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Nasal obstruction 87
Answers
Clinical cases
CASE 2.5 –
Child with nasal obstruction and snoring
A1: What is the likely differential diagnosis?
Rhinitis, commonly allergic, or physical obstruction due to adenoid hypertrophy
A2: What additional features in the history would you like to elicit?
Determine whether the nasal obstruction uctuates from side to side and whether it is seasonal or
continuous. Seasonal symptoms and uctuating symptoms are more likely to be allergic in origin.
Continuous symptoms are either due to a perennial allergy (house dust mites or pets) or enlarged
adenoids. Ask whether obstructive apnoea is present at night, as this is much more common in children
aged under 4 years. Other nasal symptoms include sneezing attacks, or clear or mucoid running nasal
discharge. Older children and adults may complain of postnasal drip, changes in the sense of smell and
facial pain. Asthma and rhinitis often coexist.
A3: What should one look for in the examination?
Watch the child in the clinic. If a child is breathing through his or her nose, the adenoids cannot be
hypertrophied. Adenoid hypertrophy causes permanent nasal obstruction and these children sit with
their mouths open. It is important to examine the tonsils because large tonsils may cause mouth
breathing. The tip of a child’s nose turns up easily to help when looking at the mucosa. A purple colour
suggests allergy. Place a metal spatula under the nose and observe the misting pattern to ensure both
nasal cavities are patent.
A4: What investigations would be most helpful and why?
Undertake allergy testing if history and examination suggest rhinitis.
A5: What are the treatment options?
If the child has an obvious allergic rhinitis, conrmed on skin prick testing, the standard treatment is
avoidance of the allergen, if at all possible, followed by medical treatment. Surgery has little part to play.
If there is no sign of rhinitis then adenoidal hypertrophy is likely, and these may be removed surgically.
The risks of surgery should not be underestimated and primarily involve bleeding. This may occur
immediately or 10 days post-operatively. The patient and parents should be warned about a change in
voice after the nasal blockage has resolved.
CASE 2.6 –
Adolescent with nasal trauma
A1: What is the likely differential diagnosis?
Nasal trauma leading to nasal and septal deviation
A2: What additional features in the history would you like to elicit?
Take the same history as for Case 2.5, but always ask about contact sport.
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88 Ear, nose and throat (ENT)
A3: What should one look for in the examination?
Examine the bony pyramid of the nose and make sure that this has not been fractured – this is best
performed by looking at the seated patient from behind and noting any nasal deviation. Look at the
cartilaginous septum to see whether this is displaced at either side. Turn the tip of the nose up to see
whether the front part of the septum has been dislocated outwards.
A4: What investigations would be most helpful and why?
Undertake allergy testing on all patients who have bilateral nasal obstruction because many will have an
allergic rhinitis. It is rarely necessary to undertake any other investigations.
A5: What are the treatment options?
Do not advise nasal surgery except for manipulation of a fracture when the risk of re-injury is high.
Surgery should not be undertaken until 18 years of age because the nose is still growing and surgery
may adversely affect the growth plates. Avoid septal surgery if the child plays a contact sport.
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Nasal obstruction 89
OSCE Counselling cases
OSCE COUNSELLING CASE 2.5 –
A mother asks whether their cat should
be removed if this causes allergic
rhinitis
Frequently children are not concerned about their nasal symptoms but the parents are. The cat may be
more important to the child than the symptoms. Cats should be excluded from bedrooms. If the child
is severely disturbed by the symptoms it may be necessary to re-house a pet. A cat must go if it causes
severe asthma.
OSCE COUNSELLING CASE 2.6 –
What advice should you give to a boy
who wants to continue playing football
and judo when he has repeated injuries
to his nose?
Stress that surgery on the septum makes the structure weaker and more prone to further damage. Should
another injury occur cosmetic deformity could be extreme and exceptionally difcult to correct. The septum
can be corrected at any time, because nasal obstruction is not a life-threatening condition.
REVISION PANEL
Full rhinological history and examination are always necessary as allergy often co-exists with other
rhinological complaints and needs treating.
Childhood non-traumatic nasal blockage is typically due to allergy or enlarged adenoids.
Allergic rhinitis is treated with allergen avoidance and, if unsuccessful, medical therapy.
Septal surgery is not advised in childhood and should be delayed until after 18 years of age.
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90 Ear, nose and throat (ENT)
LANGUAGE DELAY AND DEVELOPMENT
Questions
Clinical cases
For each of the clinical case scenarios given
Q1: What is the likely differential diagnosis?
Q2: What additional features in the history would you like to elicit?
Q3: What should one look for in the examination?
Q4: What investigations would be most helpful and why?
Q5: What are the treatment options?
CASE 2.7 –
Parents are worried about a 1-year-old who is not speaking
CASE 2.8 –
A mother comes with a child of three and a half who is
badly behaved and also not talking well
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Language delay and development 91
OSCE Counselling cases
OSCE COUNSELLING CASE 2.7 –
Parents would like their 3-year-old
child’s hearing tested, but would like
you to explain how this is possible
OSCE COUNSELLING CASE 2.8 –
What advice would you give to a
mother who is concerned about
swimming and grommets?
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92 Ear, nose and throat (ENT)
Key concepts
⦁ Language⦁delay⦁may⦁be⦁the⦁result⦁of⦁hearing⦁loss,⦁which⦁may⦁be⦁sensorineural⦁or⦁conductive.⦁
Sensorineural⦁hearing⦁loss⦁is⦁reduction⦁in⦁cochlea⦁or⦁cochlear⦁nerve⦁function.⦁In⦁children⦁this⦁is⦁
typically⦁congenital,⦁due⦁to⦁genetic⦁defects,⦁syndrome⦁or⦁intrauterine⦁infections,⦁or⦁acquired⦁
secondary⦁to⦁birth⦁trauma⦁or⦁infections⦁like⦁meningitis⦁(Figure2.3).
⦁ Conductive⦁hearing⦁loss⦁is⦁the⦁reduction⦁of⦁the⦁external⦁and/or⦁middle⦁ear’s⦁ability⦁to⦁conduct⦁sound⦁
into⦁the⦁inner⦁ear⦁(cochlea).⦁In⦁children⦁it⦁is⦁often⦁associated⦁with⦁normal⦁cochlea⦁function⦁–⦁no⦁
associated⦁sensorineural⦁hearing⦁loss.
⦁ Assess⦁development.
⦁ Genetic⦁50⦁per⦁cent⦁–⦁Typically⦁related⦁to⦁
dysplasia⦁of⦁the⦁cochlea
Syndromic⦁20⦁per⦁cent
⦁− Autosomal⦁recessive
⦁− Pendred’s syndrome⦁–⦁SNHL⦁and⦁a⦁
thyroid⦁goitre
⦁− Usher’s syndrome⦁–⦁SNHL⦁and⦁
retinitis⦁pigmentosa
⦁− Revel⦁and⦁Lange-Neilson⦁–⦁
prolonged⦁Q-T⦁and⦁SNHL
⦁− Autosomal⦁dominant
⦁− Waardenburg’s syndrome –
telecanthus,⦁pigment⦁disorders⦁and⦁
SNHL
⦁− Treacher Collins syndrome⦁–⦁
hypoplasia⦁of⦁the⦁malar⦁bones,⦁
maxilla⦁and⦁mandible;⦁there⦁may⦁be⦁
microtia⦁or⦁multiple,⦁external⦁and⦁
inner⦁ear⦁abnormalities
⦁− X-linked
⦁− Mitochondrial
⦁− Chromosomal
Nonsyndromic⦁80⦁per⦁cent
⦁− Autosomal⦁recessive⦁80⦁per⦁cent⦁–⦁
Connexin⦁26
⦁− Autosomal⦁dominant⦁20⦁per⦁cent
⦁− X-linked
⦁− Mitochondrial
⦁− Chromosomal
⦁ Acquired⦁50⦁per⦁cent
Prenatal
⦁− Non-infective⦁insults⦁–⦁environmental⦁
hazards,⦁diabetes,⦁toxaemia,⦁ototoxic⦁
drugs,⦁teratogens⦁(alcohol)
⦁− Infections⦁–⦁rubella,⦁cytomegalovirus⦁
(CMV),⦁measles,⦁chickenpox,⦁herpes,⦁
toxoplasmosis,⦁syphilis,⦁HIV
⦁− It⦁has⦁been⦁suggested⦁that⦁up⦁
to⦁30⦁per⦁cent⦁of⦁all⦁childhood⦁
sensorineural⦁deafness⦁is⦁due⦁to⦁
CMV,⦁the⦁onset⦁of⦁which⦁is⦁delayed⦁
in⦁40⦁to⦁50⦁per⦁cent.
⦁− Risk⦁of⦁congenital⦁hearing⦁loss⦁
following⦁maternal⦁rubella⦁is⦁50⦁per⦁
cent.⦁The⦁classic⦁congenital⦁rubella⦁
syndrome⦁(CRS)⦁comprises⦁a⦁triad⦁
of⦁hearing⦁loss,⦁cataracts,⦁cardiac⦁
abnormalities
Perinatal
⦁− Hypoxia
⦁− Hyperbilirubinaemia
⦁− Low⦁birth⦁weight
⦁− Jaundice
Postnatal
⦁− Infections
⦁− Acute/chronic⦁otitis⦁media⦁and⦁
complications
⦁− Meningitis⦁–⦁most⦁common⦁cause⦁
of⦁acquired⦁sensorineural⦁hearing⦁
loss⦁in⦁children
⦁− Viral⦁labyrinthitis⦁including⦁measles⦁
and⦁mumps
⦁− AIDS
⦁− Ototoxic⦁drugs
⦁− Trauma⦁–⦁temporal⦁bone⦁fractures
⦁− Neoplasia
⦁− Developmental⦁–⦁delayed⦁auditory⦁
maturation
⦁ Genetic⦁causes⦁–⦁those⦁that⦁present⦁later⦁–⦁
Pendred’s,⦁large⦁vestibular⦁aqueducts
Figure 2.3 Causes of congenital sensorineural hearing loss.
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Language delay and development 93
Treat mild to severe bilateral sensorineural hearing loss with a hearing aid.
Treat bilateral profound hearing loss by cochlear implantation.
Children may swim with grommets in situ.
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94 Ear, nose and throat (ENT)
Answers
Clinical cases
CASE 2.7 –
Parents are worried about a 1-year-old who is not speaking
A1: What is the likely differential diagnosis?
Variation in speech development is common, typically investigations start for children who do not speak
between 18 months and 2 years, unless there are risk factors (see A2).
A2: What additional features in the history would you like to elicit?
Determine whether the child is at risk of developing sensorineural hearing loss. Risks include
prematurity, jaundice, hypoxia or a difcult birth, infections either during pregnancy or postpartum (e.g.
measles or rubella), neonatal unit admission and a family history of hearing loss. Ask whether the child
babbled and responded to sound when younger. Also ask about the developmental milestones during
the rst year, and the age of sitting, crawling and use of a spoon. Sometimes language delay is the
result of a general developmental delay, so is it important to exclude this.
A3: What should one look for in the examination?
Observe the child while he is sitting in the clinic and see whether he responds to sound when people
move around behind him. Examine the ears and determine whether there is a congenital deformity
(altered position or shape), increasing the risk of a syndrome with hearing loss. Make sure that both the
eardrums and middle ears are normal and that there is no glue ear (otitis media with effusion).
A4: What investigations would be most helpful and why?
See explanation of hearing tests in OSCE answer. This child is too young for subjective audiometry
and hence objective audiometry is required. A tympanogram may demonstrate an effusion (glue ear).
Otoacoustic emissions testing can demonstrate whether the cochlea outer hair cells are functioning.
Hearing thresholds are determined by evoked response audiometry. Depending on whether
sensorineural hearing loss is conrmed, further investigations to determine potential congenital causes
are undertaken (Figure2.3).
A5: What are the treatment options?
This depends on the underlying cause. If the child does have bilateral sensorineural hearing loss, it is
important to provide hearing aids so that language development can occur as quickly as possible. If
the child has a profound sensorineural hearing loss, or does not improve with hearing aids, a cochlear
implant should be considered. The earlier a cochlear implant is inserted the better the long-term result.
If surgery is undertaken before the age of 2 years, the child stands a very good chance of developing
normal language. If the child has glue ear that does not resolve after 3 months of observation, it can be
treated with ventilation tubes (grommets) or hearing aids.
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Language delay and development 95
CASE 2.8 –
A mother comes with a child of three and a half who is
badly behaved and also not talking well
A1: What is the likely differential diagnosis?
Otitis media with effusion – glue ear
A2: What additional features in the history would you like to elicit?
Ask whether language development was normal previously or whether this change in behaviour and
language has suddenly happened. Determine if the child has any older brothers and sisters, because
language may be slower in later children. Exclude recurrent acute otitis media (episodes of pain and
hearing loss) and discharging ears in a child of this age. There may occasionally be a sensorineural
hearing loss, particularly if the child has had meningitis, so a full past history should be taken. However,
the most likely cause at this age is glue ear (otitis media with effusion).
A3: What should one look for in the examination?
The patient requires examination of the ears, nose and throat.
Ear: inspection of the pinna and outer ear canal (any congenital deformities which are often linked
with middle-ear pathology, perforated acute otitis media will reveal pus in the external canal)
Otoscopy: examine the ear canal looking for discharge and patency. Inspect the tympanic membrane
and determine whether it is intact, perforated or if a cholesteatoma is present. The middle ear can be
examined through the tympanic membrane – in acute otitis media the ear is bulging with (yellow) pus
behind the drum. In glue ear there is no bulging, but a straw-coloured uid behind the drum, often
with bubbles in the middle ear.
Nasal patency should be examined by seeing if a metal spatula placed under the nares (nostrils) mists
bilaterally.
The neck should be examined for masses, especially thyroid and branchial cysts – associated with
features in Pendred’s syndrome and branchial otorenal syndrome.
A4: What investigations would be most helpful and why?
Children of this age may be old enough to undertake a pure-tone audiogram but may require
conditioned response audiometry – see OSCE case on audiometry. Tympanometry can determine
whether glue ear is present.
A5: What are the treatment options?
A child with glue ear and language delay should have ventilation tubes (grommets) inserted, although
hearing aids are another option. Behavioural problems reinforce the need to intervene. It is normal
practice to observe the condition to see whether the glue ear resolves over a 3-month period. As many
of these children have been seen at least 2 or 3 months before their ENT clinic visit the effusion is
usually previously documented.
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96 Ear, nose and throat (ENT)
OSCE Counselling cases
OSCE COUNSELLING CASE 2.7 –
Parents would like their 3-year-old
child’s hearing tested, but would like
you to explain how this is possible
Audiological testing can be broadly split into subjective and objective testing. Subjective testing requires
active input from the patient to inform the tester of the sounds he/she can hear. Pure tone audiometry
is the commonest subjective test, sounds are presented to each ear in turn by headphones and the
patient presses a button when he or she can hear the tone (air conduction). A range of tones are tested
in each ear. A bone conducting device is then used to determine the cochlea function (due to bone
conduction directly stimulating the cochlea, bypassing the outer and middle ear) using a similar process.
Children can be conditioned to perform a task when they hear a sound (put a toy in a boat etc.) rather
than press a button.
Objective testing does not require patient input and hence can be used at all ages. Evoked response
audiometry involves interpreting electrical activity in the brain in response to sound presented by
headphones. When the patient’s brain detects a sound, there is a change in response demonstrating the
threshold of hearing. Tympanometry involves measuring the reection of sound off the eardrum whilst
the pressure in the external ear is altered. This can determine whether there is uid in the middle ear
(glue ear or acute otitis media) or air at normal pressure as occurs in a normal middle ear. Otoacoustic
emissions test the function of the outer hair cells in the cochlea. These are typically damaged in
sensorineural hearing loss. Normal outer hair cells create a sound in response to detecting sound. This
can be detected determining whether the hair cells are functioning normally.
OSCE COUNSELLING CASE 2.8 –
What advice would you give to a
mother who is concerned about
swimming and grommets?
There is much controversy about swimming and grommets. Work from Australia would suggest that the
prevalence of discharge is no greater in children who swim with grommets than in those who do not.
A child should not dive or jump into water. Hair washing is more risky because the soap or detergent
reduces the surface tension and makes middle-ear contamination and discharge more likely. Advise
parents to protect the ears in younger children and ask the child to make sure that water and soap do
not run into the ear during a shower or bath.
REVISION PANEL
Assessment of a child with hearing loss requires the assessment of risk factors for sensorineural
hearing loss and global development.
Audiological testing can differentiate sensorineural and conductive hearing losses.
A child with severe to profound sensorineural hearing loss requires tting of hearing aids as soon
as possible followed by assessment for cochlear implantation.
Conductive hearing losses are commonly caused by glue ear and can be treated with ventilation
tubes (grommets) or hearing aids.
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