Snoring and sleep apnea in children

Most children snore on occasion, and about 10 percent or more snore on most nights. Snoring is a noise that occurs during sleep when the child is breathing in and there is some blockage of air passing through the back of the mouth. The opening and closing of the air passage causes a vibration of the tissues in the throat.

Majority of the children that snore have obstructive sleep apnea syndrome (OSAS).
How do you know if your child is just a normal snorer or if he has obstructive sleep apnea? Children who snore and do not have OSAS should be otherwise well, without daytime sleepiness and they should have normal sleep patterns. In contrast to normal primary snoring, children with OSAS usually have disrupted sleep with short ‘pauses, snorts, or gasps’ in their sleep.

Other signs or symptoms might include:
• large tonsils and/or adenoids with frequent mouth breathing, hyponasal speech and nasal obstruction
• poor weight gain or being overweight
• high blood pressure
• Snore loudly and on a regular basis
• Have pauses, gasps and snorts and actually stop breathing. The snorts and gasps may waken them and disrupt their sleep.
• Be restless or sleep in abnormal positions with their head in unusual positions
• Sweat heavily during sleep
• During the day, children may have headaches, especially in the morning
• Have behavioral, school and social problems
• Be difficult to wake up
• Be irritable, agitated, aggressive and cranky
• Be so sleepy during the day that they actually fall asleep or daydream
• Speak with a nasal voice and breathe regularly through the mouth

Once it is determined that your child has obstructive sleep apnea syndrome, it will be time to discuss treatment options, which usually include removing enlarged adenoids and tonsils -adenotonsillectomy.
Other treatments might include treating a child’s allergies and helping overweight children lose weight.

Remember to be especially suspicious that your child may have OSA if he regularly snores and has apnea, daytime sleepiness, and/or school and behavioral problems.

Sleep apnea is a common disorder in which you have one or more pauses in breathing or shallow breaths while you sleep.
Breathing pauses can last from a few seconds to minutes. They often occur 5 to 30 times or more an hour. Typically, normal breathing then starts again, sometimes with a loud snort or choking sound.
This results in poor sleep quality that makes you tired during the day. Sleep apnea is one of the leading causes of excessive daytime sleepiness.
The most common type of sleep apnea is obstructive sleep apnea. This most often means that the airway has collapsed or is blocked during sleep. The blockage may cause shallow breathing or breathing pauses. Enlarged tonsils with redundant uvula and soft palate is the usual cause of OSA.
Tonsillectomy before LAUP or UPP will give a better result in these type of patients.

The tonsillectomy can be an important component of surgery for OSA, especially if the tonsils are at all enlarged. The removal of redundant tissue by tonsillectomy increases the caliber of the throat thereby reducing blockage to breathing. In a mature adult, pain following tonsillectomy can be unpleasant, but is reasonably well controlled with prescription medication. The UPPP and tonsillectomy remain a very important part of surgery to expand the upper breathing passage for treatment of OSA

The uvulo-palato-pharyngoplasty (UPPP) and tonsillectomy are often performed as a part of Obstructive Sleep Apnea surgery. The UPPP procedure shortens and stiffens the soft palate by partial removal of the uvula and reduction of the edge of the soft palate. Most patients who snore, but do not have apnea should enjoy a dramatic decrease in loudness of snoring after UPPP.

Apthous Ulcers (Mouth Ulcers)

Aphthous ulcers are ulcers that form on the mucous membranes of the mouth or oral cavity. Aphthous ulcers are typically recurrent round or oval sores or ulcers that occur inside the mouth .Aphthous mouth ulcers are very painful sores that can occur anywhere inside the mouth. At least 1 in 5 people develop aphthous mouth ulcers at some stage in their life.
There are three types:
• Minor aphthous ulcers are the most common they are small, round, or oval, and are less than 10 mm across. They look pale yellow, but the area around them may look swollen and red. Only one ulcer may develop, but up to five may appear at the same time. Each ulcer lasts 7-10 days, and then goes without leaving a scar. They are painful.
• Major aphthous ulcers these are 10 mm or larger. Usually only one or two appear at a time. Each ulcer lasts from two weeks to several months, and then goes but leaves a scar. They can be very painful - eating may become difficult.
• Herpetiform ulcers’, these are tiny, about 1-2 mm across. Many occur at the same time, but some may join together and form irregular shapes. Each ulcer lasts one week to two months. (These are sometimes called but they have nothing to do with herpes or the herpes virus.)
Aphthous ulcers usually first occur at any age. They then recur from time to time. There can be days, weeks, months, or years between each bout of ulcers. The ulcers tend to recur less often as you become older. In many cases, they eventually stop coming back. Some people feel a burning in the mouth for a day or so before an ulcer appears.

Causes of Aphthous ulcers?

The exact reason why aphthous ulcers develop is not yet clearly defined. Current thinking is that the immune system has been disturbed by some external factor and these results in the development of aphthous ulcers. Also, approximately 40% of people who get ulcers have a family history of aphthous ulcers.
Some factors that seem to trigger outbreaks of ulcers include:
• Emotional stress and lack of sleep
• Mechanical trauma, for example self-inflicted bite , improper brushing
• Nutritional deficiencies, particularly vitamins B, iron, and folic acid
• Certain foods including spices, chocolate
• Certain toothpastes and hard tooth brushes
• Smoking, but Some ex-smokers find they develop ulcers only after stopping smoking.
• Changes in hormone levels. Some women find that mouth ulcers occur just before their period. In some women, the ulcers only develop after the menopause.
• Rarely, a food allergy may be the cause.
• A reaction to a medication is a rare cause. For example, anti-inflammatory drugs, and oral nicotine replacement therapy have been reported to cause mouth ulcers in some people.
• Aphthous ulcers are commonly present in certain medical conditions. Many of these conditions are associated with impaired immune systems and include Behcet disease, Crohn disease and inflammatory bowel disease.

Treatments for Aphthous ulcers?

Treatment aims to ease the pain when ulcers occur, and to help them to heal as quickly as possible. (There is no treatment that prevents aphthous mouth ulcers from recurring.)
• No treatment may be needed. The pain is often mild, particularly with the common ‘minor’ type of aphthous ulcer. Each bout of ulcers will go without treatment.
• General measures include:
o Avoid spicy foods, acidic fruit drinks, and very salty foods (such as crisps) which can make the pain worse.
o Use a straw to drink, to by-pass ulcers in the front of the mouth. (Note: do not drink hot drinks with a straw, as you may burn your throat. Only cold drinks.)
o Use a very soft toothbrush.
o If you suspect a medication is causing the ulcers, then a change may be possible.
• Chlorhexidine mouthwash may reduce the pain. It may also help ulcers to heal more quickly. It also helps to prevent ulcers from becoming infected. Chlorhexidine mouthwash is usually used twice a day. It may stain teeth brown if you use it regularly. However, the stain is not usually permanent, and can be reduced by avoiding drinks that contain tannin (such as tea, coffee, or red wine), and by brushing teeth before use. Rinse your mouth well after you brush your teeth as some ingredients in toothpaste can inactivate chlorhexidine.
• Steroid lozenges may also reduce the pain, and may help ulcers to heal more quickly. By using your tongue you can keep a lozenge in contact with an ulcer until the lozenge dissolves. A steroid lozenge works best the sooner it is started once an ulcer erupts. If used early, it may ‘nip it in the bud’, and prevent an ulcer from fully erupting. The usual dose is one lozenge, four times a day, until the ulcer goes. In children, use for no more than five days at a time.
• Steroid paste (gel) is an alternative to a lozenge.
• A painkilling oral rinse, gel, or mouth spray may help to ease pain. For example, benzydamine spray, or choline salicylate gel. However, the effect of each dose does not last very long.
• Steroid -Other treatments may be tried if the above do not help or where the pain and ulceration are severe. For example, a course of steroid tablets, strong steroid mouthwashes, colchicine, tetracycline or doxycycline mouthwashes, and some immunosuppressant drugs.
• Cautery with Silver nitrate under local anesthetic is very effective. It destroy the nerve endings under the ulcer base reducing pain and early healing
• Biopsy to be done if mouth ulcer doesn’t heal after 2-3 weeks, to rule out any malignancy.

How much water do you need to drink a day

Every day you lose water through your breath, perspiration, urine and bowel movements. For your body to function properly, you must replenish its water supply by consuming beverages and foods that contain water.
A couple of approaches attempt to approximate water needs for the average, healthy adult living in a temperate climate.
Replacement approach. The average urine output for adults is 1.5 liters a day. You lose close to an additional liter of water a day through breathing, sweating and bowel movements. Food usually accounts for 20 percent of your total fluid intake, so if you consume 2 liters of water or other beverages a day (a little more than 8 cups) along with your normal diet, you will typically replace the lost fluids.
Dietary needs. The Institute of Medicine advises that men consume roughly 3.0 liters (about 13 cups) of total beverages a day and women consume 2.2 liters (about 9 cups) of total beverages a day.
Urine color?
Even apart from the above approaches, it is generally the case that if you drink enough fluid so that you rarely feel thirsty and produce between one and two liters of colorless or slightly yellow urine a day, your fluid intake is probably adequate.
water needs depends on

You may need to modify your total fluid intake depending on how active you are, the climate you live in, your health status, and if you’re pregnant or breast-feeding.
Exercise. The more you exercise, the more fluid you’ll need to keep your body hydrated. An extra 1 or 2 cups of water should suffice for short bouts of exercise, but intense exercise lasting more than an hour (for example, running a marathon) requires additional fluid. How much additional fluid is needed depends on how much you sweat during the exercise, but 13 to26 ounces (or about 2 to 3 cups) an hour will generally be adequate, unless the weather is exceptionally warm.
During long bouts of intense exercise, it’s best to use a sports drink that contains sodium, as this will help replace sodium lost in sweat and reduce the chances of developing hyponatremia, which can be life-threatening. Fluid also should be replaced after exercise. Drinking 16 ounces of fluid per pound of body weight lost during exercise is recommended.
Climate. Hot or humid weather can make you sweat and requires additional intake of fluid. Heated indoor air also can cause your skin to lose moisture during wintertime. Further, altitudes greater than 2,500 meters (8,200 feet) may trigger increased urination and more rapid breathing, which use up more of your fluid reserves.
Fever. Signs of illnesses, such as fever, vomiting and diarrhea, cause your body to lose additional fluids. In these cases you should drink more water and may even need oral rehydration solutions, such as Gatorade, Powerade or Ceralyte. Certain conditions, including bladder infections or urinary tract stones, also require increased water intake. On the other hand, certain conditions such as heart failure and some types of kidney, liver and adrenal diseases may impair excretion of water and even require that you limit your fluid intake.
Pregnancy or lactation. Women who are expecting or breast-feeding need additional fluids to stay hydrated. Large amounts of fluid are lost especially when nursing. The Institute of Medicine recommends that pregnant women drink 2.4 liters (about 10 cups) of fluids daily and women who breast-feed consume 3.0 liters (about 12.5 cups) of fluids a day.
Constipated? Drink more water. You donot have to strain in the toilet.
Eat more vegetables and fruits

Although it’s a great idea to keep water within reach at all times, you don’t need to rely only on what you drink to satisfy your fluid needs. What you eat also provides a significant portion of your fluid needs. On average, food provides about 20 percent of total water intake, while the remaining 80 percent comes from water and beverages of all kinds.
For example, many fruits and vegetables - such as watermelon and cucumbers - are nearly 100 percent water by weight. Beverages such as milk and juice are also comprised mostly of water. Even beer, wine and caffeinated beverages such as coffee, tea or soda can contribute, but these should not be a major portion of your daily total fluid intake. Water is one of your best bets because it’s calorie-free, inexpensive and readily available.
Dehydration

Failing to take in more water than your body uses can lead to dehydration. Even mild dehydration - as little as a 1 percent to 2 percent loss of your body weight - can sap your energy and make you tired. Common causes of dehydration include strenuous activity, excessive sweating, vomiting and diarrhea.
Signs and symptoms of dehydration include:
Mild to excessive thirst
Fatigue
Headache
Dry mouth
Little or no urination
Muscle weakness
Dizziness
Lightheadedness
Mild dehydration rarely results in complications - as long as the fluid is replaced quickly - but more-severe cases can be life-threatening, especially in the very young and the elderly. In extreme situations, fluids or electrolytes may need to be delivered intravenously.
Stay well hydrated
To ward off dehydration and make sure your body has the fluids it needs, make water your beverage of choice. Nearly every healthy adult can consider the following:
Drink a glass of water with each meal and between each meal.
Hydrate before, during and after exercise.
Substitute sparkling water for alcoholic drinks at social gatherings.
Always take sips of water than gulping.
Though uncommon, it is possible to drink too much water. When your kidneys are unable to excrete the excess water, the electrolyte (mineral) content of the blood is diluted, resulting in a condition called hyponatremia (low sodium levels in the blood).

Dry Mouth
Dry Mouth, (Oral Dryness) also known as “XEROSTOMIA”is a very common condition. It affects about one in every four to five adults, mainly women. Moreover, its prevalence increases with age, about 30-40% of the old age people suffer from oral dryness. .

What are the causes of a dry mouth?

A dry mouth is not a diagnosis in itself. It is a symptom and there are various causes which include:
• Medication. Various drugs can cause a dry mouth as a side-effect. For example, tricyclic antidepressants, antihistamines, some antiepileptic drugs, some antipsychotic, beta-blockers, and diuretics .Many of these drugs cause a dry mouth by affecting the salivary glands which reduce the amount of saliva that these glands make.
• Anxiety.
• Mouth breathing - which can be due to a blocked nose or other causes.
• Dehydration (low body fluid). This may occur for many reasons, but you will usually be quite ill with fever or other symptoms if you are dehydrated.
• Sjögren’s Syndrome. This is a condition which can affect various parts of the body including the joints (which can cause arthritis), the salivary glands (which can cause a dry mouth), and the tear glands (which can cause dry eyes).
• Radiotherapy to the head or neck. The radiotherapy can damage the salivary glands.

What are the treatments for a dry mouth?

Treat the causes
in some cases; it may be possible to treat the underlying cause.
• If a drug is causing the dry mouth as a side-effect, it may be possible to change to a different drug, or to reduce the dose.
• Dehydration, a blocked nose, and anxiety can often be treated.
Practical measures
whatever the cause, the following will often help.
• Petroleum jelly to your lips to prevent drying and cracking.
• Sucking on sugar-free candy or chewing sugar-free gum
• Drinking plenty of water to help keep your mouth moist
• Protecting your teeth by brushing with a fluoride toothpaste, using a fluoride rinse, and visiting your dentist regularly
• Breathing through your nose, not your mouth, as much as possible
• Using a room vaporizer to add moisture to the bedroom air
• Using an over-the-counter artificial saliva substitute.

Artificial saliva
if the above measures are not adequate, then your doctor may prescribe a spray, gel or lozenge which acts as a substitute for saliva. Each dose only lasts a short time and so they need to be used frequently. Some people find artificial saliva products more helpful than others.
Saliva Stimulants
In some cases of dry mouth, the saliva glands are only partially affected and can be ’stimulated’ to make more saliva.
Chewing sugar-free gum can help to increase the production and flow of saliva.
Pilocarpine is a drug which can stimulate salivary glands to make more saliva. It may be prescribed if other measures have not helped much. Pilocarpine usually works well and quickly in most people with a dry mouth caused by a medication side-effect.

Having a cold or Flu?

The cold and flu are both respiratory illnesses, but they are caused by different types of viruses.

Flu symptoms usually come on quickly (within 3-6 hours) and consist of a fever, body aches, dry cough, and extreme tiredness. Cold symptoms are less severe and people experience a stuffy nose, productive cough, slight tiredness, and limited body aches.

Flu Virus
Influenza A and B viruses are responsible for seasonal flu epidemics each year …

Symptoms

Avoid Getting a Cold and Flu

Wash your hands often. You can pick up cold germs easily, even when shaking   someone’s hand or touching doorknobs or handrails.

Avoid people with colds when possible.

Sneeze or cough into a tissue and then throw the tissue away.

Clean surfaces you touch with a germ-killing disinfectant.

Don’t touch your nose, eyes, or mouth. Germs can enter your body easily by these paths.

A flu shot can greatly lower your chance of getting the flu.

What to do then?

Drink plenty of fluids.

Get plenty of rest.

Use a humidifier — an electric device that puts water into the air.

Avoid alcohol and tobacco

Antibiotics rarely help

Medicines

With the advent of more expensive modern medications like antibiotics , there are some good old medications now going to oblivion. There was a time when a pharmacist used to dispense these medications, but gone are those days. Now everything comes in blister packs and fancy labels.

I had the privilege to work with a veteran ENT consultant some 30 years ago in UK, who participated in the First World War that was before the Penicillin Era. He used to tell us the stories of great invention in the history of medicine, of the life saving Penicillin. It was used only in serious life threatening patients. Penicillin was a controlled drug, they used to keep a register and only the registrar has the key to the penicillin cupboard.

There are some remarkable medications used in ENT practice still works

BIPP - Bismuth iodoform paraffin paste

This was used before the penicillin era for packing the war wounds.

We still Use this wonderful product to pack mastoid cavities after mastoidectomy surgery. There is no adverse effect by using BIPP packs; one can leave the pack for weeks or months. The longer you leave it is better.

Also used to pack the nose in Epistaxis patients when all the other packing fail. But the stringent smell is not very pleasant.
Why not try in MRSA patient

Icthamol in Glyerine

What is it?

A viscous ointment, brownish black, with a strong, characteristic, empyreumatic odor, soluble in water and in glycerin; obtained by the destructive distillation of certain bituminous schists, sulfonating the distillate and neutralizing the product with ammonia.

The clinical efficacy of glycerine-ichthammol may be due to an anti-inflammatory action of ichthammol or a dehydrating effect of glycerin on the edematous ear canal. Its antimicrobial activity and antifungal, against the common organisms in otitis externa is well known. It has analgesic and stimulant property too. It is used in 10-20% concentrations in an ointment .It is not fully understood how it works, but it works, it is magic

Uses

In Otititis externa, funrunculosis of the ear, apply on the face who has mumps
Why not try in MRSA patients?

Mandls Throat Paint

As a child my family doctor has used it in my throat when I used to get sore throat, as I vaguely remember.
Used to be very popular in those days. But now no one knows how to make it.
Dispensing Mandls Paint- To make 20 ml-Iodine 0.25gm, add Potassium 0.5gm, menthol oil 4 drops, glycerine and distilled water.

Fish bone in the throat

If you have swallowed a fish bone there will be pain and dysphagia. And also will be drooling of saliva. Attempted removal by putting finger might have caused further damage.
Chicken bone, bottle tops, bay leaf, pills, battery and coin are the other common foreign bodies stuck in the throat and commonly seen in the ENT clinics.

On examination

If symptoms are mild, test the patient’s ability to swallow, first using a small cup of water and then small piece of bread. See what symptoms are reproduced, or if the bread eliminates the foreign body sensation.
With the patient sitting in a chair, inspect the oropharynx with a tongue depressor, looking for foreign bodies or abrasions

Inspect the hypopharynx with a good light or headlamp mirror, paying special attention to the base of the tongue, tonsils and vallecula, where foreign bodies are likely to lodge. Maximize your visibility and minimize gagging by holding the patient’s tongue out (use a washcloth or 4×4″ gauze for traction and take care not to lacerate the frenulum of the tongue on the lower incisors) and have the patient raise his soft palate by panting. This may be accomplished without topical anesthesia, but if the patient is skeptical or tends to gag, you may anesthetize the soft palate and posterior pharynx with a spray (10% lidocaine spray) or by having the patient gargle with Xylocaine viscous.

A small fish bone is frequently difficult to see. It may be overlooked entirely except for the tip, or it may look like a strand of mucus. If the object can be seen directly, carefully grasp and remove it with Tilley forceps .Objects in the base of the tongue or the hypopharynx require a mirror or indirect laryngoscope for visualization.

Fiber optic nasopharyngoscopy is preferred when available.

Further treatment is probably not required, but you should instruct the patient to seek follow-up if pain worsens, fever develops, breathing or swallowing is difficult, or if the foreign body sensation has not totally resolved in 2 days.

X-ray neck

If you and your patient are not satisfied, you may proceed to a soft tissue lateral x ray of the neck. This will probably not show radiolucent or small foreign bodies, such as fish bones, or aluminum pop tops, but may point out other pathology, such as a retropharyngeal abscess, or severe cervical spondylosis, which might account for symptoms .Lateral soft-tissue x rays, can be very misleading because ligaments and cartilage in the neck calcify at various rates and patterns. The foreign body you see on a plain x ray may simply be normal calcification of thyroid cartilage.

Barium swallow-Contrast study

You may also want to proceed to a barium swallow, if available, to demonstrate with fluoroscopy any problems with swallowing motility, or perhaps coat and thus visualize a radiolucent foreign body. Remember that endoscopy is technically difficult after barium has coated the mucosa and possibly obscured a foreign body. It may be preferable to use a water-soluble contrast (e.g., Gastrographin) but even under the best of circumstances, contrast studies are of limited value.

Endoscopy

Rigid laryngoscopy, esophagoscopy, and bronchoscopy under general anesthesia for the few cases where your suspicion of a perforating foreign body remains high (e.g., when the patient has moderate to severe pain, is febrile or toxic, cannot swallow, is spitting blood, or has respiratory involvement.

Antibiotic cover

If X rays are negative and careful inspection does not reveal a foreign body, and the patient is afebrile with only mild discomfort, the patient may be sent home and observed.A short course of broad spectrum antibiotic is prescribed.

Reassure him that a scratch on the mucosa can produce a sensation that the foreign body is still there, but that if the symptoms worsen the next day or fail to resolve within two days he may need further endoscopy.
All patients who complain of a foreign body of the throat should be taken seriously. Even relatively smooth or rounded objects that remain impacted in the esophagus have the potential for serious problems, and a fish bone can perforate the esophagus in only a few days.

Impacted batteries represent a true emergency and require rapid intervention and removal because leaking alkali produces liquefactive necrosis. A pill, composed of irritating medicine (e.g., tetracycline) swallowed without adequate liquid, may stick to the mucosa of the pharynx or esophagus and cause an irritating ulcer. Bay leaves, invisible on x rays and laryngoscopy, have lodged in the esophagus at the cricopharyngeus and produced severe symptoms until removed via rigid endoscope.

The sensation of a lump in the throat (Globus Pharyngis), unrelated to swallowing food or drink, which is related to crico- pharyngeal spasm and anxiety. The initial workup is the same as with any foreign body sensation in the throat.