was first used: sometime in the early 15th century. - Spire Healthcare

Samuel M. Jayaraj MBBS FRCS(Eng) FRCS(Eng) 

FRCS(ORL- FRCS(ORL 

HNS) 

Consultant Paediatric & Adult ENT Surgeon 

ENT Lead Clinician, Barts Health NHS Trust 

Whipps Cross University Hospital and Forest Medical Centre 

General ENT, ear and balance problems, throat problems 

Rhinology, Rhinology, 

all nose and sinus problems 

Facial plastic surgery, rhinoplasty, rhinoplasty, 

pinnaplasty, pinnaplasty, 

facial skin 

lesions 

Paediatric ENT

Paediatric ENT 

• Appointed as Consultant ENT Surgeon at 

Whipps Cross Hospital 2005 

• Special experience and expertise in 

– Rhinology and Facial Plastic Surgery 

– General ENT 

– Paediatric ENT 

• Senior SpR at Great Ormond Street Hospital 

and Chelsea & Westminster and Royal 

Brompton Hospital (Specialist Paediatric ENT 

Centres) 

Mr Sam Jayaraj Consultant ENT 

Surgeon

Paediatric ENT - Local Care 

• Almost all paediatric ENT problems can be 

managed locally 

• Elective anaesthesia for children 3 yo 

• Most local ENT surgeons do a bit of paeds – 

Spire Roding is now limiting this to those who 

have a dedicated paediatric ENT practice 

This will ensure your patients receive the best 

care 


Surgeon

What do you do with..........? 

The snotty child 

The child who has gone deaf 

Picture quiz

The Snotty Child 

The Catarrhal Child 

Samuel M. Jayaraj 

Consultant Paediatric and Adult Ear, Nose and Throat 

Surgeon

Catarrh 

An inflammatory affection of any 

mucous membrane, in which there 

are congestion, swelling, and an 

alteration in the quantity and quality 

of mucus secreted; as, catarrh of 

the stomach; catarrh of the bladder. 

Note: In America, the term catarrh 

is applied especially to a chronic 

inflammation of, and hyper 

secretion from, the membranes of 

the nose or air passages; in 

England, to an acute influenza, 

resulting in a cold, and attended 

with cough, thirst, lassitude, and 

watery eyes; also, to the cold itself. 

[Webster1913]. 

Inflammation of mucous 

membranes, especially of the nose 

and throat. [Heritage]. 

"catarrh" was first used: sometime 

in the early 15th century. [Webster] 

from a Civil War Hospital Record: 

Example

What is catarrh? 

• Excessive secretions of inflamed mucous 

membranes of the upper respiratory tract 

• Can affect the nose, middle ear or sinuses

• Toddler 

• Nasal obstruction 

• Mouth breathing 

• Mucoid or purulent 

rhinorrhoea 

Typical child

• stuffy nose 

• Bad breath 

• Mouth breathing 

• snoring 

• runny nose 

Symptoms 

• deafness 

• feeling of fullness in 

the head 

• Cough 

• Hoarse voice 

• lethargy

Cause 

• Recurrent URTI 

• Adenoidal hypertrophy 

• Allergy 

• Immunological deficiencies 

• Mucociliary disorders

• Often unnecessary 

Treatment 

– Resolves as child grows 

• Reassurance


Treatment 


• Saline drops

Saline nasal douche 

• Saline nasal douching 

– Cupped hand and sniff 

– Syringe and squirt up 

nose 

• Saline drops 

• Sterimar 

• Rhinomer 

• NeilMed

NeilMed nose and sinus rinse 

• New Paediatric 

version


Treatment 



• Antibiotics 

– Especially if purulent rhinorrhoea and 

soreness of nostrils and upper lip

Persistent nasal discharge 

• This may be caused by allergy or infection but the constant 

production of excessive mucus predisposes to infection that may 

perpetuate the condition. 

• A Cochrane review. 

• Children with persistent nasal discharge or older children with 

radiographically confirmed sinusitis, antibiotics given for 10 days will 

reduce the probability of persistence in the short to medium-term. 

• The benefits appear to be modest and around 8 children must be 

treated in order to achieve one additional cure (NNT 8, 95% CI 5 to 

29). No long term benefits are clear. There are a small number of 

small randomised controlled trials and further data may change the 

opinion.




• Decongestants 

Treatment 

– Short term use only if at all





• Topical Nasal steroids 

Treatment 

– Betamethasone drops 

– Flixonase nasal spray > 4 yo 

– Nasonex or Avamys nasal spray > 6 yo






• Treat Allergy 

– Allergen avoidance 

– Antihistamines 

– Topical steroids 

– Topical antihistamine 

Treatment

Treatment 






• Treat Allergy 

• Dairy avoidance 

• Check the Ears

Alternative treatments

Herbal Therapy 

• Give teas or tinctures from those herbs 

that will help loosen and expel the catarrh, 

such as chamomile, peppermint, 

elecampagne, elecampagne, 

thyme, mullein and 

fenugreek.

Homoeopathy 

• Pulsatilla 6C for when the mucus is yellowish-green, yellowish green, is 

worse in stuffy areas, child weepy, clingy, has no thirst 

• Kali bich. bich. 

6C if the mucus is ropy, tenacious, child is 

listless, chilly, prefers warmth 

• Nux vom. vom. 

6C for when your child is irritable, nose runs 

during the day, is blocked at night 

• Nat. mur. mur. 

6C if your child's mucus is like raw egg-white, egg white, 

has cold sores, finds breathing is difficult, is sneezing 

early morning, is possibly constipated 

• Ars. Ars. 

alb. 6c when there is a thin and watery discharge, 

child is thirsty for sips of cold water

Nutritional Therapy 

• Vitamin B complex, vitamin C, zinc, iron. 

• Lemon juice sweetened with honey is 

beneficial, as is fenugreek tea. 

• Avoid dairy products, and include plenty of 

fresh fruit and vegetables in the diet as 

well as lots of purified water. Since 

constipation may be associated with 

catarrh, see remedies for that.

When to refer? 

• Unilateral symptoms 

• Suspect Obstructive Sleep Apnoea 

• Persistent catarrh 

• Severe nasal obstruction

Surgical management 

• Adenoidectomy 

• Surgery to reduce turbinate size/bulk 

– Cautery to turbinates 

– Surface diathermy 

– Submucous diathermy 

– Turbinoplasty 

– Out-fracture Out fracture turbinates 

• Balloon sinuplasty and lavage


– Curettage 

– Blind technique 

– Haemostasis by 

packing 

– Post-operative Post operative risk of 

haemorrhage 

• >3% 

Surgery


– Suction diathermy 

adenoidectomy 

– Single use instrument 

– Developed at GOSH 

1998 

– Universally adopted at 

GOSH, RNTNE, C&W 

and across the USA 

– Adenoids visualised 

– No bleeding 

Surgery

• Suction diathermy 

Adenoidectomy 

– No bleeding 

– I introduced this 

technique locally to 

Whipps Cross Hospital 

and Spire Roding 

– Recognised as the 

gold standard 

Surgery 

Video_004.mpg

The Catarrhal Child 

Summary of management 

• General measures 

• Medical therapy 

• Surgical management

The child who has gone deaf 

• 4 year old boy 

• Mother concerned 

about hearing 


Surgeon

Hearing loss 

• Differential diagnosis 

• Glue ear (OME) 

• AOM 

• CSOM / cholesteatoma 

• Ear drum perforation 

• Wax impaction 

• Congenital hearing loss 


Surgeon

• Hearing 

Hearing loss 

– Misses things 

– Ignores 

– T.V. volume up loud 

– Teachers have raised concerns 

• How long? 

• Ear symptoms 

• Snoring 

• Speech delay 


Surgeon

• Hearing 

• Ear symptoms 

– Otalgia 

– Otorrhoea 

• Obstructive nasal 

symptoms 

– Blocked nose 

– Snoring 

– Mouth breathing 

History 


Surgeon 

• Speech delay 

• Behavioural change 

• Born locally 

– Neonatal hearing 

screening 

• Head injury 

• Meningitis

Hearing loss - examination 

• Otoscopy 

– Tympanic membrane 

features ? 

– Bulging 

– Retracted 

– Air fluid levels 

• Tuning fork tests 

• Free field voice tests 

• Nose 


Surgeon


Surgeon


Surgeon

Glue ear - management 

No evidence of benefit 

• Low dose antibiotics 

• Topical nasal steroid spray 

• Nasal decongestants, mucolytics, mucolytics, 

anti- 

histamines 

• Homeopathy, cranial osteopathy 

– 40% OME resolves spontaneously in 3 months 

Known to be of preventative benefit 

• Parents stop smoking 

• Breast feeding reduces OME 


Surgeon

Glue ear - management 

• Auto-inflation 

Auto inflation 

– Valsalva 

– Otovent balloon 

• Period of ‘watchful watchful waiting’ waiting 

– 40% OME resolves spontaneously in 3 

months 


Surgeon

• Refer early if 

Glue ear - Refer 

– Speech delay 

– Significant loss suspected 

– Behavioural change 

• Persistent OME 


Surgeon

• Children under three years of 

age with persistent bilateral 

otitis media with effusion and 

hearing loss of =

Glue ear – What do I do? 

• History 

• Examination 

• Tympanometry 

• Audiometry 


Surgeon


• History 




• Conservative 

management 



Surgeon

• Nose tube mounted with 

a balloon 

• Balloon inflated through 

the nose 

• +ve ve pressure 600 dPa in 

nasopharynx 

• Equalises middle ear 

pressure via ET 

Otovent balloon 


Surgeon


• History 




• Conservative 

management 


– Hearing Aid 


Surgeon


• History 




• Conservative management 


– Hearing Aid 

• Surgical intervention 


Surgeon

7 


Surgeon



• Grommet insertion 

• TARGET trial 

• Day case procedure 


Surgeon


Surgeon



• Grommet insertion 

• AND Adenoidectomy (TARGET trial) 

– Suction diathermy adenoidectomy 

– Zero post-operative post operative haemorrhage rate 

– Reduces possible infective load leading to 

Eustachian tube dysfunction 

– Even small adenoidal pads removed 

– Reduces risk of recurrent glue ear 

• Day case procedure 


Surgeon

• Post-op Post op 

• Analgesia 

• Otorrhoea 

– Antibiotic ear drops 

– Microsuction / mopping 

– Remove grommet 

Case 2 

• Extrude spontaneously after 9-12/12 9 12/12 


Surgeon

• Post-op Post op follow up 

• Swimming 

Case 2 

• After extrusion 10-20% 10 20% recurrence of OME and 

need further grommet insertion 

• If adenoidectomy performed at time of grommet 

insertion – longer beneficial effect even after 

grommet extrusion (TARGET Trial) 


Surgeon

• Indications 

• Misconceptions 

• Method of removal 

Tonsillectomy 

ent.sam@hotmail.co.uk

Misconceptions: ‘you you don’t don t take out 

tonsils any more!’ more! 

• In 2003/04 50,531 patients underwent 

tonsillectomy within English NHS Trusts. 

• Just over half of the operations were 

performed on children under the age of 15. 


Tonsillectomy indications 

�� Recurrent tonsillitis 

�� Obstructive sleep 

apnoea 

�� Snoring 

�� Suspected neoplasia 

�� Relative indications 

�� Poor eating 

�� Speech 

�� Bad breath 


Tonsillectomy misconceptions 

• Function 

– ‘Will Will I miss my tonsils?’ tonsils? 

• Protection 

– ‘Will Will I get more chest infections?’ infections? 

• Post-operative Post operative eating 

– ‘Do Do I have to eat toast?’ toast? 


Tonsillectomy method 

• National Tonsillectomy Audit 

• BAO-HNS BAO HNS / ENT-UK ENT UK 

• NICE 


Tonsillectomy method 

• Higher risk of post-operative post operative bleeding from 

‘hot hot’ techniques 

– Laser (NICE guidelines) 

– Coblation 

– Monopolar diathermy 

• Cold steel techniques better 

• Post-operative Post operative morbidity 


Post-op Post op tonsillectomy 

ent.sam@hotmail.co.uk 

�� Post st-op op slough 

�� EAT 

�� Appropriate post-op post op 

medication 

�� Analgesia nalgesia 

�� Oral ral rinses 

�� Antibiotics ntibiotics 

�� Steroids teroids 

�� Day case (6 hrs post-op post op 

care)

Picture quiz 

What would you do with .........?


Orbital cellulitis 


• i.v. i.v. 

antibiotics (3 rd gen 

cefs) cefs) 

& decongestants 

• Urgent CT scan 

• Eye opinion 

• decompression if 

collection present 

– Externally 

– endoscopically 

• Do not delay! 

– 100 minutes


Acute Otitis Media 


• Analgesia 

• Systemic 

antibiotics 

• Decongestants


Acute Mastoiditis 


• Symptoms / Signs: 

• Recent URTI 

• Fever / unwell 

• Swelling / protrusion 

• Bulging TM 

• Systemic antibiotics 

• Analgesia 

• URGENT REFERRAL


Surgeon


Surgeon

Thank-you Thank you for listening 

Questions? 

• Sam Jayaraj, Jayaraj, 

Consultant Paediatric & 

Adult ENT Surgeon 

• ent.sam@hotmail.co.uk 

• Appointments at Spire Roding Hospital on 

Thursday & Friday evenings and Thursday 

afternoons 020 8709 7878 to book 

• Private secretary, Shirley Hill 

– Tel 020 8936 1239 

– Fax 020 8936 1170

was first used: sometime in the early 15th century. - Spire Healthcare

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