PS: Upper respiratory infections very often coexist with an enlarged adenoid. Specialists differ in their views on this subject. In clinical practice, we should ask several basic questions. Does the child snore? Do they keep their mouth open? Do they have difficulty breathing properly through the nose? If these symptoms are present, we may suspect adenoid enlargement. Air then passes through the mouth rather than the nose, so it is not warmed. Airborne microorganisms and bacteria also settle more easily in the mouth than in the nose and are not filtered. These factors may make infections more frequent.
If there is accompanying recurrent otitis, initially intermittent, the adenoid enlargement is already greater than a few centimetres and the ear should be examined. During surgery, after removing the adenoid that compresses the Eustachian tube openings, we also inspect the ear. It is best to perform tympanopuncture, a gentle incision of the eardrum, and check for accumulated fluid. What complications can an enlarged adenoid cause? Which tests should be performed during differential diagnosis?
PS: A basic examination that any ENT specialist can perform involves asking the child to open their mouth, checking whether the palatine tonsils are enlarged, and asking them to say ‘aaa’ or ‘eee’. The palate then lifts backwards. If it lifts properly, we can see that there is no obstruction. If doubts remain and symptoms suggest infection or adenoid enlargement, we should check whether allergy is responsible. Fibreoptic examination is then indicated. A flexible fibrescope with a camera is inserted into one nasal passage to view the adenoid directly. Allergies typical of early spring, when birch and alder pollen are present, and later, near summer, grass pollen, may explain the problems. We should ask whether these situations have occurred before and whether the child always reports symptoms at a particular time of year. Further differential diagnosis and allergy testing are needed. Is adenoid enlargement a minor condition, or can it cause more serious complications?
PS: Adenoid enlargement should not be dismissed. Many specialists say, ‘It may still shrink’ or ‘Perhaps we can give medication’. However, any episode of otitis is a warning that the adenoid should be removed. Several guidelines exist, and medical societies in different countries approach this differently. Clinical practice and discussing previous symptoms with the patient are very important. The worst scenario is that patients repeatedly get through episodes involving an enlarged adenoid, then the palatine tonsils enlarge, fluid appears in the ears and, eventually, a cholesteatoma may develop. This involves skin growing in the middle ear, creating a risk of irreversible structural damage and permanent hearing loss. Which conditions are described as sudden deafness? How are they diagnosed, and what causes sudden hearing deterioration in children?
PS: Sudden deafness is rare in children. The literature describes it as sporadic and more common in adults. Sudden deafness means a sudden deterioration in hearing: someone wakes in the morning and cannot hear. The change is substantial enough to worry them. I always warn students, residents and doctors in my lectures that this requires going to hospital as quickly as possible, promptly inserting an intravenous cannula and administering relatively high doses of intravenous glucocorticoids, an effective treatment. Some people have underlying conditions, which must also be considered. Such a short, intensive course of glucocorticoids can restore hearing, if not completely, then at least partially, even by 80 per cent. Differential diagnosis is always necessary. A highly stressful situation, such as losing a job, may be a cause. Another possible cause is a growing neuroma, a slow-growing tumour of the eighth cranial nerve, which is assessed with MRI.
Sudden deafness is uncommon in children but may present similarly. Hearing deterioration may result from acute otitis media with effusion. It starts with an infection causing very severe ear pain. Alternatively, chronic otitis may allow fluid to accumulate without pain. Treatment then includes medication and local therapy; inhalations can help. Sometimes a small puncture is made in the eardrum and the fluid is suctioned out, and glucocorticoids are used to relieve symptoms. What besides acute otitis media can cause similar symptoms in a child?
PS: With pain around the ear, two situations need consideration: teething and inflammatory conditions in the mouth. The trigeminal nerve, whose branches carry sensation from the face, may make a child report pain more around the ear when the cause is simply an erupting tooth accompanied by fever. This should always be assessed. In older children wearing orthodontic appliances, pain associated with degeneration of the ankle joint may occur. The appliance can change the position of the lower jaw. Other possible causes include upper respiratory infections, initially involving an accumulation of discharge, which may have an allergic background. Inflammation can then spread to the middle ear, so otitis is present but originates at lower levels of the upper respiratory tract. Does acute otitis media in a child always require an ENT consultation?
PS: It depends on the perspective. An experienced paediatrician knows how to manage acute otitis. I often observe family doctors and paediatricians recommending ear drops that are subsequently used for too long. Using some preparations beyond the recommended 5 days, as parents sometimes do, can deplete the external ear’s normal flora and lead to a fungal infection. I have seen children given drops for a month or even two, eventually requiring antifungal treatment. If acute otitis media persists despite oral or local antibiotics, video otoscopy is an absolute indication, rather than examination only with a speculum or microscope. Video otoscopy involves inserting an otoscope into the ear canal and viewing the image on a monitor. It allows close examination of the eardrum and a decision on modifying treatment, which may require surgery.
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