Children's ENT care that starts with the cause

In young children the tube that ventilates the middle ear is short, soft and almost horizontal. It drains less easily than an adult's, so a common cold can leave fluid sitting behind the eardrum. That fluid is a comfortable place for infection to settle, which is why one ear infection can be followed by another.

The examination looks for the reason rather than the episode. We check the eardrum under magnification, measure how it moves, and look at the back of the nose where the adenoid sits. Repeated infections often have a mechanical explanation, and that explanation changes what happens next.

Some children need nothing more than time and a planned review. Others need the ventilation problem addressed. The examination is what tells the two apart.

Glue ear is fluid in the middle ear without an active infection. There is often no pain and no fever, so it can go unnoticed for months. What parents notice instead is the television turned up, a child who answers only when facing you, or speech that has stopped moving forward.

Sound still reaches the ear, but it arrives muffled. During the years when a child is building vocabulary, a muffled version of speech is harder to learn from. That is why we measure hearing rather than estimate it.

Tympanometry shows whether the eardrum is moving normally. Otoacoustic emissions and, where indicated, BERA show how the hearing pathway is responding. None of these tests ask the child to answer anything.

A child who sleeps with an open mouth is usually telling you that the nose is not passing enough air. In children the most common reason is an enlarged adenoid at the back of the nose, sometimes with allergy or a lingering cold on top of it.

Sleep is where the effect shows. Snoring on most nights, restless sleep, unusual sleeping positions and daytime tiredness or irritability are all worth mentioning at the consultation. Mouth breathing during the day matters too, and over the years it can influence how the face and jaw grow.

We look at the adenoid directly with a thin flexible endoscope, on a screen the child can watch. It takes a moment, and it removes the guesswork about how much space there actually is.

Large tonsils are not automatically a problem. What matters is whether they obstruct breathing during sleep, and whether infections are frequent enough to interrupt school and family life.

When tonsils do need treating, the options are not identical. Tonsillotomy reduces the tonsil and leaves part of it in place; tonsillectomy removes it. Which one is appropriate depends on the reason for treating, because obstruction and recurrent infection are different problems.

We explain what is indicated, what it involves, and what happens if we wait and review instead. Nothing is decided in the first ten minutes of a consultation.