Pediatric Ear Nose Throat

What is pediatric ENT and who is it for?

Pediatric ear, nose and throat (ENT) care covers the examination and treatment of problems involving the ears, nose, adenoids, tonsils, throat and neck in children, from infancy to adolescence. Children are not small adults: their Eustachian tube is shorter and more horizontal, their adenoids and tonsils are naturally larger in the preschool years, and their immune system is still developing. The same symptom can therefore mean something different in a child than in an adult.

Most visits are about recurrent infections, enlarged adenoids and tonsils, fluid behind the eardrum, snoring, and concerns about hearing or speech. Many of these settle with time and appropriate treatment; in some children, surgery can noticeably improve breathing, sleep and hearing. The aim is to tell apart the children who can safely be watched from those who need treatment.

What should parents watch for?

Young children cannot always describe what is wrong, and parents are usually the first to notice. The following are good reasons for an ENT check-up:

• Constant mouth breathing, a permanently blocked nose or a nasal-sounding voice
• Snoring every night, pauses in breathing or struggling to breathe during sleep, restless and sweaty sleep
• Daytime tiredness, poor concentration, irritability or difficulty waking up
• Feverish throat or ear infections that keep coming back several times a year
• Turning the TV up, responding late when called, often asking ‘what?’
• Speech that lags behind other children of the same age or is unclear
• Ear discharge, frequent ear pulling or ear pain
• Long-lasting runny nose, bad smell, cough or facial pain
• A lump in the neck that grows or does not go away

Examination and diagnosis

The visit starts with the parents’ account: how long the problem has been going on, how many infections there have been in a year, which medicines were used, how the child sleeps and how things are at nursery or school. The ears, nose, mouth, throat and neck are then examined. The appearance of the eardrum gives important clues as to whether there is fluid in the middle ear.

Because the adenoids sit in an area that cannot be seen directly, in children who are old enough and cooperative they can be assessed through the nose with a thin endoscope; in some cases a side X-ray of the nasopharynx may be used instead. The method is chosen according to the child’s age and cooperation.

Hearing tests depend on age. Tympanometry is a short, non-invasive test that measures how the eardrum moves and shows whether there is fluid behind it. Younger children are tested with play-based hearing tests, while older children can do standard audiometry with headphones. For babies, the newborn hearing screening result is taken into account, with referral for further testing when needed. If sleep apnea is suspected, a sleep study may be requested.

Enlarged adenoids and tonsils

The adenoids sit behind the nose and the tonsils on either side of the throat; both are lymphatic tissue. It is normal for them to grow in the preschool years as children meet new infections, and in most children they shrink towards adolescence. They become a problem when they are large enough to block breathing, disturb sleep, interfere with eating or affect ventilation of the ears, or when they become a source of frequent infections.

Large adenoids can cause mouth breathing, snoring, a nasal voice, a runny nose and fluid in the ears due to a blocked Eustachian tube. Long-term mouth breathing may also affect facial and dental development. Large tonsils can cause difficulty swallowing, breathing problems during sleep and recurrent throat infections.

Fluid in the ear and ventilation tubes

Fluid behind the eardrum, also called glue ear or otitis media with effusion, is one of the most common causes of hearing loss in childhood. It often follows a cold or an ear infection, may not cause pain, and is often noticed only through inattention, turning up the volume or a setback in speech.

A large share of these effusions clear on their own within a few months, so watchful waiting with follow-up hearing tests is usually the first step. If the fluid persists for months, clearly reduces hearing, affects speech development or causes structural changes in the eardrum, a small ventilation tube (grommet) placed in the eardrum may be considered. The tube lets air into the middle ear and usually falls out by itself within months. If large adenoids are also present, removing them in the same session may be discussed.

Recurrent infections

Children who start nursery or school commonly catch several upper respiratory infections a year. What matters is how often and how severe the infections are, whether they cause missed school days, and how well the child is in between. Recurrent tonsillitis, frequent middle ear infections and long-lasting sinus symptoms are assessed in this light.

A single number is not enough to decide on surgery. Whether the infections were documented by a doctor, the need for antibiotics, the child’s general health and the burden on the family are considered together. Keeping a note of infection dates and medicines used is therefore very helpful at the appointment.

Snoring and sleep apnea in children

Occasional snoring, especially during a cold, is usually harmless. Loud snoring every night, pauses in breathing, the chest pulling in with each breath, frequent waking and sweating, however, may point to obstructive sleep apnea. In children the most common cause is enlarged adenoids and tonsils.

Unlike adults, children with poor sleep are not always sleepy during the day; they may instead be hyperactive, have trouble concentrating, do worse at school, wet the bed or grow more slowly. Depending on the examination findings, a sleep study may be requested and treatment planned accordingly.

Hearing and speech development

Children learn to speak by imitating what they hear, so even mild or fluctuating hearing loss can affect speech development and learning at school. Hearing should be assessed in every child whose speech is delayed. If the cause is treatable, such as fluid in the ear, hearing is retested after treatment; if the hearing loss has another origin, further assessment and follow-up with the relevant specialists are arranged.

Treatment options: observation and medication first

In pediatric ENT, the first step is often not surgery. For fluid in the ear, a period of observation; for allergic or chronic nasal blockage, nasal sprays and saline rinses; and for suspected bacterial infection, an appropriate antibiotic are among the first options. Antibiotics are not needed for every infection, since many throat and ear infections in childhood are caused by viruses.

Surgery is recommended when symptoms persist despite appropriate treatment, when breathing problems during sleep are significant, when hearing and speech are affected, or when infections clearly disrupt the child’s daily life. The decision is always made together with the family, after discussing benefits and possible risks.

How is the operation done?

ENT operations in children are performed under general anesthesia with an anesthesiologist present. The procedure is completed while the child is asleep, and nothing is felt during surgery. Fasting times and any tests needed beforehand are explained to the family separately.

The adenoids are removed through the mouth, with no external incision. Tonsil surgery is also done through the mouth: the tonsil tissue is removed and bleeding is controlled. A ventilation tube is placed under the microscope, through the ear canal, into a tiny opening made in the eardrum. Adenoid and tube procedures are usually short; adding tonsil surgery makes the operation somewhat longer. Most children go home the same day or after one night of observation; the exact length of stay is decided at the examination, based on the child’s age, general health and the procedure planned.

Recovery

Recovery depends on the procedure. Children who only have tubes placed usually return to normal activities the same day, while tonsil surgery needs a longer recovery. The timeline below is a general guide:

1. Day 1As the anesthesia wears off, the child wakes up and starts drinking. Mild throat or ear pain, drowsiness and restlessness are possible. Pain relief is given at the dose and frequency advised by the doctor.
2. First weekAfter tonsil surgery, throat pain is usually noticeable for several days; soft, lukewarm or cold foods and plenty of fluids are recommended. A white-yellow coating in the throat is a normal part of healing. After adenoid surgery, a blocked nose and bad breath may occur temporarily.
3. Week 2Pain eases in most children and eating returns to normal. After tonsil surgery, strenuous activity should still be avoided in this period and parents should watch for signs of bleeding. The return to school or nursery is planned with the doctor.
4. 1 monthMost children are back to their usual routine and sports. Healing is checked at a follow-up visit; if tubes were placed, the ears and, if needed, hearing are rechecked. Regular check-ups are advised for as long as the tube stays in place.

Risks and how they are reduced

Like any surgery, pediatric ENT operations carry risks, and these are discussed in detail with the family beforehand. The most important risk after tonsil surgery is bleeding. It can occur in the first hours after the operation or when the healing coating comes away, most often between days 5 and 10. If you notice blood from the mouth or nose, spitting blood or frequent swallowing, contact the doctor or go to the nearest emergency department without delay.

Anesthesia-related risks are minimized through a pre-operative assessment and close monitoring by the anesthesia team throughout surgery. A ventilation tube may fall out earlier than expected, become blocked or cause discharge; in some children the fluid returns and another tube may be needed. A small hole remaining in the eardrum after the tube falls out is uncommon and is assessed at follow-up. Adenoid tissue can rarely grow back. Regular follow-up helps detect these problems early.

Notes by age

A child’s age affects both how problems show up and which treatments are suitable:

1. Infants and toddlers (0–2 years)The newborn hearing screening result matters; babies who do not pass should be referred for further testing. Not reacting to sounds, difficulty feeding and noisy or wheezy breathing should be assessed. At this age, decisions are usually made together with the pediatrician.
2. Preschool (2–6 years)Enlarged adenoids and tonsils, fluid in the ears and recurrent infections are most common in this period. Because speech develops rapidly, noticing hearing problems is especially important.
3. School age (6 years and older)The adenoids usually begin to shrink. Attention problems related to poor sleep, allergic nasal blockage and sinus complaints may come to the fore. Changes in school performance should also be considered in terms of hearing and sleep.

When to seek urgent care

Go to an emergency department without waiting for an appointment if you notice:

• Bleeding from the mouth or nose after tonsil or adenoid surgery
• Marked breathing difficulty, long pauses in breathing during sleep or a bluish colour
• Inability to open the mouth or swallow saliva, or marked swelling on one side of the throat
• Redness and swelling behind the ear with the ear pushed forward
• High fever with a stiff neck, marked lethargy or inability to drink