General

Obstructive Sleep Apnoea, or OSA, is a condition in which there is an obstruction of the airways. This can be caused by a number of different things, for example a weakening or relaxation of  the muscles in the throat during sleep. This narrows the airways, reducing airflow and making it harder to breathe. This can cause irregular breathing and snoring, particularly in those with large adenoids or tonsils. This can temporarily wake the sufferer while they try to resume a normal breathing pattern, leading to disrupted, poor quality sleep.

Causes

There are various causes for OSA in both adults and children. Children with enlarged tonsils and adenoids are at risk of OSA as this will block part of their airway. This is the most common cause of obstructive breathing and/or OSA in children. Other causes include childhood obesity, Down’s syndrome and sickle cell disease.

In adults, the causes are much broader and in general more complex to evaluate as there is rarely one problem that is causing the symptoms, unlike in children where the problems are usually more straightforward. These include nasal problems (nasal blockage due to a deviated nasal septum, sinusitis, allergy or nasal polyps), throat related problems (tonsillitis, large tonsils, an elongated uvula), voice issues (eg. laryngeal swelling due to acid reflux), and issues with neck size or swellings in the neck (eg. increased neck size due to obesity, thyroid problems, enlarged lymph nodes).

Symptoms

Snoring is often the first symptom of OSA. Parents of children with OSA may notice their child is sleeping in unusual positions in order to help them to breathe. Frequent but brief arousal from sleep is also common among sufferers, along with increased sweatiness or restlessness. This is the brain alerting the body to the struggle with breathing. Being extra tired during the daytime will be a repercussion of this. Some children may be aggressive or hyperactive during the day due to feeling over-tired. Struggling to focus or concentrate is another side effect. In extreme cases, the sufferer may lose their appetite and growth as well as school- work could suffer.

Diagnosis

Difficulties with breathing while sleeping can be linked to several medical conditions, so it is important the right tests are carried out to determine a diagnosis. An over-night sleep study performed by a technologist or physiologist is the best method. Breathing, heart rate and oxygen levels will be recorded. This can often be performed as a home sleep study so you do not necessarily have to stay overnight in hospital.

Treatment

Treatment will vary from patient to patient. If the tonsils or adenoids are the primary cause, then an operation to remove those may be arranged. Other possible treatment options include positive airway pressure therapy (CPAP OR BiPAP), nasopharyngeal airway treatment (NPA), nasal steroids and mandibular advancement (moving the jaw forward).

What are chronic ear infections?

Chronic ear infections are recurring ear infections that can be caused by several things. If an ear infection does not heal by itself or keeps returning, it will be classed as a chronic ear infection. This condition can escalate to cause hearing loss, a ruptured eardrum or in extreme cases, nerve paralysis. Anyone with a chronic ear infection must seek medical help.

Causes

Children are more likely to suffer from ear infections than adults. This is due to their Eustachian tubes (the tube that drains fluid from the middle ear) being smaller and more horizontal compared to adults. When an adult suffers an ear infection, it tends to be caused by an upper respiratory infection or a swimming-related injury. Other causes of chronic ear infections include sinus issues, allergies, and bacterial infections caused by colds or flu.

Symptoms

It is sometimes the case that symptoms of recurring, chronic ear infections may be less severe than those of an acute case. They also may come and go intermittently. Symptoms include:

• Ear pressure
• Fever
• Pus or liquid leaking from the ear
• Sleep issues
• Reduced hearing
• Pain in the ear
• Dizziness
• Tinnitus (a ringing sound in the ear)
• In infants, loss of appetite, irritability and tugging on the ear

Treatment

Home remedies may include a warm compress on the ear and over the counter pain relief medications. When you see the doctor, they will examine your ear. They may take an ear swab or arrange some blood tests to check for bacteria, as well as further tests such as a CT scan to see if an infection has spread. Your doctor will likely prescribe antibiotics. These will either be in tablet or ear drop form. Surgery may be required if the chronic ear infection is severe or has spread.

Prevention

• Wash your hands often and thoroughly to stop bacteria spreading
• Do not smoke and avoid second-hand smoke
• Keep up to date with vaccinations
• Ensure an ear infection is completely gone after the treatment
• Keep the ear scrupulously dry until the ear infection has settled. This includes avoiding swimming and also protecting your ear whilst having a bath or showering, such as with an earplug or cotton wool coated in Vaseline.

Speech and language delay is a reasonably common problem in preschool children, with as many as 10% being affected. Some of the possible causes are thought to be:
• Slower than normal development
• Loss of hearing
• Autism
• Not spending enough time talking with adults
• Elective muteness – choosing not to talk
If your child does not appear to be developing at a similar rate to other children his or her age, it may be speech and language delay. Although you should always remember, children will develop at their own pace, with some being faster in certain ways than others. If you do suspect speech and language delay, take your child to their doctor, who can refer you to a specialist if they feel it is appropriate.
They may decide to begin by referring you to an audiologist to have your child’s hearing checked. A hearing problem at a young age can cause speech delay or unclear speech because when a child learns to speak, they can only repeat back the sounds that they can hear. Therefore, if what they are hearing is ‘different’ to them, their speech will reflect this and will be less clear or understandable than it should be. If a hearing problem is the issue, then hearing aids or implants may be needed, and perhaps even enable your child to ‘catch up’ with other children their age developmentally once the issue is resolved. Very commonly, hearing problems in young children between the age of 18 months and 3 years of age are due to glue ear, which is a build up of fluid behind the eardrum. This can be easily managed with either medications or in some cases a small operation where a grommet is inserted into the eardrum to release the fluid. Once the hearing of whatever cause is treated, the speech usually begins to improve within a few weeks.
If your doctor feels your child needs help from a psychologist, behavioural specialist or social worker, then they will refer you to a health visitor who can make those arrangements for your child. Sometimes, of course, it may be a case of no real treatment, just that your child is taking a little longer than others with no real cause or explanation, and they will catch up eventually with no lasting adverse effects.
Lastly, remember it can be very frustrating for both the child and parents when dealing with speech and language delay. A child who cannot express themselves may act out in other ways and it is common for behavioural issues to occur, even as the main problem. It is essential to remain patient as much as possible and praise every effort, for it is not something the child can generally control.

It’s that time of year again when the coughs and colds are everywhere and can wreak havoc with your sinuses. Sinus infections and inflammation can cause a number of unpleasant symptoms – headaches, fever and tiredness, to name just a few. But are you aware that toothache can be one of those unpleasant symptoms?
We all have a total of eight sinuses – these are air-filled holes or spaces within the bones of the face and head. They are found behind your cheekbones, over your forehead/above your eyes, in between your eyes and deeper inside the head. It is not clear why we have or need sinuses although specialists believe that they help to filter the air in your nasal cavity as well as producing mucus to clean your nose. They also contribute to the strength of the facial bones and skull. Colds can lead to these becoming blocked with fluid, which can cause inflamed and swollen sinus tissue (sinusitis as it is otherwise known) and possible infection. The pressure created by this congestion can cause what is known as referred pain. This pain can radiate through your head and nose, as well as your teeth. This is because the nerves that serve the upper teeth run in the floor of the cheek (maxillary) sinuses; therefore any inflammation in these sinuses can cause swollen nerves to the teeth, which can be painful.
So how can you tell whether your toothache is down to sinusitis or an unrelated dental problem? Here is a list of a few of the symptoms to look out for if you feel your toothache is actually sinus-related:

• Sinus toothache is felt in the upper teeth, usually the back molars, and does not feel as if it is from one specific tooth.
• The pain will intensify when you move your head, or if you jump up and down (not recommended if you’re feeling under the weather!). The pain may lessen when you lie down.
• You have general cold symptoms such as a runny nose, feeling tired and sore throat.
• Ears feeling painful and full.
• Pressure/pain around your eyes, forehead and nose.
• Not being able to taste or smell.

Before a visit to the GP for antibiotics, you could try over the counter remedies (decongestants) or home remedies. These include breathing in steam and drinking plenty of fluids. Saltwater (saline) rinses to the nose are also usually extremely helpful in clearing out mucus from the nose – they can also enable prescribed medications such as steroid sprays or decongestants to work better on the nasal lining.

If your symptoms persist despite the above treatments, you may need to see an ENT specialist for a thorough examination and further treatment as required.

What Are They?

Tonsil Stones, also known as tonsilloliths, are lumps that form within the tonsils. These can be either white or yellow and are usually firm. Though very unpleasant for the sufferer, tonsil stones are not contagious and rarely go on to be anything serious. Quite often, a person with tonsil stones will not be aware they have them to start with as they aren’t easy to see and although they can get to be the size of a grape, they can also be as small as a grain of rice. They can cause swelling and pain in the tonsils and they have an unpleasant odour.

Causes

Mucus, food, saliva and dead cells can build up in the pockets of the tonsils (tonsil crypts). This causes bacteria and fungi to develop and with time this will form a tonsil stone. Sometimes one will form, other times it can be several at a time. Things that can cause this build-up include:

• Bad oral hygiene
• Chronic sinus problems
• Oversized tonsils
• Chronic tonsillitis

Symptoms

It can be hard to visibly spot tonsil stones but there are symptoms that come with them that will make you aware there is an issue. These include:

• Yellow or white lumps on the tonsils
• Earache
• Painful and swollen tonsils
• Persistent cough
• Smelly breath
• Sore throat
• Difficulty swallowing

Prevention

Tonsil stones can return once you have them. There are several things you can do to prevent this from happening. These include:

• Keep hydrated with plenty of fresh water
• Keep on top of oral hygiene and brush your tongue as well as your teeth
• Swill your mouth out with salty water regularly
• Do not smoke

Treatment

Although tonsil stones are usually harmless, most people understandably want them gone as soon as possible. Methods to remove them include:

• Coughing – Vigorous coughing can loosen the stones
• Minor Surgery – In extreme cases, this is an option although rarely cures the underlying problem
• Gargling – Using salty water or mouthwashes to gargle can ease the pain and swelling and help to loosen the stones
• Tonsillectomy – Removal of the tonsils to prevent further infections in chronic cases will solve the problem
• Antibiotics – These will lower the build-up of bacteria but will not treat the initial cause

The National Institute of Clinical Excellence (NICE) has published guidance in September 2019 about Implant surgery for prominent ears, including Earfold. The recommendations support the use of Earfold in the context of a clinical or research study. I am in the process of preparing a clinical study protocol so that patients can continue to benefit from a choice between traditional pinnapasty and minimally invasive techniques such as Earfold, in order that the most appropriate recommendations can be made.

It is surprising and somewhat alarming how common it is for these small household batteries to be swallowed by children, and the fatality rate has actually risen in the last decade. These batteries are small and sweet-shaped which makes them a hazard with young children around. Damage from swallowing the battery can occur within two hours so it is essential that removal takes place as soon as possible to reduce oesophageal damage. The battery reacts with the oesophagus tissue and saliva, forming a hydroxide-rich alkaline substance that damages tissue.

The symptoms of a child with an oesophageal button battery include:

• Cough
• Fever
• Sore Throat
• Noisy Breathing
• Finding it hard to swallow

The serious complications that could be caused by an oesophageal button battery include:

• Vocal cord paralysis
• Tissue erosion into major blood vessels or airways
• Oesophageal perforation leading to a chest infection

The longer it is between ingestion of the battery and the removal, the higher the risk of these serious complications. This has led to research being carried out into the effectiveness of certain household products that can help to reduce potential damage before the battery is successfully removed. Sodas, juices and sports drinks have all been tested, but honey has proven to be the most effective in protecting small children against button battery injury. This has been demonstrated by a team of ENT specialists at the Philadelphia Children’s Hospital, USA,  who found that eating some honey after swallowing a button battery can help minimise injuries for young children. The research suggests that honey can reduce morbidity and mortality from the batteries significantly. The honey works by coating the battery thereby preventing the alkaline-rich solution from damaging tissue.  It should not be used in children less than a year old or where there is a known allergy to honey. It is essential that the administration of the honey should not delay the transfer of the child to their nearest A&E department for definitive management. Obviously, it is also advised to ensure all batteries are kept out of reach of children and those that are in household items and toys should not be easily accessed.

Inflamed and swollen sinuses can cause sinus headaches, and this can be due to infections, colds or allergies. It can sometimes be difficult to differentiate between a sinus headache and a migraine and it is always best to seek advice from your GP to be sure. Both conditions can cause very similar symptoms, including pain in the face and head, although there are some key differences. Sinus headaches tend to cause pain in the face and frontal part of the head (forehead), including the cheeks, eyes, ears and upper teeth, but rarely anywhere else. In migraines, the headaches are usually also more severe, one-sided and often preceded by an aura or symptoms that the migraine is about to start, such as flashing lights or a feeling of nausea. Pain that is felt predominantly in the neck area is unlikely to be due to sinusitis and is also rare due to migraine. Other causes might need to be considered, such as neck stiffness due to a musculoskeletal cause, an injury or a vascular (blood vessel) cause. It is, however, possible to get some tightness in the neck due to tension or stress, and this can also accompany sinusitis or migraine, although the neck pain is likely to be less severe than the facial pain/pressure.

In the case of a sinus infection, you may also be experiencing other sinus related issues such as nasal congestion, a stuffy or runny nose (especially with an unpleasant nasal mucus discharge which can be green or yellow), or excessive sneezing. If neck pain is present it will likely be a tension-type pain, which is often worse after long periods of inactivity such as after sleeping, on bending over or going from hot to cold temperatures. This neck and head pain together can make you feel fatigued and can be quite unpleasant especially if you also have a fever.

Remedies

To treat sinus headaches and neck pain successfully you can start by using over the counter medicines such as decongestants and anti-inflammatory painkillers such as ibuprofen. This will not only help to relieve the pain but also the pressure caused by congestion. Antihistamines can also be effective if the issue has been irritated by allergies. It is always best to consult your GP before choosing your medication. If there are also signs of an infection, such as green/yellow nasal discharge and a fever, then it is possible that you will require a course of antibiotics from your GP or specialist.

Steps to Prevent flare-ups

The first step towards preventing sinus headaches and neck pain is to find out what the cause is. If the cause is a virus or common cold, then take the usual precautions to prevent a cold by washing hands and surfaces thoroughly and avoiding close contact with people suffering from a cold. If allergies are the cause, then you can take an antihistamine daily, as well as making efforts to avoid the substances to which you are allergic. It is also advised to avoid activities that alter the air pressure such as underwater swimming and flying activities, until such time that the symptoms have improved and you are feeling much better. Otherwise, the changes in air pressure can make the sinus infection (and therefore symptoms) much worse.

Signs Of Something More Serious

It is important to note that a fever along with a headache, neck stiffness and in some cases a skin rash can also be a sign of a more serious issue such as meningitis so always be sure to consult your GP if you are not sure or if your symptoms worsen suddenly over a short period of time.

It is very common to reach for painkillers such as aspirin to ease a headache or a fever, but if you suffer from a disorder known as aspirin-exacerbated respiratory disease (AERD) taking this medication could actually make you feel much worse. AERD can often be treated easily, it causes breathing issues and is triggered by sensitivity to non-steroidal anti-inflammatory drugs (NSAIDs)

Causes

Things that can make you at risk of AERD include:

• Smoking or being exposed to second-hand smoke as a child
• AERD tends to be more common among people between the ages of 20-50
• Having asthma can increase the risk
• Nasal polyps

Symptoms

There is a range of respiratory issues that can occur for an AERD sufferer. These include:

• Sinus problems and pain
• Stuffy nose and nasal congestions
• Headaches
• Watery eyes
• Sneezing
• Nasal polyps
• Asthma attack
• Wheezing or coughing
• Tightness of the chest
• Dizziness
• Fatigue
• Abdominal cramping
• Nausea
• Some people with AERD also find that alcohol can cause respiratory issues.

Diagnosis

There is no blood test to confirm AERD but your doctor can diagnose you by checking your respiratory reactions and symptoms when taking NSAIDs. They can perform what is known as an ‘aspirin challenge’, this is when they watch you take aspirin and monitor your reaction to it. This test should be avoided if you are pregnant or have heart, liver or kidney disease.  It is increasingly the case that this test is administered within a specialist allergy or respiratory clinic in a hospital.

Treatment

There are no known cures for AERD but there are ways of treating and managing it. You may be prescribed inhaled steroids to take daily, nasal steroid sprays or steroid sinus rinses. If you have nasal polyps, you can have surgery to remove or shrink them, although the chance of the polyps recurring if you have AERD is increased. Another possible treatment is aspirin desensitisation. This involves a doctor watching you take small doses of aspirin and increasing the dose over time. When you show a reaction, you will remain on that dose until you are able to manage it with ease. Then the process continues. This has proven to be successful in up to 90% of cases. However, the benefit of aspirin desensitisation continues only for as long as you continue to take the aspirin.

Most children will occasionally snore, and some will snore frequently. Light snoring that can barely be heard is rarely a cause for concern. If a child is consistently snoring loudly this could be an indication that they have a respiratory infection or an allergy. However, it could also be a sign of a more serious illness such as sleep apnoea.

Everyone is allowed to have a short gap or break in their breathing pattern at night, however If a child’s snoring also includes frequent or particularly long pauses or gasps (10 seconds is thought to be an acceptable upper limit), this could be a symptom of  sleep-disordered breathing, or obstructive sleep apnoea syndrome (OSAS). These pauses and gasps cause inconsistent breathing patterns for the child which in turn causes the child not to get the required amount of quality sleep meaning they will be overtired in the daytime. There are some known contributing factors to sleep apnoea, which include:

• Asthma
• Allergies
• Enlarged or swollen tonsils and/or adenoids
• Obesity
• Reflux disorders
• Face or jaw (craniofacial) physical abnormalities

So how can you know if your child is suffering from sleep apnoea? Well, there are a few signs that you can look out for. Obviously, snoring is the first symptom, so keep a note of your child’s snoring pattern and volume. This isn’t the only sign to watch out for though, if your child is frequently waking up during the night then they will likely be tired during the daytime. They could also be sleeping in unusual positions in order to make their breathing easier, or be particularly restless and fidgety. If your child’s behaviour and moods seem to change then keep an eye on these changes as it could also be linked to sleep patterns due to snoring and breathing issues. Finally, excessive or increasing sweating at night can indicate that your child is working harder than they should be to breathe comfortably.

To determine if your child does, in fact, have OSAS you will first need to be assessed by an ear, nose and throat (ENT) consultant or a paediatrician, or in some cases both specialists. It is possible that further tests may be required, such as blood tests, X-rays and/or an overnight sleep study at a hospital. Your GP or specialist can make the necessary referrals for this. The sleep study will record breathing patterns and the heart rate of your child and the results will provide the diagnosis and a treatment plan can be made.

There are a number of treatments available for OSAS. These are:

• Medical treatments such as steroid drops or sprays or even antibiotics in some cases, following an ENT review
• Nasal prongs to keep the airway open – occasionally required in young children or infants with syndromic or craniofacial problems.
• CPAP – The child wears a mask while asleep which provides continuous air flow. This is usually only required in the most severe cases.
• Surgery – one of the commonest causes of sleep-disordered breathing or sleep apnoea in children is having large tonsils and/or adenoids. Surgery to address these problems (adenotonsillectomy) is occasionally required and very often extremely effective.

If you are worried about your child snoring, you should make an appointment with your GP in the first instance to discuss the treatment options.