Mid-Kansas Ear, Nose & Throat

Why does your child’s nose bleed? Inside the nose there are many blood vessels in it to help warm and humidify the air your child breathes. These vessels lie close to the surface, making them easy to injure.

For more information regarding the illness affecting your child’s nose. Review our Kids ENT health links listed below.

Allergic Rhinitis (Hay Fever)

Allergic rhinitis (hay fever) is an especially common chronic nasal problem in adolescents and young adults. Allergies to inhalants like pollen, dust, and animal dander begin to cause sinus and nasal symptoms in early childhood. Infants and young children are especially susceptible to allergic sensitivity to foods and indoor allergens.

What causes allergic rhinitis?
Allergic rhinitis typically results from two conditions: family history/genetic predisposition to allergic disease and exposure to allergens. Allergens are substances that produce an allergic response.

Children are not born with allergies but develop symptoms upon repeated exposure to environmental allergens. The earliest exposure is through food – and infants may develop eczema, nasal congestion, nasal discharge, and wheezing caused by one or more allergens (milk protein is the most common). Allergies can also contribute to repeated ear infections in children. In early childhood, indoor exposure to dust mites, animal dander, and mold spores may cause an allergic reaction, often lasting throughout the year. Outdoor allergens including pollen from trees, grasses, and weeds primarily cause seasonal symptoms.

The number of patients with allergic rhinitis has increased in the past decade, especially in urban areas. Before adolescence, twice as many boys as girls are affected; however, after adolescence, females are slightly more affected than males. Researchers have found that children born to a large family with several older siblings and day care attendance seem to have less likelihood of developing allergic disease later in life.

What are allergic rhinitis symptoms?

Symptoms can vary with the season and type of allergen and include sneezing, runny nose, nasal congestion, and itchy eyes and nose. A year-long exposure usually produces nasal congestion (chronic stuffy nose).

In children, allergen exposure and subsequent inflammation in the upper respiratory system cause nasal obstruction. This obstruction becomes worse with the gradual enlargement of the adenoid tissue and the tonsils inherent with age. Consequently, the young patient may have mouth-breathing, snoring, and sleep-disordered breathing such as obstructive sleep apnea. Sleep problems such as insomnia, bed-wetting, and sleepwalking may accompany these symptoms along with behavioral changes including short attention span, irritability, poor school performance, and excessive daytime sleepiness.

In these patients, upper respiratory infections such as colds and ear infections are more frequent and last longer. A child’s symptoms after exposure to pollutants such as tobacco smoke are usually amplified in the presence of ongoing allergic inflammation.

When should my child see a doctor?
If your child’s cold-like symptoms (sneezing and runny nose) persist for more than two weeks, it is appropriate to contact a physician. Emergency treatment is rarely necessary except for upper airway obstruction causing severe sleep apnea or an anaphylactic reaction caused by exposure to a food allergen. Treatment of anaphylactic shock should be immediate and requires continued observation and care.

What happens during a physician visit?
The doctor will first obtain an extensive history about the child, the home environment, possible exposures, and progression of symptoms. Family history of atopic/allergic disease and the presence of other disorders such as eczema and asthma strongly support the diagnosis of allergic rhinitis. The physician will seek a link between the symptoms and exposure to certain allergens.

The physician will examine the skin, eyes, face and facial structures, ears, nose, and throat. In some cases, a nasal endoscopy may be performed. If the history and the physical exam suggest allergic rhinitis, a screening allergy test is ordered. This can be a blood test or a skin prick test. In most children it is easier to obtain a blood test known as the RadioAllergoSorbent Test or RAST. This test measures the amount of specific Immunoglobulin E antibodies (IgE) in the blood responding to various environmental and food allergens.

The skin test results, often immediately available, may be affected by the recent use of antihistamines and other medications, dermatologic conditions, and age of the patient. The blood test is not affected by medication, and results are usually available in several days.

How is allergic rhinitis treated?
The most common treatment recommendation is to have the child avoid the allergens causing the allergic sensitivity. The physician will work with caregivers to develop an avoidance strategy based on the nature of the allergen, exposure, and availability of avoidance measures.

Cost and lifestyle are important factors to consider. For mild, seasonal allergies, avoidance could be the most effective course of action. If pet dander is the offender, consideration should be given to removing the pet from the child’s environment.

Severe symptoms, multiple allergens, year-long exposure, and limited resources for environmental control may call for additional treatment measures. Nasal saline irrigations, nasal steroid sprays, and non-sedating antihistamines are indicated for symptom control. Nasal steroids are the most effective in reducing nasal symptoms of allergic rhinitis. A short burst of oral steroids may be appropriate for some patients with severe symptoms or to gain control during acute attacks.

If symptoms are severe and due to multiple allergens, the child is symptomatic more than six months in a year, and if all other measures fail, then immunotherapy (IT) (or desensitization) may be suggested. IT is delivered by injections of the allergen in doses that are increased incrementally to a maximum that is tolerated without a reaction. Maintenance injections can be delivered at increasing intervals starting from weekly to bi-weekly to monthly injections for up to three to five years. Children with pollen sensitivities benefit most from this treatment. IT is also effective in reducing the onset of pollen-induced asthma.

Children and Facial Trauma

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 covering, underlying skeleton, neck, nasal (sinuses), orbital socket, or oral lining, as well as the teeth and dental structures. Sometimes these types of injuries are called maxillofacial injury. Facial trauma is often recognized by lacerations (breaks in the skin); bruising around the eyes, widening of the distance between the eyes (which may indicate injury to the bones between the eye sockets); movement of the upper jaw when the head is stabilized (which may indicate a fracture in this area); and abnormal sensations on the cheek.

In the U.S., about three million people are treated in emergency departments for facial trauma injuries each year. Of the pediatric patients, five percent have suffered facial fractures. In children less than 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.

Our fast paced world of ultra sports and increasing violence puts children at risk for facial injury. But, children’s facial injuries require special attention. A child’s future growth plays a big role in treatment for facial trauma. So, one of the most important issues as a care giver is to follow a physician’s treatment plan as closely as you can 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 the growth or further complicate recovery. Difficult cases require physicians with great skill to make a repair that will grow with your child.

Types of facial trauma
New technology, such as CT scans, have 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. A new study has shown that even when injury does not require surgery, it is important to a child’s health and welfare to continue to follow up with a physicians 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.

Bone injuries
When a fracture of the bones in the face occurs, the treatment process is similar to that of a fracture in other parts of the body. Factors that affect how the fracture should be dealt with 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 style
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 chance it will survive. Therefore, 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. Otolaryn Head and Neck Surg 1997: 117:72-75

Kim MK, Buchman R, Szeremeta. Penetratin neck trauma in children: an urban hospital’s experience. Otolaryn Head and Neck Surg 2000: 123: 439-43

Cleft Lip and Cleft Palate

What is cleft lip and cleft palate?
We all start out life with a cleft lip and palate. During normal fetal development between the 6th and 11th week of pregnancy, the clefts in the lip and palate fuse together. In babies born with cleft lip or cleft palate, one or both of these splits failed to fuse.

A “cleft” means a split or separation; the palate is the “roof” of the mouth. A cleft palate or lip then is a split in the oral (mouth) structure. Physicians call clefting a “craniofacial anomaly.” A child can be born with both a cleft lip and cleft palate or a cleft in just one area. Oral clefts are one of the most common birth defects.

Clefts in the lip can range from a tiny notch in the upper lip to a split that extends into the nose. A cleft palate can range from a small malformation that results in minimal problems to a large separation of the palate that interferes with eating, speaking, and even breathing. Clefts are often referred to as unilateral, a split on one side, or bilateral, one split on each side. There are three primary types of clefts:

1. Cleft lip/palate refers to the condition when both the palate and lip are cleft. About one in 1,000 babies are born with cleft lip/palate.

About 50 percent of all clefts
More common in Asians and certain groups of American Indians
Occurs less frequently in African Americans
Up to 13 percent of cases present with other birth defects
Occurs more often in male children
2. Isolated cleft palate is the term used when a cleft occurs only in the palate. About one in 2,000 babies are born with this type of cleft (the incidence of submucous cleft palate, a type of isolated cleft palate, is one in 1,200).

About 30 percent of all clefts
All racial groups have similar risk
Occurs more often in female children
3. Isolated cleft lip refers to a cleft in the lip only accounting for 20 percent of all clefts.

What causes clefts?
No one knows exactly what causes clefts, but most believe they are caused by one or more of three main factors: an inherited characteristic (gene) from one or both parents, environment (poor early pregnancy health or exposure to toxins such as alcohol or cocaine), and genetic syndromes. A syndrome is an abnormality in genes on chromosomes that result in malformations or deformities that form a recognizable pattern. Cleft lip/palate is a part of more than 400 syndromes including Waardenburg, Pierre Robin, and Down syndromes. Approximately 30 percent of cleft deformities are associated with a syndrome, so a thorough medical evaluation and genetic counseling is recommended for cleft patients.

How is a cleft diagnosed?
Clefting of the lip and palate is usually visible during the baby’s first examination. One exception is a submucous cleft where the palate is cleft, but remains covered by smooth, unbroken lining of the mouth. A child with cleft lip or palate is often referred to a multidisciplinary team of experts for treatment. The team may include: an otolaryngologist (ear, nose, and throat specialist), plastic surgeon, oral surgeon, speech pathologist, pediatric dentist, orthodontist, audiologist, geneticist, pediatrician, nutritionist, and psychologist/social worker.

How are clefts treated?
Treatment of clefts is highly individual, depending on the overall health of the child and the severity and location of the cleft(s). Multiple surgeries and long-term follow-up are often necessary. Because clefts can interfere with physical, language and psychological development, treatment is recommended as early as possible. Surgery to repair a cleft lip is usually done between 10 and 12 weeks of age.

A cleft palate is repaired through a procedure called palatoplasy, which is done between nine and 18 months. Additional surgeries are often needed to achieve the best results. In addition to surgery, the child may receive follow-up care from members of the multidisciplinary team on issues of speech, hearing, growth, dental, and psychological development.

What are the complications of clefts?
The complications of cleft lip and cleft palate can vary greatly depending on the degree and location of the cleft. They can include all or some or all of the following:

Breathing: When the palate and jaw are malformed, breathing becomes difficult. Treatments include surgery and oral appliances.
Feeding: Problems with feeding are more common in cleft children. A nutritionist and speech therapist that specializes in swallowing may be helpful. Special feeding devices are also available.

Ear infections and hearing loss: Any malformation of the upper airway can affect the function of the Eustachian tube and increase the possibility of persistent fluid in the middle ear, which is a primary cause of repeat ear infections. Hearing loss can be a consequence of repeat ear infections and persistent middle ear fluid. Tubes can be inserted in the ear by an otolaryngologist to alleviate fluid build-up and restore hearing.
Speech and language delays: Normal development of the lips and palate are essential for a child to properly form sounds and speak clearly. Cleft surgery repairs these structures; speech therapy helps with language development.

Dental problems: Sometimes a cleft involves the gums and jaw, affecting the proper growth of teeth and alignment of the jaw. A pediatric dentist or orthodontist can assist with this problem.

Connecting the Dots…How Allergies Affect Your Child's Ears, Nose, and Throat

Your child has been diagnosed with allergic rhinitis, a physiological response to specific allergens such as pet dander or ragweed. The symptoms are fairly simple — a runny nose (rhinitis), watery eyes, and some periodic sneezing. The best solution is to administer over-the-counter antihistamine, and the problem will resolve on its own ….right?

Not really – the interrelated structures of the ears, nose, and throat can cause certain medical problems which trigger additional disorders – all with the possibility of serious consequences. Simple hay fever can lead to long term problems in swallowing, sleeping, hearing, and breathing. Let’s see what else can happen to a child with a case of hay fever.

Ear Infections: One of children’s most common medical problems is otitis media, or middle ear infection. These infections are especially common in early childhood. They are even more common when children suffer from allergic rhinitis (hay fever) as well. Allergic inflammation can cause swelling in the nose and around the opening of the Eustachian tube (ear canal). This swelling has the potential to interfere with drainage of the middle ear. When bacteria laden discharge clogs the tube, infection is more likely.

Sore Throats: The hay fever allergens 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 husky voice. Although more common in older people and in dry inland climates, thick, dry mucus can also irritate the throat and be hard to clear. Air conditioning, winter heating, and dehydration can aggravate the condition. Paradoxically, antihistamines will do so as well. Some newer antihistamines do not produce dryness.

Snoring: Chronic nasal obstruction is a frequent symptom of seasonal allergic rhinitis (hay fever) and perennial (year-round) allergic rhinitis. This allergic condition may have a debilitating effect on the nasal turbinates, the small, shelf-like, bony structures covered by mucous membranes (mucosa). The turbinates protrude into the nasal airway and help to warm, humidify, and cleanse air before it reaches the lungs. When exposed to allergens, the mucosa can become inflamed. The blood vessels inside the membrane swell and expand, causing the turbinates to become enlarged and obstruct the flow of air through the nose. This inflammation, or rhinitis, can cause chronic nasal obstruction that affects individuals during the day and night.

Enlarged turbinates and nasal congestion can also contribute to headaches and sleep disorders such as snoring and obstructive sleep apnea, because the nasal airway is the normal breathing route during sleep. Once turbinate enlargement becomes chronic, it is irreversible except with surgical intervention.

Pediatric Sinusitis: Allergic rhinitis can cause enough inflammation to obstruct the openings to the sinuses. Consequently, a bacterial sinus infection occurs. The disease is similar for children and adults. Children may or may not complain of pain. However, in acute sinusitis, they will often have pain and typically have fever and a purulent nasal discharge. In chronic sinusitis, pain and fever are not evident. Some children may have mood or behavior changes. Most will have a purulent, runny nose and nasal congestion even to the point where they must mouth breathe. The infected sinus drains around the Eustachian tube, and therefore many of the children will also have a middle ear infection.

Seasonal allergic rhinitis may resolve after a short period. Administration of the proper over-the-counter antihistamines may alleviate the symptoms. However, if your child suffers from perennial (year round) allergic rhinitis, an examination by specialist will assist in preventing other ear, nose, and throat problems from occurring.

Day Care and Ear, Nose, and Throat Problems

Who is in day care?
The 2000 census reported that of among the nation’s 19.6 million preschoolers, grandparents took care of 21 percent, 17 percent were were cared for by their father (while their mother was employed or in school); 12 percent were in day care centers; nine percent were cared for by other relatives; seven percent were cared for by a family day care provider in their home; and six percent received care in nursery schools or preschools. More than one-third of preschoolers (7.2 million) had no regular child-care arrangement and presumably were under maternal care.

Day care establishments are defined as those primarily engaged in care of infants or children, or in providing pre-kindergarten education, where medical care and/or behavioral correction are not a primary function or major element. Some may or may not have substantial educational programs, and some may care for older children when they are not in school.

What are your child’s risks of being exposed to a contagious illness at a day care center?
Medline, a service of the National Library of Medicine and the National Institutes of Health, reports that day care centers do pose some degree of an increased health risk for children, because of the exposure to other children who may be sick.

When your child is in a day care center, the risk is greatest for viral upper respiratory infection (affecting the nose, throat, mouth, voice box) and the common cold, ear infections, and diarrhea. Some studies have tried to link asthma to day care. Other studies suggest that being exposed to all the germs in day care actually IMPROVES your child’s immune system.

Studies suggest that the average child will get eight to ten colds per year, lasting ten – 14 days each, and occurring occurring primarily in the winter months. This means that if a child gets two colds from March to September, and eight colds from September to March, each lasting two weeks, the child will be sick more than over half of the winter.
At the same time, children in a day care environment, exposed to the exchange of upper respiratory tract viruses every day, are expected to have three to ten episodes of otitis media annually. This is four times the incidence of children staying at home.When should your child remain at home instead of day care or school?

Simply put, children become sick after being exposed to other sick children. Some guidelines to follow are:

When your child has a temperature higher than 100 degrees, keep him/her at home. A fever is a sign of potentially contagious infection, even if the child feels fine. Schools often advise keeping the child at home until a fever-free period has existed for 24 hours.
When other children in the day care facility have a known contagious infection, such as chicken pox, strep throat or conjunctivitis, keep your child at home.
Children taking antibiotics should be kept at home until they have taken the medicine for one or two days.
If your child is vomiting or has diarrhea, the young patient should not be around other children. Other signs of illness are an inability to take fluids, weakness or lethargy, sunken eyes, a depressed soft spot on top of infant’s head, crying without tears, and dry mouth.

Can you prevent your child from becoming sick at a day care center?
The short answer is no. Exposure to other sick children will increase the likelihood that your child may “catch” the same illness, particularly with the common cold. The primary rule is to keep your own children at home if they are sick. However, you can:
Teach your child to wash his or her hands before eating and after using the toilet. Infection is spread the most by children putting dirty toys and hands in their mouths, so check your day care’s hygiene cleaning practices.

Have your child examined by a physician before enrollment in a day care center or school. During the examination, the physician will:

Look for otitis (inflammation) in the ear. This is an indicator of future ear infections.
Review with you any allergies your child may have. This will assist in determining if the diet offered at the day care center may be harmful to your child.
Examine the child’s tonsils for infection and size. Enlarged tonsils could indicate that your child may not be getting a healthy sleep at night, resulting in a tired condition during the day.

Alert the day care center manager when your child is ill, and include the nature of the illness.

Day care has become a necessity for millions of families. Monitoring the health of your own child is key to preventing unneccessary sickness. If a serious illness occurs, do not hesitate to have your child examined by a physician.

Day Care and Ear, Nose, and Throat Problems

Simply put, children become sick after being exposed to other sick children. Some guidelines to follow are:

When your child has a temperature higher than 100 degrees, keep him/her at home. A fever is a sign of potentially contagious infection, even if the child feels fine. Schools often advise keeping the child at home until a fever-free period has existed for 24 hours.
When other children in the day care facility have a known contagious infection, such as chicken pox, strep throat or conjunctivitis, keep your child at home. Children taking antibiotics should be kept at home until they have taken the medicine for one or two days. If your child is vomiting or has diarrhea, the young patient should not be around other children. Other signs of illness are an inability to take fluids, weakness or lethargy, sunken eyes, a depressed soft spot on top of infant’s head, crying without tears, and dry mouth.

Can you prevent your child from becoming sick at a day care center?
The short answer is no. Exposure to other sick children will increase the likelihood that your child may “catch” the same illness, particularly with the common cold. The primary rule is to keep your own children at home if they are sick. However, you can:
Teach your child to wash his or her hands before eating and after using the toilet. Infection is spread the most by children putting dirty toys and hands in their mouths, so check your day care’s hygiene cleaning practices.

Have your child examined by a physician before enrollment in a day care center or school. During the examination, the physician will:

Alert the day care center manager when your child is ill, and include the nature of the illness.

Accordion number 4

Pediatric Food Allergies

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 culinary culprit you must consider what type of food allergy your child has. There are two types of food allergies. They are classified as:

Fixed 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 five to 15 percent of food allergies are of the fixed variety.

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

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 which developed. Be honest! Some well-meaning parents or caregivers often create a food diary to look healthier than it typically 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 an ear, nose, and throat specialist to identify one or several food items that may be the culprits.

2. Conduct an unblinded 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 the period of elimination and challenge. During this elimination and challenge 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.

3. 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 1/2 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. Fixed food allergies should never be deliberately challenged unless under the direct supervision of a physician. For minor, moderate discomfort from the testing, the patient may take: 1) a child’s laxative to decrease the transit time through the digestive system, 2) Alka Seltzer Gold, 3) Buffered Vitamin C (one gram).

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).

Pediatric Food Allergies

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

Pediatric GERD (Gastro-Esophageal Reflux Disease) and Your Otolaryngologist

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 age four months. But an infant’s improved neuromuscular control and the ability to sit up will lead to a spontaneous resolute ion of significant GER in more than half of infants by age ten months 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 muscular 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 five to eight percent of adolescent children have GERD.

What symptoms are displayed by a child with GERD?
GER and EER in children often cause relatively few symptoms until a problem exists (GERD). The most common initial symptom of GERD is heartburn. Heartburn is more common in adults, whereas 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 could 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 stenoses, asthma/wheezing, 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.

Unlike infants, the adolescent child will not necessarily resolve GERD on his or her own. Accordingly, 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. The tests that are most commonly used to diagnose gastroesophageal reflux include:

• pH probe: A small wire with an acid sensor is placed through the nose down to the bottom of the esophagus. The sensor can detect when acid from the stomach is “refluxed” into the esophagus. This information is generally recorded on a computer. Usually, the sensor is left in place between 12 and 24 hours. At the conclusion of the test, the results will indicate how often the child “refluxes” acid into his or her esophagus and whether he or she has any symptoms when that occurs.
• 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 narrowings of the upper intestinal tract.
• Technetium gastric emptying study: The child is fed milk mixed with technetium, a very weakly radioactive chemical, and then the technetium is followed through the intestinal tract using a special camera. This test is helpful in determining whether some of the milk/technetium ends up in the lungs (aspiration). It may also be helpful in determining how long milk sits in the stomach.
• Endoscopy with biopsies: This most comprehensive test involves the passing down of a flexible endoscope with lights and lenses through the mouth into the esophagus, stomach, and duodenum. This allows the doctor to get a directly look at the esophagus, stomach, and duodenum and see if there is any irritation or inflammation present. In some children with gastroesophageal reflux, repeated exposure of the esophagus to stomach acid causes some inflammation (esophagitis). Endoscopy in children usually requires a general anesthetic.
• Fiberoptic Laryngoscopy: A small lighted scope is placed in the nose and the pharynx to evaluate for inflammation.

What treatments for GERD are available?
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 useful 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 while they sleep and have the child eat smaller, more frequent meals instead of large amounts of food at one sitting. Avoid having the child eat right before they go to bed or lie down; instead, 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 my assist in alleviating GERD. Even chewing sugarless gum may help.

• Dietary changes: Avoid chocolate, carbonated drinks, caffeine, tomato products, peppermint, and other acidic foods as citrus juices. Fried foods and spicy foods are also known to aggravate symptoms. Pay attention to what your child eats and be alert for individual problems.

• Medical Treatment: Most of the medications prescribed to treat GERD either 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.

• Surgical Treatment: It is rare for children with GERD to require surgery. For the few children who do require surgery, the most commonly performed operation is called Nissen fundoplication. With this procedure, the top part of the stomach (the fundus) is wrapped around the bottom of the esophagus to create a collar. After the operation, every time the stomach contracts, the collar around the esophagus contracts preventing reflux.

Pediatric Head and Neck Tumors

Tumors or growths in the head and neck region may be divided into those that are benign (not cancerous) and malignant (ie., cancer). Fortunately, most growths in the head and neck region in children are considered to be benign. These benign growths can be related to infection, inflammation, fluid collections, swellings, or neoplasms (tumors) that are non life-threatening. The malignant growths, on the other hand, may be life-threatening and cause other problems related to their growth and spread. Even the malignant growths in the head and neck are usually treatable.

Benign Tumors
It is very common for children to have enlarged tonsils and adenoids. These are almost always from an infection or inflammation. It is very rare that children develop a cancer, lymphoma, or sarcoma of these areas. When the tonsils, adenoids, or other areas of the mouth or throat remain enlarged or are enlarged on only one side, it is important to have an evaluation by a specialist in ear, nose and throat or otolaryngology-head and neck surgery.

The lymph nodes of the neck region may become enlarged during childhood. Most of the time, this is reactive in nature and related to inflammation or infection. However, if the lymph nodes remain enlarged for a period of time without going away, it is important to have an otolaryngologist-head and neck surgeon evaluate the problem.

Other benign growths in the face and neck include cysts (fluid collection) such as branchial cleft cyst, thyroglossal duct cyst, cystic hygroma, and dermoid cysts. These often require removal due to their continued growth and potential for infection. Growths of blood vessels often are seen in the face and neck and these are often referred to as hemangiomas, vascular malformations, lymphatic and arteriovenous malformations (AVM). Some of these may require removal or treatment depending upon the type and location.

Sinus and Nose Growths
Although most children have nose bleeds and occasional allergies and sinus infection, sometimes tumors of the nose and sinus present with similar symptoms. It is generally recommended that a child with continuous sinus problems or nose bleeds be evaluated by an otolaryngologist-head and neck surgeon to be sure it is not a tumor or other treatable condition.

Non-epithelial neoplasms constitute the majority of sinonasal (sinus) tumors in children and adolescents. Among these, rhabdomyosarcoma (RMS) or undifferentiated sarcoma and non-Hodgkin lymphoma account for the majority of cases. Among head and neck RMS 14 percent arise from the nasal cavity and 10 percent from the paranasal sinuses. Nasopharyngeal carcinoma accounts for one third of the nasopharyngeal neoplasms in children. As is the case in adult patients, it is associated with Epstein-Barr virus (EBV) infection as demonstrated by EBV DNA presence in malignant cells. Less frequently, Ewing’s sarcoma/PNET can present in this location. These tumors have also been described as secondary malignancies following treatment of retinoblastoma and other neoplasms. Esthesioneuroblastoma is a rare sinonasal tumor historically related to Ewing/PNET, although more recently comparative genomic hybridization analysis disputes this relation. Other less common sinonasal tumors presenting in children include hemangioma and hemagiopericitoma, fibroma and fibrosarcoma, malignant fibrous histiocytoma, and desmoid fibromatosis.

Salivary Gland Tumors
There are three paired sets of salivary glands in the head and neck region. These include the ones in front of the ears (parotid), below the jaw (submandibular), and underneath the tongue (sublingual). Additionally, there are numerous very small salivary glands throughout the mouth and throat. Although tumors can arise in these areas, they are rare. Thus, any child with a growth in these areas should be seen by an otolaryngologist-head and neck surgeon.

Thyroid Tumors
The thyroid gland is found in the front of the lower part of the neck just above the chest area but below the Adam’s apple on both sides. Although tumors can arise in this area, they are rare. Thus, any child with a growth in this area should be seen by an otolaryngologist-head and neck surgeon.

Pediatric Sinusitis

Your child’s sinuses are not fully developed until age 20. Although small, the maxillary (behind the cheek) and ethmoid (between the eyes) sinuses are present at birth. Unlike in adults, pediatric sinusitis is difficult to diagnose because symptoms can be subtle and the causes complex.

How do I know when my child has sinusitis?

The following symptoms may indicate a sinus infection in your child:

a “cold” lasting more than 10 to 14 days, sometimes with a low-grade fever thick,
yellow-green nasal drainage
post-nasal drip, sometimes leading to or exhibited as sore throat, cough, bad breath, nausea, and/or vomiting
headache, usually in children age six or older
irritability or fatigue
swelling around the eyes

Young children have immature immune systems and are more prone to infections of the nose, sinus, and ears, especially in the first several years of life. These are most frequently caused by viral infections (colds), and they may be aggravated by allergies. However, when your child remains ill beyond the usual week to ten days, a serious sinus infection is likely.

You can reduce the risk of sinus infections for your child by reducing exposure to known allergens and pollutants such as tobacco smoke, reducing his/her time at day care, and treating stomach acid reflux disease.

How will the doctor treat sinusitis?

Acute Sinusitis: Most children respond very well to antibiotic therapy. Nasal decongestants or topical nasal sprays may also be prescribed for short-term relief of stuffiness. Nasal saline (saltwater) drops or gentle spray can be helpful in thinning secretions and improving mucous membrane function. If your child has acute sinusitis, symptoms should improve within the first few days. Even if your child improves dramatically within the first week of treatment, it is important that you continue therapy until all the antibiotics have been taken. Your doctor may decide to treat your child with additional medicines if he/she has allergies or other conditions that make the sinus infection worse.

Chronic Sinusitis: If your child suffers from one or more symptoms of sinusitis for at least 12 weeks, he or she may have chronic sinusitis. Chronic sinusitis or recurrent episodes of acute sinusitis numbering more than four to six per year are indications that you should seek consultation with an ear, nose, and throat (ENT) specialist. The ENT may recommend medical or surgical treatment of the sinuses.

Diagnosis of Sinusitis: If your child sees an ENT specialist, the doctor will examine his/her ears, nose, and throat. A thorough history and examination usually leads to the correct diagnosis. Occasionally, special instruments will be used to look into the nose during the office visit. An x-ray called a CT scan may help to determine how your child’s sinuses are formed, where the blockage has occurred, and the reliability of a sinusitis diagnosis.

When is surgery necessary?
Only a small percentage of children with severe or persistent sinusitis require surgery to relieve symptoms that do not respond to medical therapy. Using an instrument called an endoscope, the ENT surgeon opens the natural drainage pathways of your child’s sinuses and makes the narrow passages wider. This also allows for culturing so that antibiotics can be directed specifically against your child’s sinus infection. Opening up the sinuses and allowing air to circulate usually results in a reduction in the number and severity of sinus infections. Your doctor may advise removing adenoid tissue from behind the nose as part of the treatment for sinusitis. Although the adenoid tissue does not directly block the sinuses, infection of the adenoid tissue, called adenoiditis, or obstruction of the back of the nose, can cause many of the symptoms that are similar to sinusitis, namely, runny nose, stuffy nose, post-nasal drip, bad breath, cough, and headache.

Sinusitis in children is different than sinusitis in adults. Children more often demonstrate a cough, bad breath, crankiness, low energy, and swelling around the eyes along with a thick yellow-green nasal or post-nasal drip. Once the diagnosis of sinusitis has been made, children are successfully treated with antibiotic therapy in most cases. If medical therapy fails, surgical therapy can be used as a safe and effective method of treating sinus disease in children.

What Is Allergic Rhinitis?

What is an allergy?
An allergy is your body’s reaction to something in your environment. Have you ever visited a friend’s house and started sneezing as soon as Fluffy, the Golden Retriever, ran up to give you a big wet kiss? Have you had a rash, or a red splotch, on your skin after using a particular kind of soap? These are types of allergic reaction.

What is rhinitis?
Rhinitis is the term for what occurs when the inside of your nose swells and hurts. So . . . . When you pet your friend’s dog or play outside and you sneeze and your nose starts to run, you have allergic rhinitis. Your Dad or Mom may call this ‘hay fever.’ Read on to find out why this happens, and what you can do to help stop it.

What causes allergic rhinitis?
There are two causes of allergic rhinitis: First, if your Mom or Dad is allergic to stuff like soap and dogs, you are more likely to have allergies too than someone whose family does not have allergies. Second, your body reacts to exposure to allergens (ah-lur-jenz). An allergen is anything that causes an allergic reaction in you.

You might have allergies if you sneeze when you get around these things:

Dust
Animal hair, or animal saliva
Mold and mildew
Trees, grass, and flowers

Why do allergies make me sneeze and wheeze?
When you are allergic to something, your immune system, which normally tries to keep you healthy by fighting bad bacteria or germs in your body gets confused and thinks a good allergen is actually a bad germ. Because your immune system’s job is to kill germs, it attacks the allergen and tries to get rid of it. This reaction causes us to sneeze, makes our eyes water, and causes our noses to run.

How do I know I have allergies?
Sometimes it can be hard to tell whether you have allergies or just a bad cold. Here’s a quick way to find out: do your eyes, nose, or throat itch? Then you probably have allergies.

Do you think you might have allergies?
Ask your Mom or Dad if you have had any of these symptoms for over two weeks (A symptom is a condition of your body that is not normal, and may be a signal that something is wrong.):

Itchy, watery eyes
Runny nose
Clear gunk in the tissue when you blow your nose
Stuffed up’ nose
Sore throat

Will I have to visit the doctor?
Before going to the doctor, your parents might give you a nasal spray or a medication called an antihistamine that fights the allergic reaction. If these medicines work, you’re home free. If not, an otolaryngologist (oh-toe-lair-in-goll-oh-gist), a special doctor for ears, noses, and throats, can examine you and prescribe other remedies. The doctor may suggest:
– Washing your sheets in hot water to get rid of dust mites (a very tiny insect that can only be seen with a microscope)
– Keeping your bedroom neat and clean
– Running a special air cleaner in your house
– Playing inside more in the spring and fall.Your parents will have to discuss what to do if you are allergic to family pets.

DID YOU KNOW?
If your runny nose produces a liquid that is green or yellow, you may have a condition called sinusitis. This is treated differently than allergic rhinitis.* Several of our Presidents have had allergies. They include:

Theodore Roosevelt (26th president, 1901-1909),
Calvin Coolidge (30th president, 1923-1929),
John F. Kennedy (35th president, 1961-1963), and
Bill Clinton (42nd president, 1993-2001).

* The original Tin Man from the “The Wizard of Oz,” had an allergic reaction to the make-up used to make him look silver. He ended up in the hospital for two weeks and someone else had to play that part.

Antihistamines, Decongestants, and “Cold Remedies”

Drugs for stuffy nose, sinus trouble, congestion, and the common cold constitute the largest segment of the over-the-counter market for America’s pharmaceutical industry. When used wisely, they provide welcome relief for at least some of the discomforts that affect almost everyone occasionally and that affect many people chronically. Drugs in these categories are useful for relief of symptoms from allergies, upper respiratory infections (i.e., sinusitus, colds, flu), and vasomotor rhinitis (a chronic stuffy nose caused by such unrelated conditions as emotional stress, thyroid disease, pregnancy, and others). These drugs do not cure the allergies, infections, etc.; they only relieve the symptoms, thereby making the patient more comfortable.

Antihistamines
Histamine is an important body chemical that is responsible for the congestion, sneezing, and runny nose that a patient suffers with an allergic attack or an infection. Antihistamine drugs block the action of histamine, therefore reducing the allergy symptoms. For the best result, antihistamines should be taken before allergic symptoms get well established.

The most annoying side effect that antihistamines produce is drowsiness. Though desirable at bedtime, it is a nuisance to many people who need to use antihistamines in the daytime. To some people, it is even hazardous. These drugs are not recommended for daytime use for people who may be driving an automobile or operating equipment that could be dangerous. Newer non-sedating antihistamines, available by prescription only, do not have this effect. The first few doses cause the most sleepiness; subsequent doses are usually less troublesome.
Typical antihistamines include Allegra®, Benadryl®, Chlor-Trimetron,®, Claritin®, Clarinex®, Teldrin®, Zyrtec,® etc.

Decongestants
Congestion in the nose, sinuses, and chest is due to swollen, expanded, or dilated blood vessels in the membranes of the nose and air passages. These membranes have an abundant supply of blood vessels with a great capacity for expansion (swelling and congestion). Histamine stimulates these blood vessels to expand as described previously.
Decongestants, on the other hand, cause constriction or tightening of the blood vessels in those membranes, which then forces much of the blood out of the membranes so that they shrink, and the air passages open up again.

Decongestants are chemically related to adrenalin, the natural decongestant, which is also a type of stimulant. Therefore, the side effect of decongestants is a jittery or nervous feeling. They can cause difficulty in going to sleep, and they can elevate blood pressure and pulse rate. Decongestants should not be used by a patient who has an irregular heart rhythm (pulse), high blood pressure, heart disease, or glaucoma. Some patients taking decongestants experience difficulty with urination. Furthermore, decongestants are often used as ingredients in diet pills. To avoid excessively stimulating effects, patients taking diet pills should not take decongestants.

Typical decongestants are phenylephrine (Neo-Synephrine®*), and pseudoephedrine (Sudafed®, etc.)
* May be available over–the–counter without a prescription. Read labels carefully, and use only as directed.

Combination Remedies
Theoretically, if the side effects could be properly balanced, the sleepiness sometimes caused by antihistamines could be cancelled by the stimulation of decongestants. Numerous combinations of antihistamines with decongestants are available: Actifed,®* Allegra-D,® Chlor-Trimeton D,®* Claritin D,® Contac,®* Co-Pyronil 2,®* Deconamine,® Demazin,®* Dimetapp,®* Drixoral,®* Isoclor,®* Nolamine,® Novafed A,® Ornade,® Sudafed Plus,® Tavist D,®* Triaminic,®* and Trinalin,® to name just a few.

A patient may find one preparation quite helpful for several months or years but may need to switch to another one when the first loses its effectiveness. Since no one reacts exactly the same as another to the side effects of these drugs, a patient may wish to try his own ideas on adjusting the dosages. One might take the antihistamine only at night and take the decongestant alone in the daytime. Or take them together, increasing the dosage of antihistamine at night (while decreasing the decongestant dose) and then doing the opposite for daytime use.

For Example:
Antihistamine (Chlor-Trimeton,®* 4mg)—one tablet three times daily and two tablets at bedtime.

Plus
Decongestant (Sudafed,®* 30mg)—two tablets three times daily and one tablet at bedtime.

“Cold” Remedies
Decongestants and/or antihistamines are the principal ingredients in “cold” remedies, but drying agents, aspirin (or aspirin substitutes) and cough suppressants may also be added. The patient should choose the remedy with ingredients best suited to combat his own symptoms. If the label does not clearly state the ingredients and their functions, the consumer should ask the pharmacist to explain them.

Nose Sprays
The types of nose sprays that can be purchased without a prescription usually contain decongestants for direct application to nasal membranes. They can give prompt relief from congestion by constricting blood vessels. However, direct application creates a stronger stimulation than decongestants taken by mouth. It also impairs the circulation in the nose, which after a few hours, stimulates the vessels to expand to improve the blood flow again. This results in a “bounce-back” effect. The congestion recurs. If the patient uses the spray again, it starts the cycle again. Spray–decongestion– rebound–and more congestion.

In infants, this rebound rhinitis can develop in two days, whereas in adults, it often takes several more days to become established. An infant taken off the drops for 12 to 24 hours is cured, but well-established cases in adults often require more than a simple “cold turkey” withdrawal. They need decongestants by mouth, sometimes corticosteroids, and possibly (in patients who continuously have used the sprays for months and years) a surgical procedure to the inside of the nose. For this reason, the labels on these types of nose sprays contain the warning “Do not use this product for more than three days.” Nose sprays should be reserved for emergency and short term use.

(The above description and advice does not apply to the type of prescription anti-allergy nose sprays that may be ordered by your physician.)

Your Nose: The Guardian Of Your Lungs

You might not think your nose is a “vital organ,” but indeed it is! To understand its importance, all that most people need to experience is a bad cold. Nasal congestion and a runny nose have a noticeable effect on quality of life, energy level, ability to breathe, ability to sleep, and ability to function in general.

Why Is Your Nose So Important?
It processes the air that you breathe before it enters your lungs. Most of this activity takes place in and on the turbinates, located on the sides of the nasal passages. In an adult, 18,000 to 20,000 liters of air pass through the nose each day.

Your Nose Protects Your Health By:

Filtering all that air and retaining particles as small as a pollen grain with 100% efficiency.
Humidifiing the air that you breathe, adding moisture to the air to prevent dryness of the lining of the lungs and bronchial tubes.
Warming cold air to body temperature before it arrives in your lungs.
For these and many other reasons, normal nasal function is essential. Do your lungs a favor; take care of your nose. TIP: Keep a list of all your medications; know all the potential side effects; and discuss possible interactions with your doctors.

Because the connection between the nose and lungs is so important, paying attention to problems in the nose–allergic rhinitis for instance – can reduce or avoid problems in the lungs such as bronchitis and asthma. Ignoring nasal symptoms such as congestion, sneezing, runny nose, or thick nasal discharge can aggravate lung problems and lead to other problems:

Nasal congestion reduces the sense of smell.
Mouth breathing causes dry mouth, which increases the risk of mouth and throat infections and reduces the sense of taste. Mouth breathing also pulls all pollution and germs directly into the lungs; dry cold air in the lungs makes the secretions thick, slows the cleaning cilia, and slows down the passage of oxygen into the blood stream.
Ignoring nasal allergies increases the chance that you will develop asthma; it also makes asthma worse if you already have it.
So, it is important to treat nasal symptoms promptly to prevent worsening of lung problems.

Tips To Improve The Health Of Your Nose And Lungs:

If your nose is dry, its various functions will be impaired. Try over-the-counter salt-water (saline) nasal mists and sprays to help maintain nasal health. These can be used liberally and at your discretion.
Beware of over-the-counter nasal decongestant sprays; prolonged use of these sprays may damage the cilia that clear the nose and sinuses. Decongestants can become addictive and actually cause nasal congestion to get worse.
Think of your nose when you’re traveling. Air-conditioned cruise ships may have high levels of mold in the cabins. Airplane air is very dry and contains a lot of recirculated particles and germs; a dry nose is more susceptible to germs. Use saline nasal mist frequently during the flight, and drink lots of water.

Medications Prescribed To Treat Nasal Problems:

Be aware of the nasal effects of other medications:

Diuretic blood pressure medications cause dryness in the nose and throat, making them more susceptible to germs and pollens.
Many anti-anxiety medications also have a drying effect on the nose and throat.
Birth control pills, blood pressure medicines called beta-blockers, and Viagra can cause increased nasal congestion.
Eye drops can aggravate nasal symptoms when they drain into the nose with tears.
Be sure you understand their purpose. Each one is important and plays a separate role in treating nasal symptoms. The foundation of the treatment of chronic nasal conditions is the regular use of an anti-inflammatory prescription nasal spray, which address all types of nose and sinus inflammation. These sprays should be used only as directed by your doctor. This is in contrast to medications that are inhaled by mouth into the lungs, which often have high levels of absorption into the blood stream. Always aim nasal sprays to the side of the nose; spraying into the center of the nose can cause too much dryness.
Antihistamines effectively relieve sneezing, itching and runny nose, but they have no effect on nasal congestion at least in the short term. Over-the-counter antihistamines cause drowsiness, slow the cleaning function of the cilia, and increase the stickiness of nasal mucus–causing germs and pollens to stay in the nose longer. There are prescription antihistamines that do not have any of these side effects. To achieve this safety, the relief is often slower starting, so patience is required.

Decongestants help to unclog stopped up noses but do very little for runny noses and sneezing. They work much faster to unclog the nose, but to achieve this quick action, there are often side-effects such as dry mouth, nervousness, and insomnia. The correct dose often has to be customized to get the benefit without the side-effects.

Be aware of medication side effects; no medicine works well for all people, and all medications can cause side effects.

All About Noses