ENT Specialities, Conditions And Treatment

A cholesteatoma is a benign, but locally destructive, growth in the ear. Most commonly, they are seen in patients with a history of chronic ear infections; however, they can also be congenital. Symptoms vary greatly – some patients only have mild hearing loss, and others can have pain as well as drainage from the ear. Treatment is surgical. It is important that surgery not be delayed because cholesteatomas continue to grow until they are removed, and they can become very destructive.

Ear infections are common in children, particularly in toddlers. Many ear infections are viral and resolve with time, but others are bacterial and can require antibiotics to treat. If children are having recurrent ear infections, it is important that they be evaluated for chronic fluid build-up in the ears, which includes an ENT evaluation as well as a hearing test. Some patients with recurrent ear infections may benefit from having ear tubes placed.

There are several different types of ear infections:

Otitis media (Middle ear infection)

This is the most common type of ear infection, and it is an infection of the middle ear. Children typically have fevers, are fussy, and complain of ear pain. Viral otitis media will typically resolve in 48-72 hours, and pain can be treated using Tylenol and Motrin. Other cases may require antibiotics.

Mastoiditis

This is a complication of a severe ear infection, or an untreated ear infection. Children with mastoiditis have severe ear pain, and redness/swelling behind the ear, which causes the ear to protrude forward. Patients with mastoiditis typically require intravenous antibiotics as well as surgical drainage.

Otitis externa (Outer ear infection)

Also known as swimmers ear, otitis externa is more common in somewhat older children. It is often due to water getting trapped in the ear canal, and patients get an infection of the skin in the ear canal. Patients often have significant pain, drainage from the ear, and swelling in the ear canal as well as around the ear. Depending on the severity of the infection, treatment typically involves antibiotic eardrops, sometimes in combination with oral antibiotics.

What is endoscopic sinus surgery?

Endoscopic sinus surgery (ESS) is a term used to describe a surgery using small cameras (endoscopes) to access spaces deep in the nasal cavity. Sinuses are air-filled spaces that open into the nose. If the openings become blocked, fluid and inflamed tissue can get stuck in the sinuses. Using the cameras, we open up these pathways and remove disease in the nose and sinuses. The cameras provide a magnified view allowing for very fine and precise dissection. We sometimes use image guidance systems to track our movements in the nose to make sure the surgery is done carefully and safely.

What are indications for sinus surgery?

The indications for sinus surgery are numerous. Chronic sinus infections or severe sinus infections often require procedures to remove swollen tissue and open drainage pathways in the nose. Polyps are common in patients with allergies. Sometimes tumors and vascular lesions can be present in the nose, and they can also be removed with ESS. Occasionally, we will use endoscopes to access diseases in the eye socket, since it is right next to the nose.

What are potential complications?

Common complications include minor bleeding, minor scarring, infections, recurrence of disease or need for further surgery. Serious complications after this surgery are extremely rare and include cerebrospinal fluid leaks or meningitis, severe bleeding, damage to vision or the eyes, scarring in the nose and septum or persistent pain and nasal discomfort after the nose has finished healing.

What can I expect after surgery?

• Sinus surgery is generally well-tolerated.
• Children normally do not complain about pain for more than a couple days after surgery.
• There may be some minor dripping of blood or mucous from the nose for the first few days that should decrease daily.
• Your doctor will likely prescribe your child saline sprays and pain medicine. They may also recommend antibiotics during the recovery.
• There is generally no change to the shape of the nose; however, there may be some mild swelling for a few days.
• You will generally return to the office for a checkup one-two weeks after surgery. At that time, the doctor may need to look in your child’s nose with a camera and remove some mucous and crusting from the surgery.

When should I call my doctor?

• If your child has fever that does not improve with Tylenol or Motrin.
• If your child is not behaving normally after the first 24 hours.
• If your child has lots of clear drainage from the nose.
• If your child has excessive bleeding.
• If your child has trouble seeing.

If you have any other concerns, please don’t hesitate to call your doctor.

Patients have hearing loss for a variety of reasons, and we have many different treatment options, depending on the type of hearing loss.

Conductive hearing loss

This type of hearing loss is due to a problem with transmitting sound from the outside world to the inner ear and is often (but not always) surgically correctable. Fluid in the ear, for example, can cause a conductive hearing loss and placing tubes typically resolves the hearing loss in those cases.

Sensorineural hearing loss

This type of hearing loss is permanent and is due to abnormal functioning of the cochlea (hearing organ). In mild cases, we often recommend close monitoring and preferential seating/additional services at school. For more significant hearing loss, there are a variety of hearing aid options available, and we work closely with our patients to pick what will work best for them. In patients with severe hearing loss who are not getting adequate benefits from their hearing aids, cochlear implantation may be the best option.

Vertigo (dizziness or imbalance)

The balance organ is located in the inner ear, so vertigo is a common symptoms of an inner ear problem. The presence of vertigo warrants a full ENT evaluation, including a hearing test.

What is Laryngomalacia?

The term laryngomalacia comes from the roots “larynx” (voice box) and “malacia” (soft). It describes a condition where parts of the voice box are too soft or floppy. The voice box needs to be strong enough to stay open when air flows through it (e.g., sucking air through a straw). In this condition, when a child breathes in, the soft tissue collapses. This can cause noisy breathing that is generally mild but can be life-threatening.

Is my child’s breathing safe?

Laryngomalacia is the most common cause of “stridor” (noisy breathing) in infants but can also present in older children or even adults. Most of the time, it gets better over time and will resolve by one year old. The noise itself is not a problem; however, if the weak voice box is making it hard for your child to breathe, surgery may be required. Signs that your child may require intervention include poor weight gain, frequent vomiting/spitting up, blue spells, frequent hospitalizations, recurrent pneumonias, “retractions” (sinking) of the neck or chest during breathing, trouble feeding, poor quality sleep or worsening symptoms over time. “Failure to thrive” describes a child that is working so hard to breathe that they cannot maintain their weight because they are burning too many calories or are not able to eat enough.

What work up or testing is necessary?

After talking with your doctor, they will try to figure out why your child is having breathing issues. This generally includes an office procedure, where a camera is placed in the nose to see what is causing the noisy breathing. This helps them rule out other potential airway problems. Your doctor may consider medications to treat acid reflux to reduce swelling in the voice box. Sometimes a sleep study is required. In children with genetic issues, hypotonia, acid reflux, neurologic problems, prematurity or cerebral palsy, laryngomalacia treatment is often more complicated.

What can I do at home to improve my child’s breathing now?

Using a humidifier in the bedroom can help. It is best if your child is not placed flat immediately after eating. We typically recommend holding the baby upright for 30 minutes after feeds before laying them down. If your child is spitting up or vomiting a lot, talk with your doctor about diet changes or medications. After your doctor evaluates the child, they may also recommend positioning the child a certain way to help with the breathing.

What is a supraglottoplasty?

In cases of laryngomalacia, the voice box is either too tight or too floppy. Either problem can cause the airway to collapse. If symptoms are severe, your doctor will recommend a surgery to release tightness and trim extra tissue that is blocking the airway. Sometimes this is done with special scissors and other times we will also use lasers. Occasionally, sutures will be used to lift the “epiglottis” (front of the voice box) out of the way. The entire surgery is done through the mouth and no scars will be visible after surgery.

In addition to this surgery, your surgeon will inspect the rest of the airway to assess for other problems that can impact breathing and swallowing.

What are the risks of this surgery?

The surgery is common and generally heals well. As we are operating on the airway, any swelling or scarring can cause temporary or permanent blockage of breathing. This is incredibly rare and most children are breathing better shortly after the surgery. Swallowing can also be impaired, but generally improves after the surgery. Rare complications may include pneumonia, need for intubation or tracheotomy, need for revision or additional surgery, scarring and bleeding. Ask your doctor if they expect additional concerns.

What is the recovery like for my child?

This surgery is generally well-tolerated. Patients typically have mild pain for a few days. We keep patients in the hospital or intensive care unit for at least one night, possibly longer. Most of the time, breathing and eating are back to normal or better before you leave the hospital; sometimes, it takes a couple of weeks to see the benefit of the surgery. Most patients will be sent home with an acid reflux medicine to help healing after the surgery. We will arrange for follow up two-four weeks after surgery.

When should I call my doctor?

• If your child has fever that does not respond to Tylenol or Motrin.
• If your child has trouble swallowing or drinking after the first day.
• If your child has trouble breathing.
• If your child is coughing up blood.
• If your child has weight loss after the surgery.

Please call your doctor or go to the emergency room with these or other concerns.

What is this swelling in my child’s neck?

Neck swelling in children is a common complaint, and most of the time, it represents swollen lymph nodes related to a common cold or illness. These swellings may take weeks or months to go away. If your child is very skinny, they may be visible for longer.

Very rarely, these can also represent cancers. Concerning symptoms include weight loss, fatigue, night sweats and excessive bleeding or bruising. If there are concerns or if the lymph nodes fail to return to normal size, we may obtain ultrasound imaging or even consider removing the lymph nodes for biopsy.

Other types of swelling in the neck include cysts, vascular malformations and tumors. Most of these are benign but need to be removed so they do not grow and affect other structures in the neck. Examples of these swellings include branchial cleft cysts, lymphatic malformations, ranula, sialocele, dermoid cysts, atypical mycobacterium (ATM) and teratomas.

What work up is necessary?

The tests we order will depend on what your doctor thinks the swelling represents. This can include blood work, an ultrasound, computerized tomography (CT) scan, magnetic resonance imaging (MRI), needle aspiration or biopsy. Sometimes, we will refer you to see other specialists like hematologists if additional consultation is necessary.

When is surgery necessary?

Without any other symptoms and a normal work up, we will watch large lymph nodes for months or years without considering surgery. If the lymph node is suspicious, a biopsy is necessary and this generally has to be done in the operating room. This is normally a small procedure with a quick recovery, but your doctor will discuss any additional risks or concerns before the surgery.

Larger neck masses and cysts that have to be removed may have more potential risks. The neck has many nerves and blood vessels that are critical for normal bodily functions. If the mass is near these structures, there could be weakness when the mass is removed. These nerves may include the nerves that move the tongue, facial muscles, shoulder, voice box and the diaphragm. The carotid artery, jugular vein and other large blood vessels are also in the neck and sometimes need to be considered.

What are potential complications?

As mentioned above, your doctor will have to discuss any structures in the neck that are near the cyst or mass. Other complications may include swelling, scarring, infection, bleeding, recurrence, damage to the breathing or swallowing tubes or need for further surgeries. Serious complications are very rare.

What will my child’s recovery be like?

• Depending on the size and location of the cyst or mass, the recovery may be very quick or could take up to a couple weeks to recover.
• If the mass is large, you may have to stay in the hospital until a surgical drain is removed after the surgery.
• Pain is usually easily managed with oral pain medicine that may include Tylenol, Motrin or oxycodone.
• Your doctor may also prescribe an antibiotic if there is concern for infection.
• There will often be glue or tape over the incision and these will fall off on their own.
• In young children, we rarely use stitches that need to be removed.
• Your doctor will want to see your child back in the office in one-two weeks after discharge.

When should I call my doctor?

• If your child has fevers that do not improve with Tylenol or Motrin.
• If your child has pain that is not well-controlled.
• If your child has swelling in the neck that is enlarging three days after surgery.
• If your child is having trouble with breathing, drinking or not acting appropriately.
• If your child has more than minimal bleeding from the surgical site.

If you have any other concerns, please call our office.

What is Septoplasty?

Septoplasty describes reshaping the cartilage and bone in the middle of the nose to improve nasal breathing. This is performed for a deviated nasal septum. Generally, this is done with incisions inside the nostril that are not visible.

The external appearance of the nose is made up of triangles or tripods of cartilage and bone. If the deviated septum is very severe or the tripod is unstable, it may require a more extensive surgical approach. This is referred to as a “functional septorhinoplasty,” which improves nasal breathing by correcting all of these areas. This may include reshaping the external shape of the nose. This can sometimes result in widening of the outside of the nose, if necessary, to improve breathing but often, results in straightening the outside appearance of the nose.

What are potential complications?

Complications after these surgeries are rare. The most common possible complications are as follows:

• Bleeding – Small amounts of dripping are typical for the first few days. If the bleeding is not improving steadily, please alert your doctor.
• Septal perforation – A hole in the septum is a rare complication that may require repair.
• Persistent nasal deformity – Your doctor will discuss the goals and objectives of the surgery. If there are issues you need addressed, make sure they are aware before the surgery. Some goals may be unrealistic and we can counsel you ahead of time. Healing from the surgery often takes months and the appearance of the nose may improve steadily over the course of one year.
• New nasal deformities – Rarely, after the surgery, the cartilage may weaken creating a change in the shape of the nose. If you notice anything that concerns you, alert your doctor.

What is the expected recovery?

After the surgery, your nose will often be somewhat swollen and blocked. Your surgeon may place splints on the inside and outside of your nose that can be uncomfortable. They are generally removed at the visit one-two weeks after surgery. Until that time, splints may be visible. After the splints are removed, the nose will be more comfortable.

• It may feel best to sleep with your head elevated.
• Ice can be applied to the outside of the nose for 20 minutes, then off for 20 minutes, repeat as necessary for pain and swelling during the first two-three days.
• After surgery, your doctor will likely prescribe saltwater nose sprays to be used two-three times daily for the first one-two weeks. Try to avoid blowing or rubbing your nose.
• You will receive pain medicine (Tylenol, Motrin and oxycodone) and possibly antibiotics.
• Antibiotic ointment may be prescribed – place a small amount in the nostrils and along stitches twice a day for one-two weeks.

You should not perform any heavy lifting or strenuous activity for two weeks after surgery. After this, it is okay to exercise, but avoid any activity that could cause injury to your nose for six weeks. Even after this time, the nose will still be healing, but it is ok to return to normal activity.

When should I call my doctor?

• Severe pain, not relived by prescribed medication
• Excessive bleeding
• Worsening headaches/vision changes, which do not improve with pain medications
• Fever above 101°F

A thyroglossal duct cyst (TGDC) generally presents as a swelling in the midline of the neck above the level of the “Adams Apple.” It is the most common cyst in the neck. It may get bigger over time or fluctuate in size. When you have a cold, it may swell up and occasionally can get infected. When that happens, the cyst will often be hard, red and painful. Even though the infection may improve, the cyst will not go away unless it is removed. As the infection continue, the cyst will often get closer to the skin and may drain mucous or pus. It is best to remove the cyst before the infection progresses this far.

What is the thyroglossal duct?

When a fetus is developing, a tract of tissue drops down from the tongue and settles in the lower neck. This tissue will make up a part of the thyroid gland. As the thyroid descends, it will sometimes leave a tract behind that can form a TGDC. Sometimes, these tracts are big and may have an opening in the middle of the tongue into the mouth. The path of the TGDC generally travels through a bone in the neck called the hyoid bone. Unless the entire tract is removed, it will come back.

What is a Sistrunk surgery?

Sistrunk or modified Sistrunk surgery is the best way to remove a TGDC so it does not come back. The cyst is removed with a portion of the hyoid bone and a small amount of muscle from the tongue. This makes sure the entire duct is gone. Sometimes the tract has to be traced all the way into the mouth.

What are the risks of this surgery?

• The surgery is common and generally heals well without incident.
• Serious complications are very rare but can include damage to the blood vessels and nerves going to the tongue or having saliva from the mouth enter the neck.
• Other complications include infections, bleeding, scarring, recurrence of the cyst and issues related to anesthesia.

What is the recovery like for my child?

• This surgery is generally well-tolerated. Patients typically have mild pain for a week.
• Most patients resume a normal diet right after surgery.
• There may be some swelling in the neck while the wound is healing.
• Most patients stay in the hospital overnight. Often, there is a small plastic drain in place that is removed the following day. This drain helps make sure there is no infection and little swelling in the neck after surgery.
• We ask you to avoid strenuous activity for two weeks after surgery.
• You should avoid getting the incision wet for two days after discharge and not to submerge the incision in water until we see you back in the office.
• Your doctor will likely send you home with some pain medicine and may also prescribe an antibiotic.

When should I call my doctor?

• If your child has fever that does not respond to Tylenol or Motrin.
• If your child has trouble swallowing or drinking after the first day.
• If your child has increasing swelling in the neck.
• If your child has trouble breathing.

If you have any concerns, please call our office to discuss.