Dizziness and Imbalance in Kids

Dizziness is not the easiest thing to figure out in adults. It is even more difficult to figure out in kids who may not have the vocabulary to explain what they feel. Regardless of adult or child, a good history is required to help narrow down possibilities. A flowchart of questions to help come up with a diagnosis can be found here.

Given that, a review article published in 2014 went over the most likely diagnosis of a child who is dizzy.

Based on 724 subjects over 10 studies, benign paroxysmal vertigo of childhood (18.7%) and migraine-associated vertigo (17.6%) were the two main etiologies causing vertigo and dizziness in children. Head trauma (14%) was the third most common cause of vertigo. The mean (95% CI) rate of every vertiginous form was also calculated in relation to the nine studies analyzed with vestibular migraine (27.82%), benign paroxysmal vertigo (15.68%) and vestibular neuritis (9.81%) being the three most common forms.

Benign paroxysmal vertigo of childhood is not clearly understood with some researchers feeling it is a form of adult BPPV (benign paroxysmal positional vertigo) given similar symptoms whereas others feel it is more related to a neurologic vascular basis. With this particular condition, there is no established treatment protocol.

True BPPV occurred in 1.8%. Meniere's disease accounted for only 1.5%. Othostatic hypotension only 1.2%. Middle ear problems surprisingly only occurred in 3% which was felt by the researchers to be highly under-estimated.

Given the top 3 causes of vertigo in children all have a neurologic basis, an evaluation by a good pediatric neurologist is warranted.

Reference:
Prevalence and diagnosis of vestibular disorders in children: A review. Int J Pediatr Otorhinolaryngol. 2014 May;78(5):718-724. doi: 10.1016/j.ijporl.2014.02.009. Epub 2014 Feb 15.

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Does Removing the Adenoids Decrease Risk of Ear Infections? Yes...

A recent meta-analysis has determined that risk of recurrent ear infections is significantly reduced if adenoidectomy is performed in combination with ear tube placement as opposed to ear tube placement alone. When stratified by age, removing the adenoids was found particularly helpful in children older than 4 years of age.

Combining results from over 15 studies containing over 71,000 children, the estimated rate of repeat ear tube placement for recurrent ear infections in children who also had adenoidectomy was only 17.2% vs 31.8% for children undergoing ear tubes alone. However this significance faded under the age of 4 years.

Why would adenoid removal influence ear infections?

First a little anatomy lesson...

In the back of the nose, there is an opening called the eustachian tube that goes up into the ear. That's why one is able to pop the ears when blowing into a pinched nose.

Image by Chittka and Brockmann from Wikipedia

The adenoids are located in the back of the nose immediately behind the eustachian tube opening. The adenoids can potentially lead to ear problems via two mechanisms. First, the adenoids could be very enlarged causing physical obstruction of the eustachian tube which can make it impossible to pop the ears. Second, the adenoids could be a reservoir of germs which can lead to ear infections given proximity to the eustachian tube.

As such, removal of the adenoids would allow the eustachian tube to function better as well as eliminate a potential reservoir of infection.

However, recommendation for adenoid removal typically occurs if a child requires a 2nd set of tubes which usually occurs around age 4. Adenoidectomy may be recommended with the initial set of ear tubes (after taking into consideration age) if other symptoms are present including nasal obstruction and a snotty nose.


Reference:
Adenoidectomy as an Adjuvant to Primary Tympanostomy Tube Placement: A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg. 2013 Nov 28. doi: 10.1001/jamaoto.2013.5842. [Epub ahead of print]

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At-Home Rapid Strep Testing

Rapid strep test kits can be purchased by anybody to be done at home which may save parents/patients a lot of money in doctor visits for those prone to strep infections. Indeed, should a rapid strep test be positive, than you know that a doctor's visit is definitely worthwhile. (A doctor visit may still be worthwhile since a sore throat may be due to something else like cancer, aphthous ulcer, sinus infection, reflux, etc).

Such home kits (which in fact are the same kits used in medical offices) can be purchased online through Amazon. The price is surprisingly affordable at around the cost of a single copay $30 to do 25 tests.

However, with the purchase of such DIY kits, there are some pitfalls patients should be aware of if they decide to proceed.

1) Perform the internal controls that come with the kit!!! The kit may be a dud and needs to be tested against itself to ensure accurate results whether negative or positive. If the controls do not work, throw the whole test kit out and buy another.
2) You must follow the directions precisely, otherwise the test results will be unreliable. In other words, if the directions call for 4 drops, than it MUST be 4 drops (not 3 drops or 5). If directions state to wait 4 minutes... you must wait exactly 4 minutes. This literally is like precision baking.
3) The test strips need to be kept in protected, sealed bag and used immediately after taking one out, otherwise the test results will be unreliable.
4) When swabbing the throat, you MUST get the cotton tip on the tonsil and/or back wall of the mouth which than must be rubbed around a couple times. Getting the tongue or cheek will increase the risk of a false negative. As such, it may be worthwhile to invest in some tongue blades to help push the tongue down in order to perform this test properly.

Should patients elect to start performing home strep tests, please be aware that physicians will be obligated to not only REPEAT the testing but also examine the patient to ensure antibiotics are appropriate. An actual throat culture may be performed as well which is the gold standard test.

1) Repeat testing is required because the patient may not have followed the instructions precisely. For example, the test strips must be read at 5 minutes (variable depending on the kit). If test results are read past 5 minutes, it may incorrectly show a positive result.
2) Some patients unfortunately fabricate test results just so they can get an antibiotic without an office visit.
3) Some patients unfortunately also fabricate test results in order to skip work or school for personal reasons not related to an actual medical condition.
4) There are situations that even though the strep test is positive, no treatment may be recommended. The patient may be a strep carrier for which treatment of any kind is not recommended.

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Pediatric Sinus Development and Sinusitis

There is a tendency for any type of nasal drainage to be attributed to "sinusitis" in children. Especially in young children, "sinusitis" is a relatively rare cause for nasal drainage and congestion which is actually more commonly due to viruses and enlarged adenoids.

The reason why sinuses play a relatively minor role in nasal drainage and congestion is because sinuses are not fully developed in children. It probably is not until around the age of 7 years old that "sinusitis" starts playing a more major role in disease manifestations. And even than, viruses and enlarged adenoids still play a major role in sino-nasal discomfort and as such, antibiotics not typically warranted.

Take a look at sinus development from newborn to adulthood below. In newborns, sinuses are mere indentations in the facial bone (light green). Adult sinuses are denoted by the dark green/peach.

It is for these reasons that sinus x-rays (or radiological imaging in general) are not warranted in children under 2 years. First, there is not much there, and secondly, x-rays are notoriously poor at diagnosing true sinus pathology [more info]. From 2 years to adolescence, sinus x-rays provide some guidance as to the presence of possible sinusitis, but CT Sinus scans are the gold standard to evaluate sinus disease presence or absence.

With persistent sino-nasal symptoms in children in spite of medical management, nasal endoscopy can be performed to evaluate the nasal cavity as well as the adenoids. Initial surgical management include adenoidectomy with or without turbinate reduction. While sedated for surgery, allergy testing can also be performed. If symptoms persist after these interventions, a CT Sinus scan can be obtained and consideration for sinus surgery can be made. The reason why CT Sinus scans are not obtained earlier is because whether it comes back normal or not, management does not change unless there are unusual extenuating circumstances present (significant eye or facial swelling).

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Ear Tube Placement in Kids WITHOUT Sedation (Starting at 12 Months of Age)

A recent report describes how using a relatively old technology, ear tube placement can now be performed in children starting at 12 months of age with chronic ear infections or hearing loss due to fluid buildup without the need for sedation of any kind nor aggressive restraints (ie papoose). Historically, ear tube placement in the office without sedation is typically performed starting at around 12 years of age using standard local anesthesia techniques. Any younger, a child could not be trusted to stay still during the procedure due to presence of some discomfort.

In any case, a Texan ear group reports how they accomplished this simple procedure at such young ages.

First, the ear canal is cleaned as much as possible of all earwax and debris. The ear canal is than filled with an anesthetic liquid (concoction of lidocaine, epinephrine, and sodium bicarbonate). Over 10 minutes, iontophoresis was than used to induce profound local anesthesia to the ear canal and eardrum. The liquid was than suctioned out and ear tube placement was performed with a reported 90% success rate (78 of 86 ears; 17 subjects were 3 years old or younger; 8 were 12 months old).

The key to success required 3 "new" elements.

• Iontophoresis device made by Acclarent. There are other iontophoresis devices in the market (Medtronic and Otomed), but none adapted for simultaneous bilateral ear canal usage that works within 10 minutes. Iontophoresis works by applying a gentle electric current in order to actively move charged drug molecules into the skin. In this particular case, positively charged lidocaine and epinephrine.
• Optimal anesthetic solution for iontophoresis. Dubbed "EMGIM", it contains 1:12,000 epinephrine with 3.3% lidocaine hydrochloride and 0.7% sodium bicarbonate. The solution is prepared fresh prior to use by combining 10 mL of 4% lidocaine hydrochloride with 1 mL of 1:1,000 epinephrine. After mixing the lidocaine and epinephrine, 1 mL of 8.4% sodium bicarbonate is added.
• Ear tube delivery device and placement system. Typically, a competent ENT can place an ear tube in about 10-20 seconds. However, when dealing with kids who may potentially move unexpectedly and operating within a very small ear canal space, a faster and more reliable way of placing a tube was required. Hence, this new device. [link]

Of course, during the actual procedure, age-appropriate distraction was needed to minimize movement, especially given aggressive restraint was not used.

Sounds great as sedation is something to be avoided if at all possible. However, there is one problem... the Acclarent iontophoresis device is NOT yet FDA approved contrary to what the report states (direct communication with Acclarent executives October 1, 2013). Hopefully in 2014. As such, beyond a research setting, this in-office technique is not yet available for use in the United States.

As an aside, there are FDA-approved iontophoresis devices for use in pediatric head and neck surgical procedures mainly for sub-cutaneous mass excisions and abscess incision and drainage. Check out Phoresor for such applications using lidocaine infused electrodes. It's even sold on Amazon.


References:
Otologic Iontophoresis: A No-Papoose Technique. Annals of Otology. Rhinology & Laryngology 122(8):487-491. Aug 2013.

In-Office Tympanostomy Tube Placement Under Local Anesthesia Using a Novel Tube Delivery Device. Triological Meeting Poster. Dec 2012.

Iontophoresis: a needle-free, electrical system of local anesthesia delivery for pediatric surgical office procedures. J Pediatr Surg. 1999 Jun;34(6):946-9.

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PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus)

Only in kids, there is a VERY rare (and controversial) disorder where strep throat infections can rapidly lead to involuntary tics including chronic throat clearing, cough, head/neck movements, sneeze, etc as well as OCD behavior. Known as PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus), it is felt to be an autoimmune reaction triggered by antibodies produced by the body when fighting a strep infection. With this disorder, an evaluation with a pediatric neurologist is warranted.

However, what role if any an ENT may play is less certain. Obviously, the main ENT related concern is whether tonsillectomy and adenoidectomy is helpful.

Certainly, this surgery should be pursued if the child meets the guidelines of when T&A should be performed from an infectious standpoint in any child:

• 7 or more tonsil/strep infections within past 12 months OR
• 5 infections in each of the last 2 years OR
• 3 infections in each of the last 3 years

However, it has been demonstrated that T&A does NOT seem to affect the onset nor influence the neuropsychiatric course of a child suffering from PANDAS.

According to one research, no significant differences were found between children who had T&A and those who did not in terms of PANDAS classification, and OCD or tic severity. In fact, most children with PANDAS had surgery before onset of neuropsychiatric symptoms and surgery did not affect symptomology.

More info about PANDAS can be found here.

To find a doctor who is familiar with PANDAS, click here.

References:
Tonsillectomies and Adenoidectomies Do Not Prevent the Onset of Pediatric Autoimmune Neuropsychiatric Disorder Associated with Group A Streptococcus. Pediatr Infect Dis J. 2013 Mar 20. [Epub ahead of print]

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T&A Helps with Pediatric Obstructive Sleep Apnea (But Watchful Monitoring OK Too!)

Researchers published in the New England Journal of Medicine that removal of the tonsils and adenoids absolutely helps with sleep apnea in kids along with improvements in behavior, quality-of-life, overall well-being as well as significantly greater reduction in symptoms... but apparently putting off surgery does no significant harm as well from a purely cognitive perspective.

464 children ages 5-9 years of age were randomly split into surgery or watchful monitoring groups (children with severe sleep apnea was excluded from the study). Although surgery helped in all measures tested, what surprised the researchers was that nearly half the children (46%) in the watchful monitoring group also spontaneous improved over a 7 month period of time without surgery. Furthermore, there was no difference between groups on a Developmental Neuropsychological Assessment.

Overall, surgery WAS beneficial, but it is notable that even without surgery, cognitive development was found to be no different than not doing surgery and nearly half improved to point surgery was no longer clinically indicated.

More relevant to clinicians and parents... what were the exact factors that led nearly 50% of kids with sleep apnea to improve over 7 months?

Was it a certain medication? Overall head growth? Treatment of allergies?

If there WAS an intervention, can it be replicated to all kids as something to try prior to surgical consideration?


Reference:
A Randomized Trial of Adenotonsillectomy for Childhood Sleep Apnea. May 21, 2013 DOI: 10.1056/NEJMoa1215881

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Top 3 Reasons Why Your Child Can't Shake that Cough

Guest Blog Post by Dr. Julie Wei

Any parent who has lived with a toddler or preschooler knows the pain of hearing a child’s endless cough, daytime, nighttime, all the time... It seems as if the cough never clears up in a day or two, or after a cold, but may last for weeks. Even if it does clear up, it always seems to return without much warning, and can be more stubborn than your 4 year old about eating vegetables! If you are wondering why cough medications can't stop your child's cough, or for that matter, why inhalers for "asthma", another 10 days of antibiotics, and/or allergy medications are all not working, then continue reading. Have you dragged your child all over town to see yet another specialist to find out why they just keep coughing?

Here is what I explain to all families who come to see me about cough. Cough is an involuntary reflex, or protective mechanism the body has to get unwanted particles or irritants out of our airway. So if dust got into our windpipe, or a droplet of liquid goes into the airway accidentally while your child was drinking and trying to talk at the same time, or the phlegm that he/she gets with a viral illness... all of these things can make our children cough. While most children are thankfully not intermittently or continuously inhaling dust, or running around drinking with their head tilted while talking at the same time, the one frustrating thing about young children is the fact that they get 7-10 viral upper respiratory track illnesses, or colds every year. Each one of these “colds” last 7-10 days, and so pretty quickly, you can have a child with cold symptoms for a third of the year!

So... without further ado... the top 3 reasons why the cough is still hanging on...

NUMBER 3: Post-viral neurogenic cough or habitual throat-clearing. Whatever the reason was, your child started out having a bad cold and coughed due to being sick. Even after the fever and acute illness goes away after 7-10 days, their throat and voice box somehow stays irritated and they continue to cough. At some point, your child may not even realize that he/she is "coughing". Often these are children who are throat-clearing and not really coughing (more often in short annoying bursts, as often as every few minutes). If you no longer hear them "coughing" during sleep, but only when they are awake, then this is likely what your child has. These children often show no other signs of illness or discomfort. It's a difficult diagnosis to make and usually after all other reasons have been rules out. I often offer strategies to families to help break these habits such as creating a game (older than 3 or 4 years of age can do this) whereby a kitchen timer is used to help suppress the urge to "cough" starting from 30 seconds and working up to 5 minute intervals. School aged children who do not appear ill but have a “dry” throat clearing do very well with this exercise. Another option is when they get into a coughing fit, to distract them with chewing gum, having them count backwards from 20, hopefully distracting them from this habit.

NUMBER 2: Chronic Rhinosinusitis (CRS). Your child may have developed true chronic rhinosinusitis which means inflammation from thickening of the lining inside their sinus cavities and their sinus "plumbing" is clogged up. Chronic sinus inflammation is NOT a bacterial infection so antibiotics will not make it go away completely, even if it seems to decrease the cough temporarily. This usually occurs in children older than 4, especially if they have underlying test proven allergies to common aero-allergens like trees, pollen, grass, dust-mites, and other environmental allergens. Sometimes this is bad luck and develops after your child has experienced a terrible viral illness, such that the mucous membranes inside the nasal passages were so swollen that the natural drainage points that lead each sinus cavity into the nasal passage are blocked, which then leads to the inflammation inside the sinus. Since there is a built-in mechanism called the "sinopulmonary reflex", children who have inflamed sinus mucous membrane lining will likely continue to cough until the nasal passage and sinus mucous membranes are no longer swollen and healthy again. The only way to truly know if your child has CRS is for him/her to get a CT scan, a special imaging of their sinus cavities which can involve some radiation exposure. These children tend to complain of a stuffy nose all the time along with the cough, and can't blow anything out of their nose even if they try. Mothers always tell me that their child is stuffy and can’t breathe well, leading to snoring, fatigue, sometimes headaches.

NUMBER 1: The Milk and Cookie Disease (MCD). Your child is coughing because day after day, night after night, their larynx (voicebox) is bombarded with stomach content backwash (gastroesophageal reflux and laryngopharyngeal reflux) coming up to and irritating the voicebox. The voicebox which enables humans to talk is also designed to "cough" as a way to keep unwanted materials from entering our airway. If it did not protect itself by coughing, then we would aspirate and possibly get pneumonia. Find out how your child can live and eat in "A Healthier Wei" and fight the Milk and Cookie Disease, by minimizing dairy and sugar in the evenings and then his/her voicebox can rest and not be in "fighting" mode all the time. I have met thousands of children who have chronic cough not because they are sick, but because they were eating a diet or drinking beverages containing too much dairy and sugar, as well as possibly greasy foods and processed foods. All these items increase likelihood of reflux or backwash and assault on the larynx. If the voicebox is always on “alert” and ready to “fight” and protect the body, then it really can’t relax and rest. I believe that when this happens chronically from MCD, and let’s not forget those 7-10 colds and how they also lead to an irritated overreactive cough, then together, this child has no chance and probably will cough, A LOT! By making changes in diet and dietary habits in children, we can decrease the chance of stomach backwash coming up to irritate the voicebox and cause cough, then hopefully your child only coughs when it is truly because of a cold. Don’t take my word for it, try “A Healthier Wei”. You will likely notice at least much less coughing, and coughing ending much sooner after a cold. I also ask parents to stop dairy/milk for up to 1 week during the time their child is sick. This is when digestion is not at its best, and things get sour and gross in the stomach increasing chance for reflux and more cough.

by Julie Wei, MD, FAAP

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Cheerleading A Dangerous Sport from an ENT Perspective

The American Academy of Pediatrics (AAP) published its first policy statement regarding cheerleading due to the increasing rate of injuries found in this increasingly competitive sport.

Who knew that although the overall risk of injury is lower than other sports, it has one of the highest rates of catastrophic injuries including closed-head injury, skull fractures, cervical spine injuries, paralysis, and even death.

After all, cheerleaders do not wear protective gear and safety is utterly dependent on external factors such as spotters and floor protection.

From an ENT perspective of a solo private practice, cheerleading is one of the leading causes of facial fractures in a student population.

Such fractures include nasal bone and orbital blow-out fractures sustained from elbows and other flying limbs.

Although AAP made 12 recommendation to make this sport safer, I was going to suggest that all cheerleaders should wear face-guards to minimize risk of facial trauma.

Here's one called Mueller Nose Guard. Available for purchase on Amazon.com.

Reference:
Cheerleading Injuries: Epidemiology and Recommendations for Prevention. Pediatrics 2012;130:966-971.

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Honey Helps Relieve Coughing in Kids

Ever since the FDA has withdrawn common over-the-counter medications to treat cough in kids, there has been a conundrum among pediatricians and their young patient charges on how to address the cough that occurs with viral upper respiratory infections (common cold). Beyond humidified mist, hydration, vapor baths, saline spray, and sleep, there are still some other effective options to try...

Sore throats (and coughing) can be soothed by swallowing honey straight-up or slightly diluted with warm water with honey to make it easier to swallow. The best time to do this is at bedtime given it will stick around for awhile (eating/drinking will wash away the coating). The purpose of honey is to create a throat barrier to ease the discomfort.

Think of it like chapstick to coat irritated lips, but meant for the throat.

There was a 2007 study published in the Archives of Pediatrics and Adolescent Medicine by Hershey Penn State Medical Center revealing the benefit of buckwheat honeyto help with pediatric cough. In fact, it was found to work even BETTER than over-the-counter cough suppressants. This study has been picked up by the general news media as well.

In a more recent 2012 study (randomized, double-blinded, placebo-controlled) comparing 3 different honey products (eucalyptus honey, citrus honey, or labiatae honey) against placebo, the cough improvement was greater in the honey groups for all the main outcome measures. (media report)

Use of honey is also recommended by the World Health Organization which has also published a monogram on viral colds and the various treatments explained. Pay particular close attention to Annex 3 (Page 11) which gives various recipes to treat pediatric cough including the use of honey.

Any further questions or concerns should be directed to your pediatrician. Be aware that honey should not be given to infants less than 1 year old due to risk of botulism.

You can purchase buckwheat honeyon Amazon.com.

References:
Effect of Honey, Dextromethorphan, and No Treatment on Nocturnal Cough and Sleep Quality for Coughing Children and Their Parents. Arch Pediatr Adolesc Med. 2007;161(12):1140-1146.

Effect of Honey on Nocturnal Cough and Sleep Quality: A Double-blind, Randomized, Placebo-Controlled Study. Pediatrics. Published online August 6, 2012 (doi: 10.1542/peds.2011-3075)

  

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Lithium Disc Battery Danger for Kids (and Hot Dogs)

In the last 10 years, 13 deaths related to swallowed batteries have been reported, 12 of which were due to disc batteries (20 millimeter lithium cells).

The danger is that when a disc battery is inserted into a nose (for example), a localized electric current is created between the positive and negative poles of the battery within the nose. This electric current basically "electrocutes" the lining inside the nose leading to tissue damage and ultimately necrosis (tissue death) within an hour. The same applies even if the battery is swallowed or put into the ear canal.

When swallowed, it can burn through the esophageal/intestinal lining causing a perforation which can lead to death if not promptly treated (or even in spite of it if too much time passes before treatment).

Treatment is IMMEDIATE removal... as soon as possible. Regardless of the day or time. STAT...

For illustrative purposes, lets see what happens to a hot dog when a lithium disc battery is placed inside it. This example was created by Dr. Stephen Marcus who is the director of the New Jersey Poison Information Center and published in the Pediatrics Blog here. You can also do this at home... give it a try (make a slit in the hot dog and push a lithium button battery into it... than watch).

Just 3 hours later, this is what you would see...

Keep disc batteries away from kids!!!

Please!!!

References:
A lithium battery in a hot dog is no picnic. Pediatrics Blog 7/2/2012

Pediatric Battery-Related Emergency Department Visits in the United States, 1990–2009. PEDIATRICS Vol. 129 No. 6 June 1, 2012 pp. 1111-1117

Preventing Battery Ingestions: An Analysis of 8648 Cases Published online May 24, 2010 PEDIATRICS (doi:10.1542/peds.2009-3038)

A Review of Esophageal Disc Battery Ingestions and a Protocol for Management Arch Otolaryngol Head Neck Surg. 2010;136(9):866-871. doi:10.1001/archoto.2010.146

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Head CT Scans Increase Risk of Cancer in Kids

By how much?

Brain tumor/cancer risk was 3X greater than the general population in children who received two to three CT scans of the head.

And the chance of developing leukemia was three times as great for children who received five to 10 CT scans of the head.

In the study published in Lancet, the researchers examined 176,587 children who had received a CT scan before age 22 and looked at their medical history for an average of 10 years afterward.

Though the risk sounds "high," the overall risk is still relatively small and CT scans should still be performed if medically warranted.

Phrased another way, the risk corresponds to one additional case of leukemia in the 10 years after the first scan for every 10,000 patients younger than 10 who were scanned or an extra case of brain cancer for every 30,000 children scanned.

Even so, the study does illustrate that CT scans should not be ordered unless there's a very good reason to do so, especially in children given they are more radiosensitive compared to adults.

In the ENT world, the most common reason to order a CT scan is to evaluate for sinusitis.

My own personal preference is to obtain one in children if and only if all other sinusitis interventions have already been performed.

Such "sinusitis" interventions include:

• Allergy intervention (steroid and/or anti-histamine nasal sprays)
• Failure to respond to antibiotics
• Adenoidectomy (if large adenoids present which can be determined on endoscopy)
• Turbinate Reduction (if turbinates are enlarged)
• Check for cystic fibrosis and primary ciliary dyskinesia

If above interventions have been performed, only than would I consider a CT scan of the sinuses.

Some (other ENTs) may argue that CT scan of the sinuses should be performed early as a more directed intervention can than be performed.

My argument against that is, EVEN if the CT sinus comes back abnormal, I STILL would perform the above interventions first because often the above interventions will clear up and sinus abnormality seen on a CT scan.

Only when everything else has been tried would I consider sinus surgery in a child and only than would a CT sinus be justified in my mind.

However, there are certain other situations I may consider getting a CT scan relatively quickly...

• If I find a sino-nasal mass on exam concerning for tumor or nasal polyps
• Congenital hearing loss
• Cholesteatoma (tumor of the ear)
• "Significant" Facial Trauma (ie, not just for a simple broken nose)


Reference:
Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. The Lancet. 7 June 2012. doi:10.1016/S0140-6736(12)60815-0

Source:
Children's CT Scans Pose Cancer Risk. Wall Street Journal 6/6/12

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Dental X-rays Linked to Brain Tumors

In a study spanning over decades, researchers have found an association between dental x-rays and increased risk of a non-malignant type of brain tumor called meningioma.

Of the four types of dental x-rays, only the full-mouth series was associated with this increased risk. More specifically, the risk was elevated with the aggregate number of full-mouth series in 10-year periods from approximately 15–40 years before diagnosis, with significant elevations in the 10-year periods beginning 22–30 years before diagnosis. The risks in these analyses were even greater when only women were considered.

One needs to be aware that radiation exposure from full-mouth series was much greater in the past than it is now and as such, this risk may be nominal (though not zero) with current dental x-ray technology.

However, it also should be a reminder that x-rays should not be routinely performed unless there is a very good reason to obtain especially in children who are more susceptible to radiation injury... and that applies to not only x-rays, but any kind of testing involving ionizing radiation including CT scans.

Some x-rays should NEVER be performed including sinus x-rays for sinus problems given a nearly 50% error rate in diagnosing the presence OR absence of sinus problems.

X-rays for nasal fractures is not recommended given x-rays rarely change how such fractures are managed.

Soft-tissue lateral x-rays to look for large adenoids should also be discouraged as nasal endoscopy can provide similar if not better information without any radiation exposure.

To know what the cancer risk is with different types of x-rays, check out this website!

Source:
Dental X-rays and the risk of intracranial meningioma. Cancer. Volume 100, Issue 5, pages 1026–1034, 1 March 2004

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How to Make Xylitol Nasal Flush at Home

Given the unusually large reader response to my last blog regarding xylitol nasal rinses regarding the "recipe," I thought it easier to write a blog about it!!!

To be brief, xylitol is a naturally-occurring plant-based sugar substitute that apparently has all sorts of anti-bacterial as well as anti-fungal properties. Given these properties, daily xylitol gum chewingor xylitol nasal sprayuse has been shown to help prevent recurrent acute ear infections and sinus infections... safe for use even in infants.

When used as part of nasal flushes to the nose, it seems to work even better than traditional saline flushes to the nose (read more about this here).

So, I have provided below a few different recipes to make xylitol nasal flushes at home. One may be more comfortable than the other, but it is user dependent. Obviously, convenience will play a role as well.

Just as an FYI, you can also purchase pre-packaged packets that contain xylitol for the ultimate convenience. Just open one packet and mix it in with water inside your nasal flush kit of choice (Nasopure, Neti Pot, Neilmed, etc)

Recipe #1 (Complex):
1 cup of water (8 ounces)
1/4 tsp salt
1/2 tsp of xylitol crystals
1/4 tsp baking soda
4 drops of grapefruit seed extract

Recipe #2:

1 cup of water (8 ounces)

1/4 - 1/2 tsp salt

1/2 tsp of xylitol crystals

Recipe #3:

1 cup of water (8 ounces)

1/4 - 1/2 tsp of xylitol crystals

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Magic Ears Club Founded by Fauquier ENT Hosts Halloween Party

The Magic Ears Club kicked off its existence with a first ever Halloween Party on October 29, 2011 where over 15 kids from elementary to high school ages who wear hearing aids co-mingled and played games while their parents talked amongst each other their experiences. Prizes and free hearing aid goodies were also distributed.

Dr. Catie Chalmers, audiologist with Fauquier ENT who founded the Magic Ears Club, stated that the purpose of the club is to help parents, as well as their hard-of-hearing children, connect, share, and provide support for each other.

Being a member of this unique club means being able to participate in practice-sponsored parties as well as meeting new friends who also have "magic ears" (aka, hearing aids).

Furthermore, members can participate over the internet in either open or closed forums hosted by Fauquier ENT where members can ask questions or provide other meaningful support to each other wherever and whenever they wish.

The open forum is through Facebook which is open to all who support our goals whereas the closed forum is hosted through Yahoo Groups and limited to ONLY those individuals who are patients of Fauquier ENT.

For more information, go to http://www.MagicEarsClub.com

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