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Over recent decades, antenatal diagnosis has been greatly enhanced by high-resolution ultrasonography, enabling the identification of potential airway anomalies in utero. The development of rapid-sequence magnetic resonance imaging (MRI) scanning of the foetus further enhances our diagnostic capabilities pre-natally. The role of the paediatric otolaryngologist in the management of these problems has become increasingly important, because the development of minimally invasive endoscopic techniques and advancements in intrauterine surgery and in endoscopic equipment now make the pre-natal surgical correction of airway conditions a possibility. Thus, airway obstruction in the unborn baby can be diagnosed early, and with a multidisciplinary approach, planned management of the possible neonatal airway compromise has become routine. The paediatric ENT surgeon's principal remit in this team is to secure the airway at the time of an ex-utero intrapartum treatment (EXIT) procedure. EXIT describes the technique of undertaking a Caesarian section approach, but delivering only the head and upper torso through the uterine incision, while maintaining the maternal foeto-placental circulation. [ABSTRACT FROM AUTHOR]

The auricle is often a point of fixation as well as one of the most eye-catching parts of the body. This may be the reason why the desire for an aesthetically shaped ear has developed in humans. Another reason might be that from ancient times, personality traits have been attributed to the shape of the auricle. Whereas Aristotle (384-322 BC) stated that persons with big ears have good memories and sagacity, nowadays this shape may be defined in some societies as a symbol of stupidity. Protruding ears are common. About one out of five children have them. Usually parents seek consultation for correction directly after birth or at the age of 4-5 years when children may begin to be teased by their peers. The next group of patients consists mainly of young ladies at puberty or between 20 and 25 years complaining about their limitations in hairstyling. Traumatic lesions are the second most common type of auricular deformity. They often result from fights, dog bites or accidents. Because many of the auricular lesions may result in disfigurement of the shape, an appropriate treatment plan has to be followed from the very beginning. [ABSTRACT FROM AUTHOR]

The facial nerve contains a variety of different types of fibres including somatic sensory fibres, which carry sensation from the skin of the outer ear and its immediate vicinity, visceral sensory fibres, which carry taste from the anterior two-thirds of the tongue and from the palate, visceral motor fibres, which supply secretomotor function in the submandibular and sub-lingual salivary glands, and branchial motor fibres, which innervate the muscles of facial expression and the stapedius (Fig. 47.1). These latter fibres comprise the vast majority of the facial nerve fibres. [ABSTRACT FROM AUTHOR]

Cochlear implantation is now a mainstream option for the management of children with severe-to-profound hearing loss. Worldwide, approximately 65,000 people have cochlear implants, of whom approximately 25,000 are children. Cochlear implants are suitable for children from the 1st year of life onwards. Current research indicates that among congenitally deafened children, those who are implanted at a very young age seem to have the best outcomes from cochlear implantation. With the implementation of universal neonatal hearing screening (UNHS) in many developed countries and with the ability to obtain objective, frequency-specific and earspecific hearing thresholds using auditory brainstem responses (ABR) and auditory steady state responses (ASSR) at, or shortly following birth, it is no longer necessary to delay intervention until the child is able to perform conventional behavioural tests. Yoshinaga-Itano et al. (1998) published seminal research that demonstrated that children who were identified with hearing loss early, and provided with amplification or implantation soon afterwards, were able to achieve much better outcomes in speech and language development than children whose hearing loss was identified later or who had delayed intervention. [ABSTRACT FROM AUTHOR]

Dizziness is a lay term used to describe many different sensations, including unsteadiness, imbalance, clumsiness, light-headedness and vertigo. However, vertigo is a medical term referring to an illusion of movement, which may be subjective (personal perception of motion) or objective (observation of motion of the environment), and is characteristically associated with disorders of the vestibular system. Young children are often unable to describe these different perceptions, and thus any complaint of dizziness, instability or vertigo should be considered in the broad context of the "dizzy child" for diagnostic purposes. [ABSTRACT FROM AUTHOR]

This chapter will deal with the use of bone-anchored hearing aids (BAHAs) and will also cover Softband, a non-surgical application of the hearing aid part of BAHA in certain situations. [ABSTRACT FROM AUTHOR]

Chronic otitis media is defined as chronic inflammation of the mucosa and submucosa of the middle ear. Chronic otitis media is recognised to be part of a continuum of inflammatory middle ear disease that also includes acute otitis media and otitis media with effusion. [ABSTRACT FROM AUTHOR]

Otitis media with effusion (OME or "glue ear") is the most common cause of hearing impairment in childhood. The condition is generally self-limiting, but may occur during a period when poor hearing will impede speech and language development. The effects are mostly short term, but in children in whom the condition recurs throughout childhood, some effects on behaviour and cognition are detectable up to the age of 10 years and beyond (Bennett and Haggard 1999). [ABSTRACT FROM AUTHOR]

Acute Otitis media (AOM) is one of the most common paediatric infectious diseases. The clinical spectrum may extend from a benign, self-limiting condition to a prolonged and sometimes complicated disease. Although in industrialised countries serious complications are rare, the burden of AOM is large, with impaired quality of life and high direct and indirect socio-economic costs. First described by Hippocrates in 450 BC, this disease continues to present one of the more troublesome medical problems of infancy and childhood. [ABSTRACT FROM AUTHOR]

Deafness is the most common sensory deficit, and more than 50% of all childhood deafness is due to hereditary disorders. The prevalence of permanent hearing impairment (>40 dB hearing threshold) is approximately 1.3 per 1000 children (Parker et al. 1999). [ABSTRACT FROM AUTHOR]

The main types of congenital abnormality of the middle and external ear will be discussed in this chapter. In many cases, a single child may well have congenital malformations in two or three of the separate parts of the ear. It is relatively uncommon, however, for congenital problems in the middle and outer ear to be accompanied by parallel malformations in the inner ear (in about 8%), since this is formed in the embryo at a different period of intrauterine development. In discussing this group of congenital anomalies, there is still some variation in the use of descriptive terms. For this reason we begin with definitions of the terms to be used in this chapter. [ABSTRACT FROM AUTHOR]

Management of any child with a hearing loss will depend on several factors including the age at which the child presents, the cause of the hearing loss and its degree. The most common cause of deafness in childhood, otitis media with effusion (OME), is the subject of a separate chapter and will not be referred to further in this chapter other than in the context of OME being superimposed on a sensorineural hearing loss. It is fundamental that the paediatric otologist involve other agencies, both medical and non-medical, in the management of patients in his or her care; these will include the paediatric audiologist, teacher of the deaf, geneticist, general medical paediatrician and developmental paediatrician. Large numbers of children with congenital deafness may also have visual difficulties and the paediatric ophthalmologist will also be a part of the team managing such children, partly to exclude visual problems, but also to manage those discovered. Some children with complex hearing disorders such as auditory neuropathy (auditory dysynchrony) or central auditory processing disorders (APD) may also need the involvement of the paediatric neurologist. [ABSTRACT FROM AUTHOR]

The assessment of hearing in children requires several different testing techniques to be available. The choice of test will depend upon the age of the child, his or her medical state and whether an objective or behavioural investigation is needed. [ABSTRACT FROM AUTHOR]

Rhinitis and sinusitis usually coexist and are concurrent in most individuals. Therefore, rhinosinusitis is a more appropriate term. The clinical definition of rhinosinusitis in children is an inflammation of the nose and paranasal sinuses, characterised by nasal blockage (congestion, discharge) and one or more of these signs and symptoms (i.e. anterior/posterior secretions, or post-nasal drip, facial pain or pressure, and reduction or loss of smell). [ABSTRACT FROM AUTHOR]

Allergic rhinitis (AR) is a prevalent, yet underappreciated, inflammatory condition of the nasal mucosa, characterized by pruritus, sneezing, rhinorrhea, and nasal congestion. It is mediated by early- and late-phase hypersensitivity responses to indoor and outdoor environmental allergens. AR affects a large portion of children in the developed world. Both basic science and epidemiological studies have demonstrated that AR is part of a systemic inflammatory process and is associated with other inflammatory conditions of the mucous membranes. These include otitis media with effusion, rhinosinusitis, allergic conjunctivitis (AC), and asthma. The ARIA guidelines (Allergic Rhinitis and its Impact on Asthma) have provided a pragmatic, stepwise approach to treating AR. Allergen avoidance remains one of the guiding principles of treatment, although it may sometimes be difficult to implement. While there is an ever-increasing armamentarium of pharmacotherapeutic agents available to the clinician, intranasal corticosteroids remain the single most effective class of medications for treating AR. [ABSTRACT FROM AUTHOR]

Choanal atresia, a malformation in which the nasal fossae do not open onto the aerodigestive pathway, was first described as early as 1755, by Roederer. A variety of corrective surgical approaches, transmaxillary, transseptal, transpalatine and sublabial intranasal, have been developed over the subsequent 250 years. Surgical management has recently made significant progress, thanks to developments in endonasal surgery. [ABSTRACT FROM AUTHOR]

This chapter covers the common childhood conditions of nasal foreign bodies, epistaxis and nasal trauma. In general, patients with these conditions can be managed in the outpatient setting without requirement for follow up. [ABSTRACT FROM AUTHOR]

Thyroid disease is uncommon in children. The most commonly encountered surgical pathologies of the thyroid apparatus in children are thyroglossal duct cysts and fistulae. These and the management of ectopic thyroid tissue are discussed elsewhere (Chapter 19). This chapter reviews the embryology, anatomy and physiology of the thyroid gland, investigation of thyroid disease, functional thyroid diseases and thyroid neoplasia in the paediatric population. It assumes in the reader a knowledge of the management of adult thyroid disease. [ABSTRACT FROM AUTHOR]

The upper aerodigestive tract, which consists of the nose, mouth, pharynx, larynx and oesophagus, allows for the passage of air and food. These structures form one of the most complex neuromuscular systems of the body, providing the structural and dynamic components for swallowing, respiration and speech. [ABSTRACT FROM AUTHOR]

Recurrent respiratory papillomatosis (RRP) is a disease of viral origin that occurs in both pediatric and adult populations. Its symptoms, primarily hoarseness and manifestations of airway obstruction, are due to human papilloma virus (HPV) infection of the laryngotracheal airway and the development of exophytic growths that alter airflow. RRP is the most common benign laryngeal tumor to occur in children and the second most frequent cause (after vocal cord nodules) of chronic hoarseness (Wiatrak et al. 2004). RRP has no known cure, and it can cause significant morbidity. [ABSTRACT FROM AUTHOR]

In this chapter, the following are discussed: the changing indications for tracheotomy, the changing nature of the population of children with a tracheotomy, alternatives to a tracheotomy, the surgical technique and its complications, home care of a child with a tracheostomy, and how to decannulate a child. [ABSTRACT FROM AUTHOR]

Tracheomalacia is a condition that is characterised by weakness of the cartilages supporting the trachea. It is usually suspected when endoscopy shows tracheal collapse with greater than 50% tracheal obstruction during expiration (Benjamin 1984). Two anomalies account for these findings: weakness of the tracheal wall resulting from reduction of the ratio between the cartilaginous rings and posterior transverse muscle, and hypotonia of the posterior transverse muscle, resulting in forward ballooning, especially during expiration. Tracheomalacia can be classified as primary and secondary. In secondary tracheomalacia, lesions are usually limited to one segment, whereas primary tracheomalacia (tracheal dyskinesia) extends for the entire length of the airway (see Table 27.1). [ABSTRACT FROM AUTHOR]

The vast majority of paediatric tracheal stenosis is congenital and relates to the presence of complete tracheal rings, so that the entire circumference of the airway is cartilaginous (Fig. 26.1). [ABSTRACT FROM AUTHOR]

The older term "subglottic stenosis" has largely been replaced by laryngotracheal stenosis (LTS) to highlight the glottic component of the stenosis, which is particularly important when considering resection. [ABSTRACT FROM AUTHOR]

Within the anatomic confines of the larynx, a variety of pathologies may compromise air flow, causing airway obstruction. This chapter describes two such anomalies - laryngeal webs and subglottic hemangiomas. This chapter includes a description of these disorders followed by a synopsis of diagnostic guidelines and current management strategies. [ABSTRACT FROM AUTHOR]

Laryngitis is an inflammatory process affecting the larynx. Acute infective laryngitis is the most frequent form of laryngitis seen in clinical practice in the primary care setting. In children it is usually associated with an upper respiratory tract infection. The vast majority of cases are of viral aetiology, the usual causative agents being rhinovirus, adenovirus, parainfluenza virus or respiratory syncytial virus. Rarely nowadays, since the introduction of widespread vaccination, laryngitis may also occur during the course of measles and Bordetella pertussis infection. Most cases are relatively benign and self-limiting, resolving spontaneously with only supportive treatment necessary. Occasionally, a child is referred with persistent hoarseness after a typical sounding episode of laryngitis, and then flexible laryngoscopy is required to exclude any other pathology. In the absence of such pathology, the usual finding is of some persistent oedema of the laryngeal mucosa, particularly of the vocal cords. This will generally settle over time. [ABSTRACT FROM AUTHOR]

The exact incidence of congenital abnormalities of the airway is uncertain, but a figure has been quoted for congenital laryngeal anomalies of between 1:10,000 and 1:50,000 births (Van den Broek and Brinkman 1979). Furthermore, some of these children will have more than one anomaly in the airway (Shugar and Healey 1980). [ABSTRACT FROM AUTHOR]

In managing upper-airway problems in neonates, infants and children, it is important to understand the differences between the anatomy and physiology of their respiratory system and that of adults. It is obvious that the neonate's airway is considerably smaller than that of an adult. The average diameter of the subglottis in a full-term baby is around 3.5 mm, that of an adolescent around 7 mm and in an adult around 10-14 mm. The impact of a reduction in the diameter of the airway upon its cross-sectional area (Fig. 21.1) is increased by the direct relationship of this area to the square of the radius (cross-sectional area = πr2). The clinical implication of this is further magnified by the inverse relation of resistance of flow to the radius4 in a tubular structure, as defined by Poiseuille's law, originally describing laminar flow of a fluid in a cylindrical tube (resistance αl×∂/πr4, where l is the length of the tube, r is the radius and ∂ is the density of the gas). Figure 21.2 illustrates the dramatic differences in the impact of 1 mm of mucosal oedema in an adult, a child of 6-8 years of age and a neonate. An adult will barely notice the change, a child will have significant difficulty, and for a neonate, it may have a fatal outcome. [ABSTRACT FROM AUTHOR]

Recent advances in airway endoscopy have made it an essential tool in the management of several pathologies of the pharyngolarynx, oesophagus and trachea. It can be performed using a flexible fibroscope or a rigid endoscope, and may require back-up examinations - notably by x-ray. [ABSTRACT FROM AUTHOR]

An understanding of human developmental anatomy is important in appreciating the congenital abnormalities that can occur within the head and neck region in children. Although some cysts, sinuses and fistulae are immediately apparent at presentation, others are not, and children may be examined on several occasions before a diagnosis is made. Appropriate medical and surgical treatment at an early stage will help to avoid recurrence. This chapter will outline the underlying developmental anatomy, and discuss the presentation, investigation and treatment of the lesions most commonly encountered by paediatric otolaryngologists and head and neck surgeons. [ABSTRACT FROM AUTHOR]

The salivary glands include: 1. The parotid glands. 2. The submandibular salivary glands. 3. The sublingual glands. 4. The minor salivary glands distributed throughout the oral and pharyngeal mucosa. [ABSTRACT FROM AUTHOR]

Clefts of the lip and palate occur as a result of the failure of fusion of the maxillary and frontonasal processes during embryonic development. At around 5 weeks of gestation, the palate anterior to the incisive foramen fuses progressively through the anterior hard palate, alveolus and lip. The failure of this fusion process produces a cleft lip, which can be either unilateral or bilateral. At about 7 weeks of gestation, a fusion process moves caudally from the incisive foramen through the hard palate and the soft palate to the tip of the uvula. Failure of this fusion process produces a cleft palate. The part of the palate anterior to the incisive foramen that fuses first is often referred to as the primary palate for that reason, but occurs as part of a cleft lip, not a cleft palate. A midline cleft of the upper lip is a very unusual anomaly and is often associated with other midline developmental problems such as absence of the corpus callosum and holoprosencephaly (failure of the hemispheres to divide). [ABSTRACT FROM AUTHOR]

The defining feature of obstructive sleep apnoea (OSA) is that reduction (hypopnoea) or cessation (apnoea) of oronasal airflow occurs despite continuing thoracic and abdominal respiratory effort (Guilleminault et al. 2005). OSA is at one end of a spectrum of disorders ranging from mild and innocuous snoring to multiple sequential episodes of prolonged nocturnal apnoea. Both adults and children are affected. [ABSTRACT FROM AUTHOR]

The tonsils and adenoids are part of the lymphoid tissues that circle the pharynx known as Waldeyer's ring. This consists of the lymphoid tissue on the base of the tongue (lingual tonsil), two (palatine) tonsils, the adenoids (nasopharyngeal tonsil), and the lymphoid tissue on the posterior pharyngeal wall. (Fig. 14.1) Waldeyer's ring grows throughout childhood until the age of 11 years and after that decreases spontaneously (Arens et al. 2002). [ABSTRACT FROM AUTHOR]

The term "developing country" essentially refers to a country with low levels of economic development generally accompanied by poor social and infrastructural development. The United Nations compares countries in terms of the Human Development Index, a relative measure of wealth. This is assessed by: (1) gross domestic product, (2) health (life expectancy at birth) and (3) education (literacy levels). [ABSTRACT FROM AUTHOR]

due to reactive lymphadenopathy associated with tonsillitis and other common upper-respiratory infections. These are usually self-limiting but may progress to cellulitis, suppuration and abscess formation. Chronic infections are less common but need to be considered if the swelling persists. [ABSTRACT FROM AUTHOR]

Cystic fibrosis (CF) and primary ciliary dyskinesia (PCD) are inflammatory airway diseases that may impinge on ENT practice in one of two ways. Firstly, a child thought previously to be healthy may present to the ENT surgeon with features that are suggestive of one of these conditions. Such a child should be referred for a diagnostic work up to a specialist unit. Secondly, a child known to have one of these conditions may be referred for treatment, either of a known complication, or of an unrelated condition. [ABSTRACT FROM AUTHOR]

Many adults and children with an underlying immunodeficiency can present to the ENT surgeon. This chapter deals with the presentation, investigation and management of immunocompromised children in ENT practice. The reader should also consider the chapter on cystic fibrosis and primary ciliary dyskinesia. Both primary immunodeficiency (PID) and human immunodeficiency virus (HIV) infection are discussed, as PID is under-diagnosed and retroviral infection is an increasingly common problem in the UK. Immunodeficiency is a complex area of medicine and this chapter is not meant to be exhaustive, but instead we aim to outline basic principles to guide clinical practice [ABSTRACT FROM AUTHOR]

ENT surgeons dealing with children need to know the ENT features of a few common syndromes, for example Down syndrome, Treacher Collins syndrome and Goldenhar syndrome, as they are likely to meet children with these conditions in their paediatric practice. The ENT surgeon may be presented with two distinct clinical scenarios. In the first, a patient with a known syndrome presents with an ENT problem. In this instance, the ENT surgeon needs to be aware of the ENT features of the syndrome so that the appropriate investigations and management can be instigated. The second and less common situation is when the ENT surgeon suspects that a child may have a syndrome that has not yet been diagnosed. This is rightly the province of the geneticist and, while it is intellectually stimulating to try to piece together a syndrome, it is best to avoid mentioning any suspicions at this stage. Much anxiety can otherwise result from ready access to the Internet. Nevertheless, they should know how to find out about these less common syndromes. This chapter provides a brief list of the more common ENT-related syndromes. [ABSTRACT FROM AUTHOR]

The prevalence of permanent sensorineural hearing loss in the UK has been shown to be approxymately 1:1000 children under 3 years and 2:1000 of children under 16 years (Fortnum et al. 2001). The late identification of congenital hearing impairment in particular may lead to delay in language development, significant educational underachievement and ultimately reduced employment opportunities. A Health Technology Assessment review conducted by Bamford and Davis in 1997 highlighted that large numbers of hearing-impaired children were being diagnosed late, and recommended the introduction of a universal neonatal hearing screening programme (Newborn Hearing Screening or NHS), which has since been established in the UK and which exists in other countries (Davis et al. 1997). [ABSTRACT FROM AUTHOR]

Paediatric laryngology is a discipline that is in its infancy when compared to the practice of adult laryngology. One reason is that a young child is often more difficult to examine than an adult, which can impede our ability to make an accurate diagnosis. Another is the lack of knowledge that has existed about the fine structure and development of the vocal fold as a child grows. Furthermore, outcome-based results have not previously existed for our treatments of common paediatric vocal fold pathologies. [ABSTRACT FROM AUTHOR]

One of the most remarkable things about human development is that within the span of approximately 5 years, babies progress from making only physiological noises, such as crying and coughing, to being fluent users of the language (or languages) spoken around them without receiving any direct instruction to do so. Mastery of such complex skills as knowing when to use the pluperfect tense, embedding dependent clauses and using thousands of different words productively occurs before children begin formal, academic schooling. This mastery occurs in children living all over the world, hearing thousands of different languages, under vastly different socioeconomic conditions. [ABSTRACT FROM AUTHOR]

Most people feel rather uneasy when reminded that we share 90% of our DNA with our ape ancestors. The idea that we evolved from monkeys was Darwin's most controversial claim in the Origin of the Species, much more unsettling than his hypothesis that the mechanism of evolution was by natural selection; "nature red in tooth and claw" actually fitted very easily with Victorian beliefs in unbridled capitalism. However, human descent from apes was embarrassing and seemed to denigrate our spirituality, so it was natural to seek ways of distancing ourselves from biology. The most quintessentially human attribute to emphasise was obviously the human ability to communicate by speech and language. Hence, until very recently it was believed that speech was uniquely human. Even chimpanzees, it was thought, could not be taught to communicate beyond rudimentary emotional calls. The power of speech had been bestowed on humans to make us human, all at once by a lucky mutation in the 1% of DNA we do not share with chimps. Chomsky and followers thought that this endowed us with an "encapsulated linguistic processing module" (Chomsky 1975) and a generative language "instinct" (Pinker and Jackendoff 2005). [ABSTRACT FROM AUTHOR]

The paediatric anaesthetist works very closely with his ENT surgical colleague. Surgery may be undertaken on the airway, responsibility for which is, of necessity, shared by both practitioners, who must understand each other's requirements to ensure safe patient care. Good communication and understanding between surgeon and anaesthetist are essential for the safe management of the more challenging problems of paediatric ENT surgery. [ABSTRACT FROM AUTHOR]

ENT surgery accounts for nearly 40% of all paediatric surgery, as recorded in the report of the Childrens' Surgical Forum published by the Royal College of Surgeons of England (2000) "Childrens Surgery: a first class service". The UK National Service Framework for Children, together with this report, require that children should be nursed on dedicated paediatric wards, staffed by trained nurses with both paediatric and ENT training, and that ENT surgeons who operate on children, and anaesthetists who anaesthetise them, perform sufficient numbers of operations to keep their skills honed. Other countries will have similar principles and clinicians should be aware of them. [ABSTRACT FROM AUTHOR]

Children are not small adults and their developmental status and metabolic needs must be considered carefully by those entrusted with their medical care. In a paediatric consultation, the history (anamnesis) is especially important, as it is essential to have a clear idea of the nature of the problem before examining the child. This is because children are often reluctant to be examined by strangers. [ABSTRACT FROM AUTHOR]

While all babies dribble until their oral and swallowing reflexes mature, it is not normal in the older child, who has usually gained control by the age of 4 years or so. Persistent and uncontrollable dribbling or drooling is socially unacceptable even in children, and is a source of embarrassment to the parents. It may lead to ostracism and social isolation, and as children get older and develop insight, they too will become distressed by it. [ABSTRACT FROM AUTHOR]