COMMON ENT CONDITIONS
IN CHILDREN

What causes the symptoms?
There are numerous causes why the nose and the sinuses will overproduce mucus. The most common ones are listed below:

Colds and flus: Influenza and other respiratory viruses often cause an upper respiratory tract infection that is marked by a significant amount of mucus production. These are usually intermittent and well defined episodes of runny nose that are associated with the other signs of a flu infection like sore throat and a fever.

Allergic rhinitis: This is probably the most common cause of persistent and recurrent rhinorrhea. This is due to the body being overly sensitive and reactive to respiratory allergens that are inhaled through the nose. Exposure to these allergens leads to histamine release and a runny/drippy nose, together with other symptoms such as sneezing, nose itch and also blocked nasal breathing.

Vasomotor rhinitis: Sometimes, the nose is sensitive to changes in the environmental air quality and produces excessive amounts of mucus to protect the nasal mucosa or skin lining. Triggers include environmental air that is too dry or too cold, or when the change in temperature of the environment is sudden.

Sinusitis: Occasionally, infection of the paranasal sinuses may cause excessive mucus production. In such situations, the mucus is usually much thicker and may be coloured - yellow, brown or green are typical. This may be accompanied by high fevers and pain around the cheeks.

Foreign body insertion: This is an often missed diagnosis where foreign bodies may be left in a nostril or nasal cavity for many years without anyone discovering. In this situation, usually the runny nose may be coloured and smelly and will be occurring in only one nostril, the side where the foreign body has been inserted. Sometimes this is associated with blood stains in the mucus and also an offensive smell detected by the patient in the nostril.

Nasal polyps: Nasal polyps are benign growths of tissue within the nasal cavity and sinuses that usually result from underlying allergies. They tend to produce a lot of slightly coloured mucus and may also be obstructive leading to poor nasal breathing and also a loss of smell.

Enlarged adenoids: These usually cause nasal obstruction and poor nasal breathing. These would sometimes also lead to excessive mucus production in the nose.

Nasal cysts and tumours: These rarely obstruct the nose and also lead to excessive mucus production. They may be benign or cancerous and usually would affect one side of the nose only.

How is it treated?
The treatment really depends on the underlying cause. The first step is to have a consultation with an ENT surgeon. A history and physical examination will be conducted in a safe and playful environment for the child so as to gain his/her cooperation. An examination of the oral cavity and the nasal passages would be mandatory. If the child is able to tolerate, a Nasoendoscopy would provide invaluable information to determine whether the nasal tissues are swollen and inflamed and whether there are abnormal tissues like polyps and enlarged adenoids. Thereafter, depending on the history and the physical examination findings, certain laboratory and imaging investigations may be recommended. To determine if there are any underlying allergies to respiratory allergens, a blood test or a skin prick test may be ordered. These would indicate the circulating levels of antibodies to these allergens or the body’s reaction to exposure to these allergens and confirm the presence of the allergies. Sometimes, a lateral neck X-Ray or Sinus X-Rays may also be ordered to visualize the sinuses and the adenoids or nasal passages. These may be especially important in children who are not able to tolerate a Nasoendoscopy examination. If any unusual nasal masses are detected, these may need to be biopsied under local or general anesthesia.

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What is it? (Continued)

Most times the nosebleeds from the front part of the nose on the septum (cartilage and bone in the middle that separates the left and right nasal passages) where there are numerous superficial blood vessels that are easily damaged and broken.

What causes it?

The most common causes of a nosebleed are:

Dry air: This causes the skin lining in the nose to dry up and then to crack easily, thereby causing the blood vessels to start bleeding.

Nose picking: Oftentimes children enjoy picking their noses with their fingers and these lead to trauma of the skin lining and superficial blood vessels.

Trauma: A knock to the nose can lead to a break in the skin-lining and bleeding.

Excessive blowing of the nose: The forceful jet of air in blowing of the nose may also lead to trauma and breakage of the superficial blood vessels

Colds and allergies: The skin lining of the nose becomes swollen and inflamed in times of flu and allergies. These are more fragile than usual and easily break and cause bleeding

Foreign bodies of the nose: Foreign bodies that get stuck in the nose cause inflammation of the skin lining of the nose, as well as physically traumatizing the skin lining leading to easily bruising and bleeding.

Bleeding tendencies and clotting abnormalities: there are some medical conditions where there is difficulty clotting such that bleeding episodes are particularly prolonged. In such patients, minor trauma may lead to nosebleeds and the bleeds can last for a much longer duration than usual.

Tumours: there are some rare tumours in children such as Juvenile Nasal Angiofibromas which may affect boys and young men from 10 years old to 25 years old, which lead to massive bleeding episodes, nasal obstruction and sometimes changes in facial appearance.

What can the ENT surgeon do for my child with nosebleeds?

Most nosebleeds are self limiting or can be stopped with the first aid measures described above.Persistent and frequent nosebleeds, and bleeding from multiple sites may warrant a visit to see an ENT surgeon to have a closer examination and also possible treatment.

The ENT surgeon can perform a thorough examination of the entire nasal passage to diagnose where the site of the bleeding is from. This is done with a combination of direct visualization with a headlight as well as through the use of a flexible nasoendoscopy (Flexible tube with a video camera at the end).

Once the site of bleeding and abnormal blood vessels is identified, a variety of methods can be used to stop the bleed and also “seal” the blood vessel. The most common area where the bleeding occurs is from an area on the nasal septum near the front of the nose called the “Little’s Area”. There are numerous blood vessels that supply the nasal septum at this area and usually the superficial blood vessels that bleed can be easily cauterized (“burnt and sealed”). Cautery can be achieved using chemicals like Silver Nitrate (applied using chemical sticks) or by means of electrical and heat energy delivered through an electrocautery device. This may require some local anesthesia to be applied.

If there are any abnormal masses discovered on examination, these may warrant further investigations with either imaging scans like CT Scans/ MRI scans or may require a further biopsy. These can then give more information on the underlying abnormal tissue and a discussion on the appropriate treatment may then ensue.

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