one finger repeatedly press and release the tragus (small elevated part in front of the ear) to help better delivery of ear drops.

8. Keep the treated ear in the upright position for an average of 5-10 minutes (the longer, the better) after ear drops are instilled.

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One thing I never fail to warn my patient with ear wax not to try to clean the wax by themselves after putting the drops however tempting it may be as wax may be further pushed inside and become impacted.

In case you experience pain or giddiness following an use of ear drop report to your doctor.

To decide we need to make a diagnosis first…

To understand the definitions- What is AOM and OME?

Acute otitis media AOM – an acute bacterial infection of the middle ear of less than 6 weeks duration

There is usually pain in the ear and fever. If ear drum ruptures there may be pus discharge (Otorrohea) from the ear with rapid relief of pain. Pus may be mixed with blood.

Chronic suppurative otitis media (CSOM) – If ear drum infection persists for more than 3 months and is associated with a chronic perforation of the tympanic membrane.

Otitis media with effusion (OME) - Fluid in the middle ear without signs or symptoms of inflammation

It can occur just prior to AOM or persist after AOM for a few days or up to many weeks.

How we decide about giving antibiotic?

Age and severity of symptoms are deciding factors but most important is correct diagnosis.

• If it is OME antibiotics are unnecessary.

• Uncomplicated AOM in an otherwise healthy child above 2 years of age where we are assured that parents will be coming for follow up visit can be considered for observation without use of antibiotic.

• If child is less than 6 months of age antibiotics are to be given even if diagnosis is not certain. (Contrary to parent’s belief that small kid should not be given antibiotics).

• Most controversies exists in treating child above 6 months but less than 2 years of age where current guidelines by the AAP (American Academy of Pediatrics) and AAFP (American Academy of Family Physicians) advises to avoid antibiotic for uncertain diagnosis or if illness is mild.

So How Do We Diagnose Ear Infection?

Distinguishing OME (Otitis Media with Effusion) and AOM (Acute Otitis Media)

OME is usually caused when the eustachian tube is blocked or mucus production is more and fluid becomes trapped in the middle ear. This often occurs after a common cold or viral infection, but it can also occur after an episode of AOM.

It is common in a child because eustachian tubes are shorter and more horizontal as compare to adults and muscles to close the tube are not properly developed in children.

Symptoms – The child with OME does not have ear pain or draining ear. He may have slight hearing impairment. There may be history of frequent URTI & mouth breathing.

Examination of Ear by Pneumatic otoscope– Single most important diagnostic tool –

• Tympanic membrane may be dull looking, Pulled in (retracted) and immobile.

• Ear drum is not red or bulging as it is in AOM.
• Air Fluid level seen as bubbles

Tympanometry can be advised to confirm the diagnosis of OME

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AOM occurs when fluid in the middle ear becomes infected, usually following a common cold or viral upper respiratory infection.

Symptoms – Child usually have fever and sudden ear pain after a common cold or stuffy nose. Infant may be irritable with pulling of ear. If tympanic membrane gets ruptured liquid may be coming out from ear (Otorrhoea/ear discharge).

Examination of ear-  symptoms alone are not enough to diagnose AOM and examination of ear drum with otoscope to see the signs of inflammation (redness or erythema) and pneumatic otoscopy to conform the fluid in the middle ear is necessary. (Opacification & Bulging of ear drum with reduced mobility)

If tympanic membrane is ruptured Ear discharge may be present, and hole (Perforation) in the ear drum may be seen

Audiogram may show mild to moderate conductive hearing impairment.

Tympanogram may show type “B” curve

How to treat AOM and OME?

Management of children with OME

• Aim is resolution of fluid, restoration of ear drum mobility and restoration of hearing

• As OME usually resolves without treatment for 3 months it is just wait and watch.

• Antihistamines and decongestants are not effective and antibiotics are not recommended for routine management.
• Steroids with beta lactame antibiotics are proven to be beneficial in few studies and and no benefit in others.

• Children with persistent effusion reexamined at 3-6 months interval till it resolve.

• Hearing testing is done if OME persists for more than 3 months or if Child is at risk of speech or language delay.

• If the effusion persists for more than 3 months and/or hearing loss exceeds 20 dB surgery Tympanostomy tube (Grommet) insertion is done.

• Adenoidectomy is done if indication for surgery is present.

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Management of Children with acute otitis media

Aim is to relieve pain and fever, to treat infection and restore hearing along with prevention of recurrence.

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) clinical practice guideline for OME emphasizes the management of pain as a major management goal.

• Analgesics are usually prescribed to provide relief from pain; acetaminophen and ibuprofen are commonly given medicines.

• Uncomplicated AOM in an otherwise healthy child above 2 years of age or very mild infection in children below 2 yrs but more than 6 months of age where we are assured that parents will be coming for follow up visit can be considered for observation without use of antibiotic or amoxicillin can be used.

• If there is no response within 2-3 days antibiotic is to be started or antibiotic is changed.

• Ear drops (Ototopical formulations) antibiotic with or without steroid are prescribed if ear drum is ruptured as steroid reduces inflammation and antibiotic improves infection eradication.

• Tympanic membrane perforation in children usually heals spontaneously in 1-2 months. During this time child should come for periodic follow to visits to assess the healing process, water entry in the ears should be avoided and all possible preventive measure to reduce chances of catching common cold are to be taken.

Role of Surgery in brief

Surgical management of otitis media is indicated for recurrent AOM, AOM with complications, chronic suppurative otitis media (CSOM) and otitis media with effusion where chances of hearing and speech problem are predicted

Most common surgical procedure is placement of tympanostomy tubes (Grommets).

Tympanostomy tubes allow drainage of fluid in the middle ear and ventilaton of middle earspace. Grommets usually fall out of the tympanic membrane within 6-14 months.

Coming Back to original question

It is important to distinguish between the presence of middle ear fluid (OME) and the presence of middle ear fluid with infection (AOM) by pneumatic otoscopy. If wax is obscuring the view of ear drum it has to be removed.

OME does not benefit from antibiotic therapy; child should be carefully monitored for recurrent AOM and hearing loss, which, if chronic, can impair speech and language development. AOM, if it does not resolve spontaneously, can result in serious complications, and benefits from antibiotic therapy.

So with utmost patience and gentleness we examine the crying 3 year old of worried parents and find that ear drum is red and bulging, our diagnosis is AOM.

So again the question of mother – Is Antibiotic Required?

We reassess the situation, explain the risk and benefit of antibiotic and we feel parents are anxious but motivated to come for follow up visit after 2 days, we give symptomatic treatment and avoid antibiotic.

Child of more than 2 years age observation without use of antibiotics is an option for treatment of acute otitis media but children must be followed carefully and antibiotics should be prescribed if spontaneous resolution does not occur.

Child if less than 2 years but more than 6 months of age and diagnosis of AOM is certain I usually prefer to give appropriate antibiotics in proper dose after explaining to parents as usually child has already waited or took treatment with family doctor or pediatrician with pain medicines and because there is chance of ear drum rupture unless parents are concerned about use of antibiotics or it is first day of onset of symptom which are mild. We keep a strict watch and wait in these children with assurance of prompt visit in case of worsening symptoms, fever, or drainage from the ear.

Special consideration

Antibiotics should be prescribed if child is –

• Less than 6 month of age

• Cleft palate

• Downs syndrome

• Immunodeficiency

• Cochlear implant

Summary

Most of the parents usually scared of the word ‘antibiotic’. Antibiotic does have side effects like loose stools or stomach upset but most feared side effect is development of resistance means antibiotic becomes ineffective to kill the bacteria.  Thus when there is nothing to fix it should not be fixed but parents should be given time in busy opd hours and explained to understand what doesn’t need to be done and why?

During the winter months, viral upper respiratory infection is the most common cause of Eustachian tube dysfunction and ear infection in children. Adenoids may also cause obstruction.

Though this winter is prolonged and there are more number of children with ear infection but in general awareness about preventive measures and vaccination against influenza and pneumococcus have decreased the incidence of winter AOM.

According to current guidelines by the AAP (American Academy of Pediatrics) and AAFP (American Academy of Family Physicians for use of antibiotics –

“Otitis Media with effusion does not require antibiotics and Acute Otitis Media does not always require antibiotics“.

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Usually with winter respiratory and throat infection cases increases, but this year physicians and ENT clinics are witnessing increased number of Patients as Mumbai is experiencing unusual low levels of temperature for prolonged period.

With High level of pollutants and particulate matter trapped in the morning fog allergic cold (rhinitis)  and sore throat cases are on rise.

You can read more about air pollution in Mumbai at agreeneryoutoo.blogspot.com by Sunita purushottam

Usually you can wait for 7-10 days for symptoms to go away with some home measures if it is improving or not worsening.

Here are few home care tips to fight with stuffy nose/sore throat:–

 

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cc Flickr Photo by assbach

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• Dress in layers wear woolen cloths

• Protect hands and feet (30% of heat escapes through hands and feet

• Cover head with hat or scarf (40% of heat lost through head)

• In excessive old cover your face with scarf

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• Decongestants shrink the blood vessels in the lining of the nose and relieve stuffiness. Decongestant nasal sprays and drops should not be used for more than 3 days, because they have rebound effect and can make the congestion worse.

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• Antihistamines may reduce the amount of mucus but most antihistamines make people drowsy.

• Gentle saline nasal sprays are quite helpful.

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• For a baby an infant nasal aspirator can help remove the mucus. Putting two or three saline nose drops into each nostril helps in loosening of thick mucus. Discharge can be cached outside the nostril on a tissue rather than inserting cotton swab inside the nose.

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• Warm saline gargles (lukewarm water with common salt) soothes throat.

• Use of vaporizer (Steam inhalation) or humidifier can be done to increase the humidity in the air.

• Maintain hydration as cold air has drying effect.

• Keep the head elevated while sleeping.

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• Adhesive strips can be placed on the nose. These strips help widen the nostrils, making breathing easier.

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• Hot tea, broth, or chicken soup may be especially helpful.

• Keep balanced diet with vitamins and minerals to boost immunity.

• Avoid outside food
• Take adequate rest

• Wash hands regularly
• Avoid smoking and alcohol as it increases nasal irritation

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• • Get flu vaccine

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It is important to understand the symptoms of common cold, flu and sinusitis for appropriate treatment.

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Last but not the least  to share with all health care professionals

Nasal blockage is the sensation of reduced air flow either through one nostril (unilateral) or both nostrils (bilateral).

It is common thinking amongst people that blocked nose (congested or stuffy nose) is because of thick mucus and they try to blow it out. But it is wrong thinking.

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Nasal block is a common complaint in children and it usually resolves without treatment. However it may cause a significant problem with abnormalities in teeth and face as well as heart and lung of child. Nasal block can interfere with the ears, hearing, and speech development. In first few months of life it can interfere with feeding and cause life threatening problems.

Thus every nasal block and mouth breathing in children should be evaluated carefully and potential serious causes must be considered in the differential diagnosis.

Causes of Nose Block

There are many different causes of nasal obstruction. Some causes are present at birth (congenital), oOther causes are acquired later in life.

Infectious/inflammatory mucosal swelling

• Allergic rhinitis
• Chronic rhino-sinusitis

Structural problems

• Enlarged Adenoids

• Deviated nasal septum (DNS)
• Enlarged turbinate
• Nasal polyps

Foreign Body nose

Congenital

• Posterior choanal stenosis/atresia
• Encephalocele/meningoencephalocele
• Craniofacial deformities
• Dermoids/Craniopharyngiomas/Teratomas/Chordomas
• Nasoalveolar and Nasopharyngeal (Tornwaldt’s) cysts

Evaluation of a child with nose block

The goals of the evaluation are to determine specific causes of problems, the severity of the obstruction, and the presence of associated medical complications.

This is achieved by thorough history of symptoms and clinical examination of nose along with endoscopic examination of nose and nasopharynx.

Examination of nose of a young child can be done by simply tilting the tip of the nose upwards or using an otoscope.  An extensive examination of nose is often difficult and not possible.

Following diagnostic tests based on clinical findings may be advised:-

• Allergy skin tests
• Blood tests (such as CBC)
• Sputum culture and throat culture
• X-rays of the sinuses, Nasopharynx and chest
• Serum total IgE

Differential diagnosis

Rhintis –

Nasal mucosa is thin pinkish lining that covers inside of the nose.  Swelling or inflammation of this mucosa can be caused by allergies, irritants (smoke and pollution), infection, hormonal (vasomotor rhinitis) and abuse of nasal drops (rhinitis medicamentosa).

Careful history and evaluation of the nose (nasal endoscopy for detailed examination) is all that is required to find out the likely diagnosis. Sometimes, additional tests may be advised to confirm the cause.

Usually medical treatment along with antibiotics and steroid nasal spray are required along with preventive measures to avoid allergen/irritants.

Allergy shots are successful treatment method. SLIT skin tests and sometimes blood tests are used to make allergy-inducing substances specific to an individual patient.

Chronic sinusitis is evaluated by CT scan during the quiet periods. A very conservative approach is followed as far as children are concerned. If patient fails to respond to medical treatment endoscopic sinus surgery may be necessary.

Deviated Nasal Septum (DNS)

Nasal septum is mid line partition which divides the nose into two halves. Child may be born with a deviated septum, or may develop after injury to nose.

Clinical examination by headlight and mirror is enough to conform the diagnosis, nasal endoscopy may be done for detailed examination of nose to rule out other anatomical abnormalities inside the nose and nasopharynx.

Sometimes DNS does not cause any symptoms but if it is severe enough to block the nasal passage it is to be corrected with surgery of septum (septoplasty)

Adenoid Enlargement

Second most common cause of nose blockage is enlarged or hypertrophied adenoids. Adenoids are lymphoid tissue similar to tonsils situated at back space of nose.

Adenoids are not directly visible and mirror examination or nasal endoscopy is required to see it. X-ray of nasopharynx may be done to see the enlarged adenoids.

If adenoids are blocking nasal airway leading to sleep apnea it has to be removed surgically.

You can read more about tonsils and adenoids in previous post

Foreign Body Nose–

A common cause of nasal obstruction in the younger child is an object (foreign body) placed in the nose (such as peanut, seeds, beads, button cell).

Characteristic history usually raises strong suspicion. Child usually comes with a foul smelling drainage from the nose on the side of the foreign object.

Removal can be done in the office without anesthesia but occasionally, if the foreign body has been present a long time, a short general anesthesia is necessary to remove it.

Congenital  Malformations

Choanal atresia (back opening of the nose is blocked with either tissue or bone), if bilateral (both sides are involved) surgical repair is needed immediately to allow the child to breath normally. If only unilateral (one sided) the diagnosis may be made much later in life.

Tumors such as nasal dermoids, chordoma and craniopharyngiomas most often present during infancy and early childhood however, they may be missed early in life.

Summary:

In summary, chronic nasal obstruction in children is a common symptom that requires careful evaluation, a correct diagnosis and treatment plan. Both the diagnostic evaluation and the treatment must take into account not only the nature and severity of the primary disease, but also the possible adverse effects on hearing, facial growth as well as cardiac and pulmonary systems.

Adenoid facies is typical changes in the face of young children because of enlarged adenoids.

Chronic mouth breathing because of enlarged adenoids during the age of  active facial skeleton growth results in facial structural changes.

The features of adenoid facies include elongated face, pinched nostrils, open mouth, high arched palate, shortened upper lip, and vacant expression.

Jaws and teeth are affected and disfigured ; usually teeth of the upper jaw are irregular and crowded and there is malocclusion of upper and lower jaws.

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