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Paediatric ENT

Tonsils and adenoids?

There are two tonsils, one on each side of the back of the mouth. They a can be seen through the mouth. There is one adenoid. It is located deep behind the nose just above the tonsils but it can not be seen without performing a telescope exam or ordering an x-ray. Although there is only one adenoid, it is often referred to as adenoids.

Tonsils and adenoids are “lymphoid” or “immune” tissues that are involved with recognising and processing germs and allergens. They can become enlarged because of allergies, infection, and other reasons. There is a lot of other similar tissue throughout the body. Therefore, not having tonsils and adenoids does not cause any long term problems.


Why might a child need to have the tonsils and adenoids removed?

There are a number of reasons to consider a tonsillectomy. Some of the reasons are frequent sore throats, very large tonsils interfering with breathing and /or sleep, difficulty swallowing, bedwetting if it is due to sleep problems, mouth breathing, speech difficulties, snoring, sleep apnoea, frequent or chronic bad breath, crooked teeth, abnormal facial growth, frequent or chronic sinus infection, or very rarely to look for a tumor. Usually only one or two of the reasons noted above pertains to any one patient.

Adenoids usually behave the same as tonsils and contribute to the same problems and require removal. The adenoids are directly examined at the time of surgery and if they are tiny and completely healthy appearing, they will not be removed.


What is the surgery like?

This is a common surgical procedure done under general anesthesia. Usually there are no needles until after the child is completely asleep and unaware of what is happening. To go to sleep, a small mask attached to a balloon is gently placed over the nose and mouth. The child is then asked to blow up the balloon. With each breath, oxygen another anaesthetic is breathed in. Within several breaths the child is asleep. An IV is then started. The surgery is done through the mouth and takes about ½ hour. There are no outside incisions. Children usually go home about 6-8 hours later.


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To understand how ear tubes work, you must first know about the middle ear and Eustachian tube.  The ear has three parts: the outer ear, the middle ear, and the inner ear. The eardrum is a very thin membrane that separates the outer ear from the middle ear.  The middle ear is an air chamber.  It is connected to the back of the nose and throat via a narrow tube called the eustachian tube. The eustachian tube is a pressure-equalising valve and a drainage tube.  Normally, the eustachian tube opens with swallowing and yawning.  In infants and young children, the eustachian tube is narrow and flat.  By age 7 or so, the eustachian tube is larger and more upright which improves its ability to function.

Many Problems within the middle ear space are related to the Eustachian tube.  Blockage of the Eustachian tube creates negative pressure in the middle ear and over time can pull the eardrum inward.  If this occurs, clear fluid may be drawn from mucous membranes into the middle ear space causing a fluid buildup.  This Frequently occurs in the children with upper respiratory infections or allergic symptoms.  Sometimes the fluid can last a long time.  When it does it is called “Chronic” fluid , or “chronic otitis media with effusion. “

If bacteria or a virus enters the middle ear fluid through the Eustachian tube, a pus infection can accumulate behind the ear drum.  This is called “acute otitis media” and is often accompanied by symptoms of fever, ear pain , irritability and sometimes drainage (if the infection ruptured the eardrum.)  If not treated, both recurrent episodes of acute otitis media as well as chronic otitis media with effusion can have potentially serious complications. 


What are pressure grommets?

Since it is not possible to surgically alter the Eustachian tube , a PE tube is placed within the eardrum to serve as an  artificial Eustachian tube.  It is a small, usually round piece of specialised plastic with a tiny hole in the center.  PE tubes stay in place about 6 months to two years before they fall out on their own into the ear canal. 

Although PE tubes greatly decrease the frequency of middle ear infections, it is still possible to get one.  A tube will allow the infection to drain out into the ear canal so that pain, fever, and the possibility of hearing loss are minimized. 

What happens during the procedure?

The surgery is performed under a microscope.  Wax is removed and a small incision (“myringotomy”) is made in the front part of the ear drum.  Fluid, plus, and/or debris are suctioned from the middle ear space and a tiny pressure equalization tube is placed in the ear drum.

What happens on the day of surgery?

Your child is placed under general anesthesia by breathing a light anesthesia medicine through a mask.  The procedure is then performed.  It usually takes 5 to 15 minutes.  The doctor will talk to you right away after the surgery but you will not be able to see your child for about 10 minutes more.

Does my child stay the night?

This is an outpatient procedure.  Most children go home within one hour of surgery  

What can I expect the first few days?

Your child may be irritable and tired the first 24 to 48 hours after surgery.  More commonly, they will be feeling normal by the early evening.  You can expect a small amount of thin, blood-tinged drainage from the ears (more if there was active infection at the time of surgery) for about 2-3 days.

When should my child return to school/daycare/sports?

This is at your discretion. Generally, children return to school/daycare and may resume normal activity and sport the following day.  However, swimming should be avoided for one week. 

What should my child eat?

Lighter foods and plenty of liquids are encouraged during the first 24 hours.  A normal diet may be resumed the following morning.

When will my child follow-up in clinic?

The office will provide you a follow-up anywhere from 7-10 days after surgery.  The timing is not critical.

Do I need to keep water out of my children’s ears?

Only bath water needs to be avoided

What are the benefits of surgery?

1. 90% reduction is acute middle ear infection-As the number of middle ear infections declines after surgery, the need for antibiotics is also reduced, and decreases the likelihood of developing antibiotic-resistant bacterial ear infection.
2. Resolution of conductive hearing loss- The most common type of hearing loss related to chronic otitis media with effusion(chronic fluid) and acute otitis media is a “conductive” hearing loss.  After removal of fluid from the middle ear space during PE tube placement, the conductive hearing loss is usually resolved.  (Of note, most children will have a few decibels of “inconsequential” very low frequency conductive hearing loss just because of the biomechanics of having an ear tube in the ear drum.  It might show up if a post –operative audiogram was performed.)
3. Minimize or prevent the longer term complications of chronic ear disease including:

  • Permanent, irregular holes in the eardrum
  • Severe scarring within and between the eardrum and tiny middle ear bones
  • Bone deterioration
  • Cholesteatoma (middle ear cyst of dead skin cells)
  • Development of eardrum retraction pockets
  • Permanent Conductive hearing loss

4. Improve speech development- As ear tubes help correct conductive hearing losses that occur with fluid behind the eardrum, they can also improve speech development. 

5. Retained PE tube –Less than 5% of tubes stay in longer than 3 years at which time a brief anesthesia may be required to remove the tube.

6. Early PE tube extrusion-4% of ear tubes fall out before 6 months.  This is usually in younger children and is usually associated with a middle ear infection that generates enough pus to push the tube out.

7. Persistent hole in eardrum*- There is a 2% chance that a hole will remain in the eardrum after the tubes falls out.  Some of these holes will require a patch procedure or graft surgery to close the hole.

*If a PE tube is not placed it is much more likely for the chronic ear issues to progress.

Please let us know if you have any questions.

North Country Ear, Nose & Throat – Head & Neck Surgery
Julie A. Berry, M.D, March J. Lebovits, M.D., F.A.C.S

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