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ENT Conditions In Children

A DxD Session with Dr Annabelle Leong


Ended on Fri Mar 08 2019
Ended
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Top Answers


It is quite common to notice your toddler covering his or her ears and it is usually nothing to worry much about.

The top reason for little kids to do this is because they feel overly stimulated by too much sound or loud noises. Pretty much what we would do too as adults if we heard irritating or loud sounds around us. So it is a sort of protective reflex.

The next most common reason is that they may feel scared and this may represent an emotional reaction to what is going on around them. The world can be a pretty frightening place for little ones as they are still finding their feet and learning about the great unknown out there. 

Of course, if you notice that your toddler isn’t eating well, is running a fever, being crabby for no good reason or keeps tugging at his ears repeatedly, especially if he has just suffered a bad cold or flu, then he may have an underlying ear infection and perhaps trying to tell you that his ears are painful by touching his ears. Your doctor can perform a quick examination of his ears inside with a special tool called an otoscope, to tell you whether this is the case. 

As Dr Gan mentioned too, though less commonly, behavioural issues may present in this manner to suggest an underlying condition such as autism. However, there are usually other warning signs like the lack of eye contact and difficulty interacting socially with adults as well as other kids which would point more towards autism and its associated spectrum of behavioural disorders.

I just want to reassure you that in the vast majority of cases where little kids cover their ears, it is a way of protecting themselves from unpleasant or loud sound stimuli. 

18 Aug 2018

From your photo, that white lump on your left tonsil looks like a mucous cyst (collection of trapped secretions from your tonsil glands). It may also be a tonsil stone. Both these conditions are commonly seen in people who suffer recurrent episodes of tonsil infections, such as yourself.

The fact that you have suffered from nasty tonsil infections for so many years puzzles me as to why you have chosen to continue to do so, when there is a relatively straightforward solution: remove those tonsils as they are the source of your infections! Repeat courses of antibiotics often fail to help as many cases of tonsillitis are virally-caused and instead only lead to growth of antibiotic-resistant organisms (“bugs”).

If you didn’t have such a turbulent history with tonsil infections, then these benign mucous cysts or tonsil stones may be left alone. But in your case, it sounds like it might be worth considering having your tonsils removed in a tonsillectomy procedure.

Many of my patients have experienced your situation, and gone on to have their tonsillectomy without problems. It may be done as a daycase though most patients prefer to stay overnight in hospital. The main risk of a tonsillectomy is postop bleeding due to secondary infection but in the right hands, this is rather low 1-2%. The other postop issue is sore throat but again, those patients who suffered from bad tonsil infections like yourself usually find their postop pain isn’t as bad as their pain caused by the tonsillitis episodes.

Take care and hope you recover soon.

24 Sep 2018

Thanks for the D2D. Snoring in children is quite common but in about 10% of children who snore, this may be a sign of underlying airway obstruction leading to problems with sleep-related breathing or obstructive sleep apnea (OSA).

OSA in children is mostly caused by enlarged tonsils and adenoids but suffering from a blocked nose due to allergy problems may worsen the breathing when asleep. The concern with OSA in children is that it prevents them from getting good quality sleep, which in turn, affects their general wellbeing, as well as their mental, emotional and behavioural development, possibly even impairing their academic performance.

Some of the children we see at our clinic may have subtler signs such as bedwetting at night or hyperactive behavior, while others turn up feeling tired and lethargic during the day or wake up regularly at night as they find it difficult to breathe. 

The tonsils and adenoids form part of a specialized ring of lymph gland tissue behind the nose and throat, and may be quite prominent in young children, and even teenagers and young adults. Enlarged tonsil and adenoid tissue may obstruct the airway when the child is asleep, affecting his breathing and resulting in poor sleep quality due to a chronic lack of oxygen.

Some studies suggest that, in children with enlarged adenoids, chronic mouth-breathing over a prolonged period, may result in permanently elongated facial shape and structure, described as “adenoidal face”. 

If simple measures such as anti-allergy sprays do not help, then surgical removal of the enlarged tonsils and adenoids may be indicated to clear the airway blockage. Although it is natural for parents to be concerned about the option of surgery in their children, the procedure is generally straightforward and usually cures the problem in approximately 90% of children.

3 Oct 2018

Hi Emma, Thanks for the D2D.

It may not always be easy to tell if your child might be suffering from an ear infection, especially if they aren’t able to speak properly yet.

But the parents of my kiddie patients with ear infections have told me that they were worried about their child tugging repeatedly at his or her own ears, or trying to stick their fingers into their ears, so that was why they brought their child to see me for a thorough checkup.

Occasionally, kids with ear infections may be in pain or run a fever. They may also be more grumpy or cranky than usual. Some kids may be unfortunate enough to have yellowish or unpleasant-smelling liquid discharge coming out of their ears. 

Ear infections in kids may also cause hearing loss so if you notice that your child isn’t responding promptly as usual when you call to him, or if the TV is turned up more loudly than normal, then this may mean your child’s ears are blocked with impacted wax or infected fluid behind their eardrums.

 ent singapore

Young kids are susceptible to nose and throat infections, not just ear problems. Their immune system is not yet fully mature and most young kids usually attend daycare or nursery, where they mingle closely with other children and are at risk of catching another child’s “bug”.

The Eustachian pressure tubes of a young child are also shorter in length than an adult’s and lie at a more horizontal angle, so nose and throat infections are more likely to spread via these Eustachian tubes to the child’s ears.

3 Oct 2018

Dear Chunmei, Thanks for the D2D.

When you say your son was diagnosed with a middle ear infection, this usually means that he had an infection of his eardrum with possibly some infected fluid trapped behind. If a short course of antibiotics doesn’t help, then the usual treatment is to have a tiny ventilation tube called a “grommet”, inserted into the eardrum to improve the ventilation of the middle ear.

In young kids, this is done as a short and very safe day case procedure asleep under general anaesthetic.  Sometimes, removal of the enlarged adenoid tissue blocking the back of the nose and the Eustachian pressure tubes which connect to the ears, is performed at the same operation together with the grommet insertion.

Many children with recurrent ear infections also tend to suffer from chronic nose infections, which cause them to suffer a persistently blocked and runny nose (see photos).

Although some other doctors might prescribe a prolonged course of antibiotics lasting several weeks for the child with recurrent middle ear infections, I often find this doesn’t help much and only temporarily settles the problem.

Once the antibiotics are stopped, I notice the ear infections tend to return. In addition, the side effects of long courses of antibiotics e.g. upset tummy with loose stool, as well as the risk of growing antibiotic-resistant “bugs” in your child’s ears have to be carefully considered before starting a young child on them.

3 Oct 2018

thanks for the D2D.

Whether your child is at risk of permanent loss of hearing with recurrent ear infections, really depends on what part of his ear keeps on becoming infected. If it is the outer ear canal which becomes infected, then any swelling of the skin will temporarily block his ear and lead to hearing loss but this usually returns once the outer ear infection resolves.

However, if it is the middle ear that keeps on getting infected, basically eardrum-related infections, then there is a (small) risk that this might lead to a permanent hearing loss in the future. Usually, eardrum infections give rise to a temporary and reversible conductive type of hearing loss, due to infected fluid trapped behind the infected eardrum.

This usually recovers once the eardrum is no longer infected. Sometimes, even when the eardrum infection resolves, there may still be some thick mucus fluid called “glue” filling the middle ear, leading to a mild conductive hearing loss. Once this fluid is drained, the hearing usually returns to normal.

ENT Doctor Singapore

The real worry though is that recurrent ear infections leading to a buildup of pus (frank infected yellow liquid behind the eardrum, see picture) can potentially spread to the inner ear where the delicate hearing organ (cochlea) lies. If the inner ear becomes infected, then there is a risk of permanent severe hearing loss, as well as dizziness, vertigo and balance issues.

3 Oct 2018

Thanks for the D2D.

Swimming to prevent swimmer’s ear! Swimmer’s ear occurs when water enters the ear canal and irritates the delicate ear skin, giving rise to an ear infection (otitis externa).

This can be quite painful and uncomfortable as the ear may feel blocked. We usually treat swimmer’s ear by cleaning the ear out carefully and applying some antibacterial ointment inside or prescribe some eardrops.

From my patients’ own feedback, they have found wearing customized swim earplugs very useful in preventing swimmer’s ear (see picture).

ENT Doctor Singapore

These earplugs are specially made to fit the shape and size of your ear canal so that it is “water-tight”.  These special swim plugs may be made at specialist audiology centres. Wearing a swim cap or sports headband round the head can add further protection against the entry of water into the ears.

 

 

3 Oct 2018

thanks for the D2D.

Yes, there are. The most important first step is not to dig your child’s ears with anything, including cotton buds, as this may accidentally injure the delicate skin inside or puncture the eardrum, which could lead to a permanent hearing loss. The earwax inside your child’s ears contains natural oils to keep the skin moisturized and healthy.

ENT Doctor Singapore

Young children are at risk of suffering ear, nose and throat infections as their immune system is still not fully developed as an adult’s. Eardrum infections may originate from nose or throat infections so it would be sensible to treat any nasal allergy or infection issues, or tonsillitis that your child may also be suffering from.

Enlarged adenoid tissue can also be a source of ear infections as the inflamed and swollen adenoidal tissue will affect the opening and closure of the Eustachian pressure tubes that connect the eardrums to the back of the nose.

If your child is constantly exposed to cigarette smoke, then that is a risk factor for ear infections too as the smoke contains plenty of irritant chemicals which lead to inflammation and congestion of the lining of the nose and Eustachian pressure tubes.

So please try to make sure your child isn’t exposed to cigarette smoke or in fact, any kind of smoke, including the pollution produced during the previous haze seasons in Singapore.

Water exposure while swimming can also result in swimmer’s ear, an infection of the outer ear skin, so investing in a pair of customized swim earplugs and swim cap for your child can help to prevent this.

3 Oct 2018

True sinusitis or sinus infections are not that common in children actually as the sinuses are not fully developed until late teen years. The sinuses are normally air-filled spaces in the skull.

Children with sinus infections may present with a “cold” lasting for 10-14 days, with yellow nasal secretions, pain over the cheeks or between the eyes, fever and blocked nose. I find that a course of antibiotics such as Augmentin is usually quite effective in the treatment of sinusitis, together with a nasal steroid spray and saline nasal wash. “Injections” are usually only required if the child is quite unwell with sinusitis and needs to be admitted to a hospital to have an antibiotic drip given.

From my experience with paediatric patients, I often discover that “sinus” infections in children actually turn out to be allergic rhinitis, a hyper-sensitive inflammatory reaction of the lining of the nose, leading to sneezing, watery nasal secretions, blocked nose. Sometimes, the “sinus” infection may just be a due to a prolonged bad bout of flu or a cold and the child should recover on his or her own in this case.

I have found that some of my “sinus” patients actually have a chronically runny nose and blocked nose due to enlarged adenoid tissue blocking the back of their nose (adenoiditis).

The adenoids are made of similar lymph gland tissue as the tonsils and are commonly enlarged in young children. If anti-allergy medication doesn’t help the child with adenoiditis to improve, then removal of the adenoid tissue may be advised to help the child breathe better.

3 Oct 2018

thanks for the D2D.

ENT Doctor Singapore

It is not always easy to tell the difference between a common cold and sinusitis. But from experience with my paediatric patients, these are typically the symptoms to watch out for:

  • if the cold lasts an unusually long time such as more than 10 days
  • thick yellow-green nasal mucus
  • puffy swollen eyes (see picture above)
  • headaches, especially in children older than 6 years
  • sore throat, cough or bad breath which may be due to an infected postnasal drip

Some children may become quite unwell with sinusitis and may need admission to hospital to be given an antibiotic drip.

3 Oct 2018

Dear Amy, Thanks for the D2D.

Yes, it is definitely worth having an allergy test to identify the triggers of your daughter’s hayfever. Not only can you then learn to avoid the triggers once they are known, but there are now also newer forms of treatment for certain triggers such as grass and house dust mite which aim for a permanent cure to desensitise the immune response against these triggers.  

Some of my kiddie patients also suffer from asthma and eczema, conditions which are well known to be associated with hay fever or allergic rhinitis. So finding out what triggers are causing flare-ups of their health problems is extremely useful not only to me as the ENT specialist but also to their skin and chest doctors too!

Allergy tests may be done as skin prick tests (see picture below) or running an allergy panel in the form of a blood test. I think that each test is equally sensitive but it is important to stop all anti-allergy medication such as antihistamines (e.g. telfast, clarityn, zyrtec) 48 hours before undergoing the allergy test, otherwise, the results may come back as falsely negative.

ENT Doctor Singapore

Skin prick tests usually test for an average of 8-10 triggers whilst the blood test is able to screen for up to 46 different potential triggers.

3 Oct 2018

Hi Susan, thanks for the D2D.

ENT Doctor Singapore

Many of my paediatric patients suffer from both asthma and allergic rhinitis. Asthma is a hyper-reactive inflammatory narrowing and obstruction of the lower airways of the lung, which causes recurrent wheezing, difficulty breathing, chest tightness and cough.

Allergic rhinitis represents a hyper-sensitive inflammatory reaction of the lining of the nose (the upper airway), leading to nasal itching, sneezing, runny nose and nasal congestion. We find that allergic rhinitis typically precedes the onset of asthma and often worsens the control of asthma.

Studies show that children with allergic rhinitis are 3 times more likely to go on to develop asthma, compared to those who don't. Three-quarters of asthma patients also have allergic rhinitis!

So asthma and allergic rhinitis share a very close relationship: “One airway, one disease”. What this means is that the symptoms of allergic rhinitis such as a persistent drip of infected secretions or mucus from the nose (the upper airway) can lead to irritation of the bronchi (lower airway) of the lungs.

A chronically runny nose due to nasal allergies may trigger an acute attack of asthma, as the nasal secretions flow into the hyper-reactive lower airways of the lung and cause them to constrict, affecting breathing and airflow.

Essentially, if we want to treat asthma effectively and keep it under control, we need to treat any co-existing allergic rhinitis to prevent flare-ups. We practise evidence-based medicine by following the international ARIA (Allergic Rhinitis and its Impact on Asthma) guidelines to treat asthma and allergic rhinitis.

This means treatment with nasal steroid sprays, saline nasal washes and antihistamine medication. Montelukast (Singulair) is a useful medication to treat both asthma and allergic rhinitis, as it stabilises mast cells, a key type of immune cell involved in driving the hyper-reactive response which occurs in asthma and allergic rhinitis.

Both asthma and allergic rhinitis often share the same triggers, such as house dust mite, cigarette smoke, grass pollen and mould spores. Allergy testing may help to identify the triggers so that they may be avoided. There are now newer medications available on the market which aim to desensitize the immune system against grass and house dust mite, to hopefully achieve a longterm cure for allergic rhinitis.

3 Oct 2018

Hi Ellen, thanks for the D2D.

You don’t actually have to do anything to get rid of the earwax in your son’s ears. Earwax contains protective natural oils to moisturize the delicate skin of the ear canal. So it is all right to have some earwax in your son’s ears.

In fact, having ears which are “too clean” may lead to the ear feeling dry and itchy. Cleaning the ear may even predispose to infection because the usual harmless bacteria that reside in your ear are cleared away, allowing harmful organisms the opportunity to grow.

The ear itself is a self-cleaning device as the skin is designed to migrate outwards over time, moving earwax out of the ear by itself. One very helpful tip that I always tell my patients is to apply a few drops of clean olive oil into each ear after their shower. This helps to keep any wax inside soft and runny so that it flows out more easily.

In some cases, when wax becomes hard and impacted, then it won’t be able to come out by itself. This is when many of my patients turn up to seek my help in removing their impacted earwax because we can do gentle suctioning under the microscope in a comfortable and pain-free manner.

3 Oct 2018

Nosebleeds are quite common in children. We see many children at our clinic with this problem and sometimes, it is related to hayfever with recurrent sneezing irritating the delicate lining of the nose, the prolonged use of nasal steroid sprays or simple digging of the nose. 

The most common source of the nosebleed is usually the tiny blood vessels at the front part of the nose, as they run close to the surface of the skin and are easily injured. This is simple to treat by sealing these delicate blood vessels shut with a special silver nitrate stick applied to the area in clinic (cautery) (see picture below).

ENT Doctor Singapore

Older children can have it done in the clinic after some “magic” numbing cream is applied to the nose before the short and simple procedure is performed. Younger kids, such as your daughter, may prefer to have it done as a short day-case procedure under light sedation.

I certainly don’t think that nosebleeds are considered “normal”! You should bring your child to your friendly ENT specialist for a thorough checkup because sometimes, nosebleeds may have more worrying causes, such as tumours at the back of the nose. They may also be early signs of conditions which cause the blood to clot abnormally, such as leukaemias (blood cancers).

 

3 Oct 2018

Dear yongqin, thanks for the D2D.

Although this question is subjective, I actually find it easy to answer!  You should select the ENT doctor who is very experienced in dealing with children of all ages and can build up a totally comfortable rapport with both your child and yourself to set your whole family at ease.

Many of my adult patients bring their children to see me because they know that in addition to my years of experience managing paediatric ENT problems in the UK and Canada, I am a mother of young children and can empathise with their own concern for their ill child.

ENT doctors who have a special interest in the ENT problems of children will have undertaken their postgraduate specialist training and worked at top children’s hospitals overseas like Great Ormond Street Hospital in London and the Toronto Hospital for Sick Kids in Canada.  

As many children’s ENT problems affect the ear, ENT doctors who are experienced in treating paediatric ENT problems often also have other subspecialty training in hearing and cochlear implantation.

You should also look carefully at their academic list of research publications to check that they have been active in the advancement of paediatric ENT.

3 Oct 2018

There is technically no recommended age for a child to undergo surgery for snoring! What is most important is to have the child properly examined to find out why he is snoring, assess how severe the snoring is and finally, how badly it is affecting the child.

The concern is that your 5 year old may be suffering from a condition called paediatric obstructive sleep apnea due to his enlarged adenoids and tonsil tissue. This means he may not be breathing adequately at night while asleep so that there may be abnormally low dips in his oxygen saturation levels. Often children at this age may also suffer allergic rhinitis leading to enlarged turbinate tissue which blocks their nose further. 

If anti-allergy meds haven't helped, then I'm afraid the best way forward is probably to have surgery to remove the adenoids and tonsils and shrink the turbinates to help your child breathe better. Tonsils can't gorw back though there is a tiny 0.5 % chance the adenoids may rarely grow back. The turbinates may swell up again in future too if the underlying allergy problem isn't treated properly. Make sure your child gets an allergy test too.

However, please take note that every child is different and therefore should be assessed carefully. I think it would be extremely helpful for you to read the following informative link on common childhood conditions.

13 Mar 2019

Top Questions


My son is 7 years old. He was diagnosed with an allergy to dust mite and often has flu-like symptoms. Recently I noticed that he often snores, and also has a block nose when he goes to bed at night. The symptoms are more obvious when in an air-conditioned room. What could be the cause?