Adenoidectomy and Submucous Diathermy (SMD)
Children frequently suffer blocked nose and when this situation is a permanent feature, treatment is required.
The usual causes (alone or in combination) are overgrowth (or “hypertrophy”) of the adenoids or hypertrophy of the Inferior turbinates – which are glandular structures within the nose. These conditions may be the result of allergy or repeated viral infections. Adenoids are made of the same tissue as tonsils, but are located behind the nose.
As a result, children may have snotty, blocked noses which often causes snoring, sleep disruption, poor appetite (can’t breathe whilst trying to eat) and very often ear infections and hearing loss. The ear problems arise because the enlarged adenoids block the openings of the Eustachian tubes, which lead to the ears, causing fluid build-up behind the eardrums (called “glue-ear”).
The treatment is removal of the adenoids and/or cautery of the Inferior turbinates. Both of these treatments may be done at the same time, under general anaesthetic. These are day-case procedures which are usually quite well-tolerated by children. There is a moderate sore throat if adenoidectomy is done and the turbinates take a few weeks to shrink down after the cautery, when improved nasal patency is noted.
This treatment may result in a marked improvement in the child’s symptoms and is very worthwhile.
“Glue ear” (or Middle Ear Effusion) is a condition in which fluid accumulates in the middle ear behind the ear drum. It is the commonest cause of partial deafness in children and it is estimated that one in three to four children are affected with glue ear at some stage of their lives.
The build up of fluid in the middle ear is due to a problem of blockage of the tube that connects the middle ear to the back of the nose (Eustachian tube). The Eustachian tube normally plays an important role in maintaining equal air pressure between the outside and inside of the middle ear. When the tube becomes obstructed, (e.g. due to adenoids) the air in the middle ear becomes absorbed and the resulting vacuum draws fluid into the middle ear cavity from the lining of the ear (the mucosa).
Initially the fluid is thin and watery but eventually it becomes thick and sticky, hence the name ‘glue ear’. Because the middle ear is now filled with fluid rather than air, the hearing is muffled. Children often don’t complain about hearing loss, as an adult may. Obstruction of the tube may be due to repeated bacterial and viral upper respiratory tract infections, enlarged adenoids or nasal allergy.
It is important to note that in children the Eustachian tube is more horizontal and smaller than in adults and this is one of the reasons why glue ear is relatively more common in children.
Because of the change in size of the Eustachian tube as you get older, and because you tend to be less prone to infections as you get older, children may grow out of glue ear. However, it can take a long time, although it usually resolves by teenage years. The problem is, glue ear may lead to delayed speech development, behavioural or educational problems and permanent eardrum damage that cannot be rectified.
There is some debate about how effective medical treatments are and the mainstay of treating children with glue ear is with ventilation tubes (grommets). The decision to operate and insert a grommet in the eardrum is dependent on many factors such as the patient’s age, whether there are recurrent middle ear infections, pain, speech delay, learning or behavioural difficulties.
It can also depend on the appearance of the eardrum (for instance whether there is a retraction pocket, which is a localised area of scarring that may lead to problems). Young children with poor language development, pain or recurrent ear infections should have grommets inserted as soon as possible. Older children with few symptoms can be treated conservatively with regular follow-up visits in the outpatient clinic, to monitor their hearing and the appearance of the ear drum.
The main objective of grommet insertion is to get rid of the fluid in the middle ear by allowing air to enter through the grommet, so temporarily bypassing the problem. Normal hearing is restored once this objective is accomplished.
Grommets are smaller than a match head. On average, a grommet will stay in place between six to 18 months and will then fall out as the healing eardrum pushes it out into the ear canal.
If the child redevelops glue ear, it may be necessary to re-insert another grommet. The operation to insert a grommet is usually performed as day-case surgery under general anaesthesia and it is one of the most common operations in the world.
The main complication associated with grommets is infection, but this can be treated with oral antibiotics or ear drops. In order to prevent infection, children with grommets are usually advised to use ear plugs and a bathing cap when going swimming and also to avoid diving, although opinions among surgeons do vary. This is particularly important in children with sinusitis or rhinitis. Ear protection is also important in the bath, shower or when washing hair, to prevent soapy water from going through the grommet and causing infection.
However, infection can also arise from the nose via the Eustachian tube, even when the ears are well protected.