Conditions We Treat


The Department of Pediatric Otolaryngology offers comprehensive diagnostic and treatment services for children from birth to 18 years of age with ear, nose and throat (ENT) conditions. Our expertise encompasses all aspects of the field, and we provide multidisciplinary, state-of-the-art patient- and family-centered care. Conditions treated include:

  • Acute and chronic ear disease
  • Airway stenosis
  • Chronic tonsillitis
  • Head and neck neoplasms
  • Hearing loss
  • Microtia, aural atresia and other conditions requiring otoplasty
  • Nasal obstruction, including choanal atresia, polyps and dermoid cysts
  • Obstructive sleep apnea
  • Salivary gland disease
  • Skull base anomalies and neoplasms
  • Snoring
  • Stridor
  • Swallowing disorders
  • Tongue-tie
  • Vascular malformations
  • Velopharyngeal insufficiency and cleft palate
  • Voice disorders, including vocal cord paralysis

Airway: Breathing, Swallowing, and Talking


Aerodigestive Tract: Breathing, Speaking, and Feeding

Our pediatric otolaryngology specialists are leaders in the diagnosis and management of the upper aerodigestive tract. The aerodigestive tract includes the nose, mouth, larynx (voice box), upper esophagus (swallowing tube), subglottis (the space just below the larynx) and trachea. Diseases that affect the upper aerodigestive tract can affect the way your child breathes, speaks and/or feeds. When necessary we work together with other pediatric specialists including speech pathologists, pediatric pulmonologists, pediatric gastroenterologists, pediatric anesthesiologists and pediatric intensivists to provide the highest level of care.


Some children with airway obstruction or abnormalities may produce a vibratory noise when they breathe, called stridor. This sound is produced by the turbulent flow of air through a narrowed segment of the respiratory tract. Some children with stridor grow out of the condition and improve with time, while others experience associated feeding and breathing difficulties. In these cases, treatment is required.

At UCSF Medical Center, our pediatric otolaryngology specialists are leaders in the diagnosis and treatment of stridor and other airway problems. In providing your child with the best possible care, they work with other specialists such as pediatric anesthesiologists, pediatric radiologists and pediatric intensivists, as well as specially-trained nursing staff. In addition, patients have access to the most advanced equipment used for diagnosing and treating airway obstructions.

Stridor may be caused by a variety of conditions, including:

  • Laryngeal papilloma
  • Vocal cord paralysis
  • Subglottic Stenosis
  • Airway Hemangioma

Endoscopy is the most common tool used by pediatric ear, nose, and throat specialists to diagnose airway problems. An endoscope is a medical device consisting of a camera mounted on a flexible or rigid tube. In making a diagnosis of your child's airway obstruction, your doctor will insert the endoscopy through their nose or mouth into their lungs. This allows your doctor to visualize your child's airway to locate the obstruction. Some information can be gathered by an endoscopy at the bedside. Sometimes, your doctor will recommend an endoscopy in the operating room under anesthesia.



Laryngomalacia is the most common cause of stridor (noisy breathing) in newborns and young infants. It usually is congenital (present at birth). It occurs when floppy tissue of the larynx (voice box) collapses when your child breathes.


The cause is not entirely known, but is thought to be due to immaturity of the tissues along with irritation and swelling caused by acid coming up from the stomach (acid reflux).


  • Loud noise with breathing (stridor) that worsens with activity, feeding, excitement, or colds
  • Vomiting or spitting up (acid reflux)
  • Poor weight gain
  • Difficulty feeding
  • Chest or neck sinking in with breathing
  • Pauses in breathing (apneas)
  • Turning blue (cyanosis)


Diagnosis of laryngomalacia requires visualization of the larynx (voice box) with a special thin camera called a flexible laryngoscope placed through the nose. This procedure can be done in the office with your child awake. Some children may require a formal sleep study to determine if the laryngomalacia is causing sleep apnea.


The majority of children outgrow laryngomalacia and the associated stridor. It typically gets worse over the first six to 8 months of life. Most children will outgrow it by 12 to 18 months of age.

Because acid reflux is strongly associated with laryngomalacia, the first step in treatment is to limit the reflux. Recommendations include:

  • Elevating the head of the crib by 4 to 6 inches
  • Feeding the baby in a upright or semi-upright position
  • Keeping the baby upright for 30 to 60 minutes after eating
  • Avoiding feeding for 1 to 2 hours before going to bed
  • Avoiding tight waistbands

Some children will not benefit from these measures alone and an anti-acid medication may be prescribed.

In a small number of children, surgery is necessary in order to improve breathing. This surgery is called supraglottoplasty and involves trimming some of the floppy tissue in the voice box. This is done in the operating room under anesthesia.

Reasons to seek medical help:

  • Your baby is not gaining weight or is losing weight
  • Your baby has difficulty feeding, especially coordinating breathing and eating, and sometimes chokes
  • Your baby becomes fatigued during feedings
  • Your baby seems to be in pain when he/she is spitting up or he is vomiting
  • Your baby has turned blue
  • Your baby has stopped breathing for longer than 10 seconds
  • Your baby looks like he is working to breathe (the chest or neck is sucking in with each breath)

Laryngeal Papilloma


Laryngeal papillomas are benign growths of the voice box that if left untreated can eventually block off the airway.


Sometimes called “warts,” they are caused by a virus and are usually transmitted from mother to child when a mother has active vaginal warts during her delivery, but can sometimes occur when the mother has not ever had an obvious wart infection.


The most common symptom associated with laryngeal papillomas is hoarseness. Difficulty with breathing may also occur but acute respiratory distress is rare due to the slow growth rate of papillomas.


Diagnosis of laryngeal papillomas requires visualization of the larynx (voice box) with a special thin camera called a flexible laryngoscope placed through the nose. This procedure can be done in the office with your child awake.


The main goal of treatment for laryngeal papilloma is to maintain enough space to breathe until the disease resolves, usually by the teenage years. The exact mechanism whereby the papilloma spontaneously disappears is unclear, although a child’s immune status seems to be an important factor in the resolution of the disease.

Surgical treatment should not be considered a cure and overly aggressive surgical techniques can lead to complications such as scarring of the vocal cords. Treatment generally requires multiple excision procedures. Various techniques can be used such as the “microdebrider,” lasers and cold steel techniques.

Medical treatments have also been explored in the treatment of laryngeal papillomatosis. Interferon is a special protein produced by various cells in the body in response to viruses. The main side effects of interferon treatment are flu-like symptoms. Ingol--corbinol is a chemical found in high concentrations in cruciferous vegetables (broccoli, cauliflower). It has been shown to alter the growth factor of papilloma cell cultures. Cidofovir is an antiviral medication. Injection of this drug into the areas with papilloma have been found to increase the time between surgeries in some patients with aggressive disease. Fortunately, with the relatively recent development of a vaccine to prevent vaginal warts, this disease is becoming a much less common cause of hoarseness and breathing difficulties in children.

Reasons to seek medical help:

  • If your child develops persistent or worsening hoarseness
  • If your child looks like he/she is having difficulty breathing
  • If your child’s neck or chest retracts when he/she breathes
  • If your child stops breathing or turns blue

Vocal Cord Paralysis


Vocal cords not only allow you to make sound, they are also help to protect your lungs from food and liquid going into them. Vocal cord paralysis, in which one or both of the vocal cords do not move, is the second most common cause of stridor in newborns and infants.


There are a variety of causes of vocal cord paralysis. The nerve that controls the vocal cords starts in the brain and runs down to the chest. If there is a problem anywhere along that path, the nerve may not be able to control the vocal cord movement correctly. Some children are born with this and others develop it later in life for various reasons.


Children with bilateral (both sides) vocal cord paralysis will usually have stridor (noise with breathing). They also usually have difficulty with breathing. Children with unilateral (one side) vocal cord paralysis have a soft cry or cannot project their voice. They usually do not have trouble breathing.

All children with vocal cord paralysis have the risk of aspiration (food or liquid going into the lungs) and may cough or choke during feedings. Some may have pneumonias (infection of the lung). Some children may fail to grow or experience weight loss.


Evaluation by a pediatric otolaryngologist is necessary for diagnosis. At the bedside, a small flexible scope with a camera is passed through the nose in order to see the vocal cords within the larynx (voice box). In addition, x-rays may be taken of the airway and chest. A special kind of non-invasive imaging study, called an MRI may also be necessary. If needed a formal examination of the airway in the operating room will be performed.


There are a variety of causes of vocal cord paralysis. The nerve that controls the vocal cords starts in the brain and runs down to the chest. If there is a problem anywhere along that path, the nerve may not be able to control the vocal cord movement correctly. Some children are born with this and others develop it later in life.


The treatment for vocal cord paralysis depends on the cause. Children with bilateral vocal cord paralysis often have difficulty with breathing. Some may need a temporary or permanent procedure to widen the spaced between the paralyzed vocal cords. Others may need a tracheotomy, a surgical procedure that creates a window into the trachea (windpipe) below the level of the vocal cord. Some children are able to have surgery to make their airway larger with a graft of cartilage from their rib.

Children with unilateral vocal cord paralysis have issues with hoarseness and aspiration. These issues can be improved with the injection of bulking substances into the vocal cords. Most surgery for vocal cord paralysis is done after a child is at least one year of age.

Reasons to seek medical help:

  • Your baby is not gaining weight or is losing weight
  • Your baby is choking while feeding
  • Your baby has turned blue
  • Your baby has stopped breathing for longer than 10 seconds
  • Your baby looks like he is working to breathe (the chest or neck is sucking in with each breath)

Subglottic Stenosis


Narrowing of the airway right below the vocal cords.


The subglottis is the narrowest part of the pediatric airway and most sensitive to irritation from trauma, infection or inflammation. Newborns and infants may be born with subglottic stenosis or develop it after having a breathing tube placed to help support breathing. It is not entirely clear why some children develop subglottic stenosis and others do not. While some children who have a breathing tube in place for a very short time develop subglottic stenosis, others who have a breathing tube for a long time do not. Other factors that may contribute to subglottic stenosis, include infections, caustic ingestion and acid reflux disease, a condition in which acid from the stomach backs up into the airway.


Children who have severe subglottic stenosis cannot breathe well without a breathing tube or tracheostomy (surgical procedure that places a window in the trachea, below the stenosis) in place. Milder forms may cause no problems at rest but children may develop difficulty breathing, noisy breathing (stridor), or may not be able to catch their breath when running or exerting themselves. Milder forms may present as recurrent croup.


Diagnosis requires a formal endoscopic evaluation of the airway with special instruments and camera. This procedure is done in the operating room under general anesthesia in cooperation with a pediatric anesthesiologist. There are different severities of subglottic stenosis. Mild forms may not require intervention and may not be associated with any long-term breathing issues. More severe forms generally require intervention.


Sometimes, the airway needs to be widened and a graft placed for support (laryngotracheal reconstruction). This involves making an incision in the neck and opening up the larynx to make it wider. Newer techniques, such as endoscopic balloon airway dilation, allow the widening to happen without any incisions in the neck. When procedures are performed early in the disease process, they have been found to prevent development of more severe stenosis.

Reasons to seek medical help:

  • If your child looks like he/she is having difficulty breathing or has noisy breathing
  • If your child’s neck or chest retracts when he/she breathes
  • If your child stops breathing or turns blue

Circumferential narrowing of the subglottic
airway from prolonged intubation.



Airway Hemangioma


A hemangioma is a benign tumor of the cells that line blood vessels. Hemangiomas can appear on the skin and are commonly considered birthmarks. They can also in the airway and cause stridor (noisy breathing).


The exact cause of hemangiomas is unknown. Infants who are born premature, are one of multiples such as twins, or are the product of assisted fertility treatments have a higher risk of developing hemangiomas. They are also more common in girls.


Hemangiomas have a “proliferative” phase, usually starting at about 6 weeks of age, when they grow rapidly. This growth phase can last through the first year of life. The infant airway is already small and when hemangiomas grow in the airway, they can cause significant difficulty with breathing and stridor. If they are left untreated, they can be life threatening.


Diagnosis requires a formal endoscopic evaluation of the airway in the operating room. This procedure is done in the operating room under general anesthesia in cooperation with a pediatric anesthesiologist.


The primary goals of treatment of airway hemangiomas are to provide an adequate space to breathe during the growth period, to avoid life-threatening blockage of the airway, and to minimize therapies that may result in long-term complications.

Management of airway hemangiomas can be challenging. Multiple methods both medical and surgical have been used, but many have significant risks and complications. Today, airway hemangiomas are treated medically with propranolol. Propranolol has some potential risks including slowing the heart rate, lowering the blood pressure, and lowering the blood sugar, as well as potentially creating worse breathing problems in children with asthma. Children on this therapy must be monitored closely. Other medical therapies can include steroids, taken by mouth, given intravenously and/or injected into the lesion. Many surgical approaches have also been tried, especially in cases that have not responded to medical therapies. These include endoscopic laser removal of the hemangioma, open surgical excision and tracheotomy (making a hole in the airway through the neck to bypass the blockage). For more information go to the Birthmarks and Vascular Anomalies Center website.

Reasons to seek medical help:

  • If your child develops a barky cough or noise with breathing
  • If your child looks like he/she is having difficulty breathing
  • If your child’s neck or chest retracts when he/she breathes
  • If your child stops breathing or turns blue

Obstructive Sleep Apnea


Sleep apnea is a disorder in which a child's breathing stops during sleep due to a complete or partial obstruction of the airway. The word “apnea” means a pause in breathing. These interruptions may occur hundreds of times a night, causing your child to gasp for air and disrupting sleep. The condition occurs in an estimated 1 to 3% of children. Children between the ages of two to six years old are most commonly affected, though it can also be seen in infants and adolescents.


The most common cause of sleep apnea in children is obstruction (blockage) of the airway by enlarged tonsils and adenoids. However, some children with enlarged tonsils will not have any symptoms, whereas others with small tonsils will have severe sleep apnea. Other areas of the head and neck such as the nose, tongue or larynx (voice box) can also be obstructed leading to apnea. Children with other disorders, such as craniofacial anomalies, cerebral palsy, muscular dystrophy and Down syndrome are at an increased risk for obstructive sleep apnea. In addition, overweight and obese children are at increased risk. Another form of sleep apnea called central apnea is the result of neurologic problems that do not allow the brain to communicate a signal to the body to breathe. Central sleep apnea is rare.


When a child's breathing is obstructed during sleep, the body is affected in many ways. For instance, when breathing stops, the oxygen in the blood lowers and signals the brain to wake up in order to breathe again. This causes children to go in and out of deep sleep many times through the night. The most common symptom of obstructive sleep apnea that parents notice is snoring. Other symptoms can include gasping, restless sleep, mouth-breathing, difficulty getting up in the morning, and daytime tiredness. Repeated interruptions to sleep and sleep apnea can cause your child to be cranky and misbehaved. Children with obstructive sleep apnea have a higher likelihood of being diagnosed with attention deficit/hyperactivity disorder (ADHD), learning disabilities, or other behavior disorders. Many children with sleep apnea can have trouble performing to the best of their ability in school. Wetting the bed can also be a sign of this sleep disorder. In severe cases, a child’s ability to grow can be affected and heart and lung complications can occur.


Diagnosis of obstructive sleep apnea is most commonly made by the history (see Symptoms) and a thorough physical exam. The size of the tonsils is easily measured, however, the adenoids can only be seen with a special scope passed through the nose or by an x-ray. If the parents’ description of symptoms is clear and the examination is consistent (example: the tonsils are very large), then treatment can be performed. If there is any uncertainty about the diagnosis and treatment plan, then a sleep study can be performed. A sleep study requires your child to sleep overnight in the hospital (parents may stay with their child) so that careful observations of breathing, oxygen levels, heart rate and brain activity are performed. Some children may also require a special test called a sleep endoscopy, in which your child is put into a sleep-like state and a special scope is passed into the nose and throat in order to identify the area of obstruction. Most children with sleep apnea can be diagnosed by the history and exam alone.


The UCSF Pediatric Otolaryngologists are leaders in cutting-edge treatments for children with complex problems leading to sleep apnea. Your child will receive a tailored approach to the treatment of their sleep apnea that customizes the surgery to achieve the highest chance of cure.

Most children can be cured of obstructive sleep apnea by removal of the tonsils and adenoids. In some children, only the adenoids or only the tonsils need to be removed. A small proportion of children will continue to have obstructive sleep apnea after removal of the tonsils and adenoids and may require other procedures. Children with craniofacial syndromes, cerebral palsy, muscular dystrophy, and Down Syndrome are more likely to require further medical and/or surgical interventions beyond tonsillectomy and adenoidectomy. Other surgical procedures performed at UCSF include inferior turbinate ablation, lingual tonsillectomy and supraglottoplasty.

Some children cannot be helped by surgery alone. These children may require oxygen or may wear a special mask called CPAP or BiPAP, which will help them breathe at night. If needed, we would work closely with our pediatric pulmonary colleagues at UCSF to help your child obtain a CPAP or BiPAP machine.

Reasons to seek medical help:

  • Your child is snoring with frequent pauses or gasping episodes
  • Your child is snoring with daytime symptoms such as fatigue or behavioral problems
  • Your child is snoring and has another medical problem such as Down Syndrome, craniofacial anomalies, cerebral palsy, muscular dystrophy

Swallowing Disorders


Some children have difficulty eating and swallowing. This may be related to an aversion to specific textures or to choking on certain foods or liquids. Feeding and swallowing conditions seen but not limited to:

  • Feeding difficulty
  • Choking or coughing on foods or liquids
  • Aspiration


Depending on your child’s specific needs, various tools are available to evaluate the swallowing concern. The assessment may include a formal evaluation by a speech therapist where auditory-perceptual voice and resonance is studied. A pediatric otolaryngologist may perform a bedside evaluation of the upper airway by placing a small flexible camera into the nose while your child is awake (flexible laryngoscopy, nasopharyngoscopy) to look for anatomic causes. A strobe light can also be used to further evaluate the motion of the vocal cords (videostroboscopy). The flexible scope can also be used to watch how your child swallows difference consistencies of food in a study called a flexible endoscopic evaluation of swallowing (FEES). If further swallowing evaluation is required a modified barium swallow study (MBSS) may be completed by our speech pathologist where video x-rays are taken while your child swallows different food consistencies.

For medically complex children with additional sub-specialty needs, the multidisciplinary Pediatric Aerodigestive Clinic is available including concurrent specialty care from pediatric otolaryngology, speech-language pathology, pediatric gastroenterology and pulmonology.


We offer a comprehensive array of medical, surgical, and behavioral therapy interventions for swallowing disorders identified upon diagnostic evaluation. Surgical treatments include but are not limited to:

  • Microdirect laryngoscopy/bronchoscopy
  • Medialization laryngoplasty/vocal cord injection
  • Surgery for velopharyngeal insufficiency, including palatoplasty and sphincter pharyngoplasty
  • Laryngotracheal reconstruction

Reasons to seek medical help:

  • Your child frequently chokes with feeds
  • Your child has frequent pneumonias
  • Your child has an aversion to food
  • Your child is not gaining weight

Tongue Tie


Tongue-tie or ankyloglossia is a condition that children are born with in which the tongue is tethered to the floor of mouth. All people have a frenulum that connects the undersurface of the tongue to the floor of mouth, however some have a shorter or tighter frenulum, which prevents the tongue from moving easily and fully.


The cause of tongue-tie is not entirely known. It occurs when the developing frenulum does not become as long or thin as it normally should. Genetics play a role, as tongue-tie can often run in families.


Feeding: Newborns with tongue-tie have difficulty with sucking. This is especially true when they are breastfeeding. Mothers may experience significant and prolonged pain, compression of the nipple after feeding, clicking sounds with nursing, difficulties with obtaining a good latch, and problems with establishing an adequate milk supply. Infants may demonstrate difficulty with projection of the tongue beyond the gums, inability to touch the roof of the mouth, difficulty moving the tongue side to side, or the tongue may appear grooved at the tip or heart-shaped. Infants may have poor weight gain due to poor feeding. Tongue-tie is often overlooked as a cause of breastfeeding difficulty and lack of treatment may lead to premature abandoning of breastfeeding.

Speech: Most children are able to compensate well with a tongue-tie and develop normal speech. However, some may have difficulty with pronouncing certain sounds that require the tongue to touch the top teeth or the roof of the mouth. Common consonants that can be problematic are l, r, t, d, n, th, sh, and z. Many children under 3 have troubles with these consonants. Once children are 3, evaluation may be needed if 50% of their speech is not understood outside of the family circle. Children who successfully breastfeed with a tongue-tie are unlikely to have speech problems. However, because bottle-feeding is much easier than breastfeeding, successful bottle-feeding with tongue-tie cannot predict whether speech issues will occur. While tongue-tie can affect how intelligible speech is, it never leads to delays in developing speech. All children with speech delay should undergo a full evaluation by their pediatrician as well as a hearing test.

Appearance: Older children, teenagers and adults may find it socially awkward to have a tongue-tie.


Tongue-tie surgery is a simple procedure and the risk of complications is very small. The benefits to breastfeeding and speech can be significant.

Infants: Children less than 6 months of age can have tongue-tie treated with a simple 30 second procedure. There is no need for anesthesia; the tongue is simply pulled back and the tie is cut with scissors. There are few nerve fibers in this area and the pain is less than or equal to a vaccination shot.

Children: Most children older than 6 months require a short period of general anesthesia, as they cannot be safely held still for the procedure while awake. In addition the tongue-tie is thicker at this point and may require sutures to be placed after the clipping is done. Some older children and adults may tolerate this procedure with local anesthetic.

Reasons to seek medical help:

  • Prolonged pain with breastfeeding
  • Prolonged difficulty with latching while breastfeeding
  • Tongue-tie with problems with speech pronunciation in children who are 3 or older

Velopharyngeal Insufficiency


Velopharyngeal Insufficiency (VPI) is due to an incomplete closure of the soft palate to the back of the throat, resulting in air escape through the nose when speaking.


VPI is often found in children with cleft palate, even after the palate is repaired. Some children with VPI have a submucous cleft palate where the palate looks intact but the muscle is weak. Other causes include overall muscle weakness (hypotonia) or an unexpected complication after an adenoidectomy (removal of the adenoids). Sometimes the cause is not known.

Symptoms: A child with VPI has nasal speech. Particular consonants such as “p,” “b,” “t,” and “g” sound muffled as air escapes through the nose. Vowel sounds may sound more nasal. Speech misarticulations can also occur to compensate for the incomplete closure of the palate. A child with VPI may frequently have thin liquids such as water or milk come out their nose with swallowing.


At UCSF, our team of pediatric otolaryngologists works along side with speech language pathologists to diagnose speech-language disorders including VPI. With both providers present, a flexible scope is placed through the nose to closely examine the palate’s motion with speech. Treatment options are determined with this evaluation. It is important to diagnose VPI early to prevent long-term speech issues.


VPI is treated surgically by an otolaryngolgist or a plastic surgeon. The type of surgery would be determined after evaluation with the speech pathologist. Some children also need speech therapy following surgery.

Reasons to seek medical help:

  • Your child had a cleft palate repair and the voice sounds nasal
  • Your child’s does not have a cleft palate but you are concerned your child’s voice sounds nasal
  • Your child had an adenoidectomy and the voice sounds nasal
  • Your child frequently has thin liquids come out of the nose with swallowing

Voice Disorders


Changes in voice quality can present in various forms. Voice conditions seen, but not limited to:

  • Benign vocal fold lesions including nodules, polyps and cysts
  • Vocal fold paresis/paralysis
  • Paradoxical vocal fold motion and chronic or habit cough
  • Evaluation and therapy for the singing voice


The voice may sound hoarse, course, breathy, raspy, high pitched or low pitched. It may get weaker as the day progresses. Voice changes can also manifest as a ‘nasal’ sound with sound and air leaking through the nose.


Depending on your child’s specific needs, various tools are available to evaluate the voice concern. The assessment may include a formal evaluation by a speech therapist where auditory-perceptual voice and resonance is studied. A pediatric otolaryngologist may perform a bedside evaluation of the upper airway including the larynx (voice box) by placing a small flexible camera into the nose while your child is awake (flexible laryngoscopy, nasopharyngoscopy) to look for anatomic causes. A strobe light can also be used to further evaluate the motion of the vocal cords (videostroboscopy).


We offer a comprehensive array of medical, surgical, and behavioral therapy interventions for voice disorders identified upon diagnostic evaluation. Surgical treatments include but are not limited to:

  • Microdirect laryngoscopy/bronchoscopy
  • Microphonosurgery with or without the laser
  • Medialization laryngoplasty/vocal cord injection
  • Surgery for velopharyngeal insufficiency, including palatoplasty and sphincter pharyngoplasty

Ear: Hearing, Ear Infections, and Ear Malformations

Ear Infections


Acute otitis media (AOM) is characterized by infection and inflammation of the middle ear space (the space behind the eardrum). This is most commonly caused by a virus or a bacteria.

Chronic otitis media with effusion (COME) is characterized by fluid in the middle ear space in the absence of signs and symptoms of acute inflammation, lasting for at least 3 months. The effusion may be thin (serous) or thick (mucoid), but usually not frankly purulent (containing bacteria). The effusion may be related to an earlier episode of AOM or may have developed spontaneously.


Ear infections and/or fluid behind the ear drum (the middle ear) occur in almost all children and are the most common reason for physician office visits in preschool-aged children in the United States. Some children are particularly susceptible to ear infections because of genetic, environmental or lifestyle factors, such as attending day care, secondhand tobacco smoke, or taking a bottle to bed. Less common conditions that may predispose children to eustachian tube dysfunction and subsequent recurrent AOM or COME include Down syndrome, cleft palate, or gastroesophageal reflux disease (GERD). Children with environmental or food allergies are more susceptible and there does appear to be a protective effect from exclusive breast-feeding for the first 6 months of life.


Acute otitis media (AOM) is generally characterized by the rapid onset of signs and symptoms of infection of the middle ear (fever, ear pain, pulling at ears, irritability) frequently in the setting of a cold. Sometimes children may have rupture of their ear drum during an ear infection. This causes fluid to drain out of the ear canal. Pain often goes away if this happens because there is no longer the build up of pressure behind the ear drum.

If a child suffers from chronic middle ear fluid, he or she may not hear well (say “what” a lot or ask for the volume of the tv or radio to be turned up), may develop speech problems, or may be more clumsy than his or her peers (fluid in the middle ear can affect balance).


For AOM, looking at the ear drum (otoscopy) usually reveals an opaque or red ear drum that does not freely move with insufflation (blowing air into the ear canal). There is usually a purulent (containing bacteria) middle ear effusion present. Although it is very uncommon for an ear infection to result in permanent hearing loss, recurrent AOM or COME may affect speech, hearing, balance, sleep and behavior.

A vaccine was introduced in the United States in 2000 against one of the most common bacteria to cause AOM, Streptococcus pneumoniae. Rates of meningitis (infection of the lining of the brain), a serious complication of infection by this bacteria, and which was the most common cause of acquired deafness, have dramatically reduced since widespread use of the vaccine. Rates of AOM due to this same bacteria have also decreased.

One of the tests that may be recommended for a child with COME is an audiogram or hearing test. This test is conducted by an audiologist or hearing specialist in a sound booth with headphones. The audiologist will be able to determine the level in decibels at which speech can be heard for each ear. Tympanograms are also performed. This test uses air to assess ear drum movement. If the ear drum does not move, this can be a sign that fluid is present. If the audiogram demonstrates a significant hearing loss due to fluid in the middle ear, and this is felt to be affecting a child’s speech and language development, further evaluation by an otolaryngologist (ear, nose, and throat specialist) may be recommended. This type of hearing loss is generally characterized as a “conductive” hearing loss to distinguish it from a nerve hearing loss. Conductive hearing losses due to middle ear fluid are generally correctable (by removing the fluid), whereas nerve hearing losses are often permanent and may require hearing aids for treatment.


Antibiotics have generally been recommended for treatment of acute otitis media. Newer data suggests that children older than 2 years of age with mild symptoms may be initially observed without treatment and that a high percentage of these patients will have spontaneous resolution. First line treatment for acute otitis media in patients younger than 2 years of age or those with significant symptoms (ear pain, fever ≥39◦) includes antibiotics. These are generally prescribed for 7-10 days. If symptoms persist after several days of antibiotics, sometimes another antibiotic is needed.

Antihistamines and steroids have not been shown to be effective in treatment of acute or chronic otitis media and can have significant side-effects in children. Prophylactic antibiotics are sometimes recommended for patients with recurrent AOM. This means a low dose of antibiotics is given every day during peak upper respiratory infection (URI)-season to try to prevent bacterial infection. This treatment is not felt to be effective for COME where fluid is already present in the middle ear space.

There is some data to suggest that complimentary and alternative medicine (CAM) may be successful in some cases of acute otitis media such as osteopathic manipulation but more studies are needed to better assess the outcomes. If a child has been prescribed multiple courses of antibiotics for ear infections or there are concerns of possible hearing loss and language delay due to fluid build-up behind the ear drum, a child’s pediatrician may recommend evaluation by an otolaryngologist.

Ear Tubes

Ear tubes are one treatment which may be recommended for recurrent AOM or COME. Ear tubes are surgically inserted into the ear drum and can reduce a child’s risk for future ear infections and their associated problems. Ear tubes are small tubes made out of plastic, metal or Teflon that are placed through the eardrum to allow air into the middle ear. The middle ear is the part of the ear located between the eardrum and hard bone surrounding the inner ear. The tubes are temporary and can last from 6 months to several years, depending on what type of tube is used. During the procedure, any fluid behind the child’s ear drum is immediately drained, but the tubes also allow for continual drainage of fluid that is produced. This prevents future build-up of fluid behind the ear drum while the tube is in place, thereby reducing the chance of developing persistent ear infections or having hearing loss and language delay from chronic fluid build-up behind the ear drum. Another advantage of ear tubes is that if a child does develop an ear infection with ear tubes, often antibiotic ear drops can be used as first-line treatment without having to resort to antibiotics by mouth. The ear drops can get directly to the infection without having to circulate through the body like oral (by mouth) antibiotics would.

Ear tube insertion, is a simple and safe procedure, lasting about 30 minutes. In most cases, the total time spent in the hospital is a few hours. Before the procedure begins, a child will be given a general anesthetic. During the procedure, a small incision is made in the eardrum under a surgical microscope with a small knife. After the hole is made, the fluid behind the eardrum is removed and the ear tube is then placed in the hole. Antibiotic eardrops may be administered after the ear tube is placed and may be necessary for a few days. After surgery, the child will be taken to the recovery room where he or she will be closely monitored. Most children are able to go home within an hour or so. Although pain after the operation is minimal, a child may experience effects of the anesthesia, such as grogginess, irritability, and/or upset stomach. Also, because hearing loss caused by the presence of middle ear fluid is often resolved by surgery, some children complain that normal sounds seem too loud. Children are usually able to equilibrate within a few days.

Most tubes extrude (are expelled) on their own, leaving a healed ear drum. Occasionally, the tube will cause a small amount of scar tissue on the ear drum but this generally does not have any permanent effect on a child’s hearing. In some instances, such as when more than one tube insertion is necessary, the ear, nose, and throat doctor will recommend removal of a child's adenoid tissue, located in the upper airway behind the nose, at the same time that the ear tubes are placed. Adenoid tissue is part of the immune system but may also be a reservoir of bacteria that spreads to the middle ear through the eustachian tube (the tube that connects the ears to the nose). Adenoids are not necessary, and patients aren’t any more susceptible to infections if adenoids are surgically removed. Research has shown that removing adenoid tissue at the same time as inserting a second set of ear tubes can reduce the risk of recurrent ear infections and the need for repeat surgery.

Although the insertion of ear tubes is an extremely common and safe procedure with minimal complications, as with any surgery, complications may occur. Otorrhea or drainage from the ear canals can occur in up to 25% of patients. Antibiotic ear drops are often prescribed after surgery to treat this complication. A granuloma or scar tissue can build up and cause blockage of the tube. This can generally be treated with an ear drop that has a steroid in it. Steroids help treat inflammation. The ear tubes may come out of the eardrum sooner than anticipated (within several months). This may cause fluid in the middle ear to return and another surgery will be necessary. Ear tubes may stay in the eardrum for too long. In these instances, generally 2-3 years after the initial surgery, a separate trip to the operating room may be necessary to remove the ear tube and patch the ear drum. This happens less than 5% of the time with the more common types of tubes used, and up to three times as often with long-acting tubes which are more commonly used in children with other risk factors predisposing them to prolonged eustachian tube dysfunction. Some doctors also recommend covering the ears to avoid water exposure after ear tubes are placed. This can include cotton balls during bath time or ear plugs for swimming although studies have also shown that the risk of developing an ear infection with water exposure from baths or chlorinated pools is quite low.

Overall trends for treatment of both AOM and COME have been to try to avoid antibiotics in otherwise healthy children age 2 years and older, without other risks factors for eustachian tube dysfunction, who have only mild symptoms due to the high spontaneous resolution rates. Recent studies with long-term follow-up have not identified any significant permanent impact on speech or language development of children whether they were treated with early or delayed (greater than 9 months after initial diagnosis) placement of ear tubes. This should be reassuring news to parents.

Reasons to Seek Medical Help:

  • If your child requires antibiotics for ear infections at least 3 times in 6 months or 4 times in a year
  • If your child has ear drainage associate with an ear infection more than once
  • If your child does not appear to be hearing well
  • If your child develops speech delay

Figure 1: Acute otitis media with a bulging ear drum and pus in the middle ear

Figure 2: Chronic otitis media demonstrating thick “glue-like” fluid behind the ear drum

Figure 3: Ear tube in ear drum

Figure 4: Normal ear drum.

Hearing Loss


Hearing impairment or hearing loss is any level of decreased ability to hear sound or speech. Deafness is typically thought of as a total loss of hearing. Hearing loss is a common pediatric problem. The incidence of permanent childhood hearing loss identified at birth is 1 to 3 per 1000 newborns. The prevalence of hearing loss in older children and adolescents is as high as 3%.

Signs and Symptoms

Hearing loss is often not recognized in infants and small children. Currently almost all newborns are now routinely screened for hearing loss when they are born. However, not all hearing loss is present at birth. If children respond to or get startled by loud noises, this does not mean that they have normal hearing. The family and pediatrician should ask for a hearing test in infants and young children who are not developing normal vocalizations and responses to their environment or who have delays in speech and language development.

Preschoolers and older children are somewhat easier to assess for symptoms of hearing loss, but hearing loss can still be missed. Often not hearing can be interpreted as ignoring or not listening. Delay in speech is an important sign to look for and should always result in evaluation of hearing. Children should be observed for the following symptoms of possible hearing loss:

  • Turning up the volume of the radio or television
  • Responding inappropriately to questions
  • Having difficulty understanding what people are saying
  • Not replying when called
  • Problems with articulation or difficulty for others to understand his/her speech
  • Speech/language delays
  • Decline in previous language skills
  • Ear pain/aches or head noise complaints
  • School performance problems
  • Behavioral problems

Some children are at high risk for hearing loss. Risk factors are:

  • Admission to the neonatal intensive care unit (NICU) for
  • or more days after birth
  • Family history of hearing loss
  • Craniofacial abnormalities, especially abnormal looking ears
  • Infections during the pregnancy
  • Treatment with drugs that can cause hearing loss (ototoxic medications)
  • Diagnosis with a syndrome associated with hearing loss

Diagnosis and Treatment

No child, not even a newborn, is too young to have a hearing evaluation. Hearing loss is diagnosed by several different tests, depending on the age of your child. Newborns and young infants are tested with auditory brainstem-evoked response testing and otoacoustic emissions. These tests do not require the child to actively respond to sound and are actually best done when the child is asleep. Children as young as 6 months can be tested for their behavioral responses to sound through behavioral observation audiology or visual reinforcement audiology . All children who fail newborn hearing screening should have diagnostic hearing testing performed by 3 months of age. Children with hearing loss should be fitted with hearing aids by the time they are 6 months old.



Cholesteatoma is an abnormal growth of skin on the inside of ear. It is not a tumor, and does not spread to other parts of the body, but can continue to grow on the inside of the ear and erode into bones of the ear and cause temporary or permanent hearing loss, facial weakness, and chronic infections. Congenital cholesteatoma is a small piece of skin trapped in the inside of the ear from birth that slowly grows into a cyst. Acquired cholesteatoma usually results from many years of problems with ear infections, weakness of the eardrum, or Eustachian tube dysfunction, and results when part of the eardrum grows into the middle ear space on the inside of the ear.

Signs and Symptoms

Cholesteatoma often does not have specific symptoms. Children with cholesteatoma often have a history of multiple ear infections, and can have hearing loss, mild ear discomfort, and/or frequent drainage from the ear. Certain children, especially those with cleft palate, craniofacial abnormalities including microtia and atresia, Downs syndrome, or prolonged history of Eustachian tube dysfunction or multiple ear tubes in the past, are at higher risk of developing cholesteatoma.


There are two major goals for treatment of cholesteatoma:

  1. Complete removal of all skin from the inside of the ear where skin is not supposed to be, and to reconstruct the eardrum so that it is intact, with the skin facing out into the ear canal. Sometimes complete removal of the cholesteatoma requires removal of bones inside the ear, that can cause a temporary hearing loss.
  2. Restoration of hearing loss that may have been caused by the cholesteatoma, or by the surgery itself, by rebuilding the chain of bones of hearing on the inside of the ear and connecting that to the new eardrum.

These goals are accomplished with a surgery called a tympanomastoidectomy, where the inside of the ear is worked on under a microscope. This surgery can be long due to the delicate nature of the operation, but is typically a same-day procedure with a rapid recovery time.

Cochlear Implants

Most of the time, sensorineural hearing loss is not treated surgically. Most treatments are focused on helping your child make the best use of the hearing that he/she has in order to develop communication, speech, and language skills to the best of his/her ability. In some situations, however, a surgical treatment can help improve your child's access to sound.

What is this?

A cochlear implant is an implantable device that directly stimulates the auditory nerve going to the brain. There are three parts to the system - an electrode, which is inserted into the cochlear; a receiver/stimulator, which is implanted underneath the skin above and behind the ear, which is attached to a drives the electrode; and the processor, which sits on top of the skin and behind the ear, and contains a microphone and attaches to the receiver/stimulator via a magnet.

Who can get this?

Children over the age of 1 with bilateral moderate-profound sensorineural hearing loss who do not receive adequate benefit from hearing aids. Special considerations are made in other situations, including asymmetric hearing loss, single-sided deafness, high-frequency hearing loss, and young age. In order to receive a cochlear implant, children are evaluated by a multidisciplinary team, including an otolaryngologist, audiology, speech-language pathologist, and psychologist, to ensure that the child, family, and educational support system are all adequate to support use of the implant.

How does this work?

A cochlear implant works by picking up sound through a microphone and converting that sound into electrical signals that stimulate the auditory nerve through an electrode inserted into the cochlea. While a cochlear implant does not restore normal hearing a deaf child with a cochlear implant may be able to develop essentially normal spoken language. This is highly dependent on many factors, however, and the cochlear implant team will counsel you on appropriate expectations with a cochlear implant.

What is the process like?

The first step is the evaluation process, which can take several months and involve multiple provider visits and tests. Here at UCSF, we have a multidisciplinary team that works together and meets weekly to discuss candidates. If a cochlear implant is recommended, surgery will be scheduled. Surgery itself takes about 2-3 hours under general anesthesia. An incision behind the ear is made, bone is removed to provide a path to the inside of the ear, and the implant is placed. Usually your child can go home the same day. About 2-4 weeks after surgery, the cochlear implant will be turned on. Over the next months to years, your child will learn how to use the implant, which is a process involving your child, family, audiologist, teachers, and speech therapists.

What are the risks and benefits of this surgery?

The primary benefit is to have a long-term solution to provide access to sound and support spoken language development. Risks include weakness of the facial muscles, leakage of cerebrospinal fluid, meningitis, need for implant removal or replacement, or skin breakdown and infection.

For more information
UCSF CI website: NIH/NIDCD website with thorough discussion of cochlear implants as well as other hearing-related topics.

Bone-Anchored Hearing Aids

What is this?

A metal implant that is surgically placed in the bone above and behind the ear that allows sound to be transmitted through the bone to a functional inner ear. There are different manufacturers of this kind of device, including the Cochlear Baha, Oticon Ponto, and Sophono.

Who can get this?

Children with single-sided deafness or microtia/atresia, who use bone-conduction hearing to restore access to sound on the side that is deaf or has microtia/atresia. Prior to age 5, these bone-conduction hearing aids are worn on a softband. After age 5, there is an option to surgically implant part of the bone-conduction hearing aid. Exact timing of the surgery takes into account the timing of external ear (microtia) reconstruction and other factors, and should be discussed with your surgeon.

How does this work?

Bone-conduction hearing aids work by transmitting sound in the air directly to the bone. The sound can then go do two things: 1) in microtia/atresia, the sound goes through the bone to the functional inner ear on the same side; 2) in single-sided deafness, the sound goes through the bone to the functional inner ear on the opposite side.

What is the process like?

In this surgery, a metal implant is placed into the skull bone so it can integrate with the bone. To the implant, we then either attach a magnet, which is completely covered in skin, or a post ("abutment") which goes through the skin. The external bone-conduction hearing aid then attaches via the magnet or post to stimulate the implant. This is a simple, same-day surgery that takes about 60 minutes under general anesthesia.

What are the risks and benefits of this surgery?

The primary benefit is to have a long-term solution to provide access to sound from the affected side without need for the softband. Risks include infection or skin problems around the site of the abutment or magnet that might require medical or surgical treatment, or removal of the abutment or implant.

Microtia, Ear Splinting, and Otoplasty (Ear Pinning)

What is microtia?

Microtia means "small ear," referring to the outer, visible ear. It can range from an ear that is slightly small but mostly normal-appearing, to a completely absent outer ear. Microtia is often seen in combination with aural atresia, a complete or partial absence of the ear canal. This is usually noticed at birth and can come as a surprise to parents. Occasionally it is associated with other craniofacial abnormalities and syndromes, but most of the time it is seen in isolation, or in combination with a relatively subtle craniofacial condition called hemifacial microsomia. Sometimes it can go with kidney abnormalities, so all children born with microtia will usually have an ultrasound of their kidneys to ensure that they are normal.

How is microtia treated?

There are four primary means of management of microtia. The first is to do nothing. Many children are perfectly comfortable with the appearance of their microtic ear. The second is to create a prosthetic ear that attaches by way of an implant screw. The third is to implant an artificial template that serves as internal structure for skin grafts and flaps to create an artificial ear. The last is to use the child's own cartilage and scult it into a template to serve as internal structure for a reconstructed ear.

Is there anything that can be done earlier?

For some minor abnormalities of the shape of the outer ear that are noted right after birth, it may be possible to mold the soft cartilage into a more typical shape. It is very important to start this process as soon as possible, but no later than 2 weeks after birth. After this point, the cartilage is too soft to mold. Most times, we can mold the ears using simple tape and cotton rolls or soft plastic tubing. The tape and mold stays in place for 4-6 weeks, at which point further taping is not usually beneficial.

What can be done later in life for ears that stick out or are mildly malformed?

Later in childhood, starting around 5-6 years of age, children can undergo a procedure called otoplasty, in which the appearance of the ear is surgically changed. In the most simple of these procedures, ears that stick out are corrected by placing stitches under the skin on the back side of the ear to reduce their prominence.

What is the process of outer ear reconstruction?

Reconstruction of the outer ear can typically be done starting around age 6-7. It is done in two stages. The first stage takes about 6 hours under general anesthesia. Parts of the rib cartilages are taken and carved into a template, which is implanted under the skin where the ear should be. The parts of the ear that are present are either removed or rearranged into the new ear. This surgery typically requires an inpatient hospitalization of 2-3 days. The second stage is a 2-3-hour outpatient surgery 6-9 months later, where a skin graft is taken from the groin and the ear is elevated from the side of the head. Sometimes, a third surgery is performed to touch up areas; this surgery can often be combined with the reconstruction of the ear canal if there is aural atresia.

For more information:

Visit the Ear Community: Online forum for families of deaf/HOH children in general, with a particular focus on microtia and atresia.

Aural Atresia

What is this?

Aural atresia refers to partial or complete absence of the ear canal and ear drum. Because of this, sound cannot pass normally from the outside world to the inner ear, which is what actually turns sounds into signals that are sent to your brain. Aural atresia thus results typically in a moderate-to-severe conductive hearing loss. Not being able to hear from one side makes it harder to localize sound and to hear in noisy situations, and puts children at risk for speech, language, and educational delay.

How is this treated?

The goal of treatment for aural atresia is to provide sound input to the affected side. This can be accomplished in three ways - 1) with a bone-conduction hearing aid (BAHA) worn on a soft headband (softband BAHA) that picks up sound on the affected side and conducts it directly to the inner ear on that side; 2) with a BAHA processor that attaches to a surgically-placed implant in the skull above the ear; and 3) surgical reconstruction of the ear canal, eardrum, and connection from the eardrum to the inner ear (atresiaplasty).

Who can use a softband BAHA?

Almost any infant or child can use a softband BAHA.

Who can undergo surgical BAHA placement?

Surgical BAHA placement is FDA-approved for children 5 years of age and older.

Who can get an atresiaplasty?

Select children with microtia/atresia who have middle- and inner-ear anatomy that is amenable to surgical reconstruction of the ear canal, eardrum, and middle-ear bones. A CT scan is necessary to determine whether ear canal reconstruction is possible. Timing of the surgery is complex: it is most effective when children are at least 6-7 years of age and can tolerate frequent ear cleanings in the office. Coordination of the ear canal reconstruction with different methods of reconstruction of the outer ear (microtia) is also important, and must be discussed with your surgeon.

How does this work?

By creating an ear canal and eardrum, the goal is to restore the sound connection and transmission from the outside world to the inner ear. Sound can then travel through the new ear canal, be picked up by the new eardrum, and transmitted through the little bones in the middle ear to the cochlea.

What is the process like?

In this surgery, incisions are made around the ear, bone is removed to create the new ear canal and establish a pathway to the middle and inner ear. Skin from the groin is then used to line the new ear canal and create an eardrum. Sometimes, a tiny metal implant is used to reconstruct the bones of the middle ear. This usually takes about 5-6 hours under general anesthesia, and your child will usually be able to go home the same day.

What are the risks and benefits of this surgery?

The primary benefit is to improve hearing on the atretic side by re-establishing a pathway for sound conduction. There is a small risk of weakness of the muscles of facial movement, and of permanent sensorineural hearing loss. The most common challenges after surgery are the ear canal closing up again, or there being a residual conductive hearing loss. Because of these, there is a high chance of need for further surgery after the initial surgery, to either help the ear canal stay open, or to fine-tune the hearing result. Even in the best of circumstances, the hearing will never be perfect. In some cases, your child would still benefit from a hearing aid on the atretic side even after ear canal reconstruction. Rather than requiring a bone-anchored hearing aid, however, children with some residual conductive hearing loss after ear canal reconstruction can often use a traditional air-conduction hearing aid as long as they have had some kind of outer ear reconstruction.

For more information:

Visit the Ear Community: Online forum for families of deaf/HOH children in general, with a particular focus on microtia and atresia.

Sinus, Nose, and Skull Base

Skull Base

The skull base is an important anatomical area that is forms the ceiling of our nasal cavity and deep soft tissues and bone of the head. Many important structures pass through this area, and conditions of this region can be life threatening or debilitating if left untreated. Given that many benign and malignant tumors of the skull base can be accessed through the nose using a camera, the expertise of a Pediatric ENT Sinus Surgeon is usually necessary.

Signs and Symptoms

  • Persistent headache
  • Nasal obstruction
  • Facial pain or swelling
  • Double vision or changes in light perception
  • Frequent and persistent nosebleeds, or clear nasal discharge
  • Change in eye position or facial appearance
  • Lactation in absence of pregnancy
  • Precocious or early puberty
  • Rapid growth of the skeletal system
  • Facial pain or swelling


Patient history and physical exam are very important in diagnosing disorders of the skull base. An in-office nasal endoscopy (camera in the nose) can be performed by one of our Pediatric Otolaryngologists to assess the nasal cavity. Abnormal hormone levels on blood tests can be useful in diagnosing this condition. CAT and MRI Scans are often imperative in assessing the deep structures of the skull base. These studies sometimes require sedation depending on the age of the child.


Tumors of the skull base are most often treated through surgery. These procedures may require a team approach between a Pediatric Otolaryngologist and a Neurosurgeon. We have a successful partnership with our Neurosurgical colleagues, and offer a highly-specialized multidisciplinary team approach. Treatment of these conditions may involve other team members, such as Pediatric Intensivists, Radiation & Medical Oncologists, Ophthalmologists, Neurologists Speech and Language Pathologists and an excellent support staff of nurses and Physician Assistants. Navigation using a preoperative CAT or MRI Scan is often used to assist the sinus surgeon during tumor removal. Patients with skull base disorders require close and frequent follow up care with several specialists.

Choanal Atresia


Choanal atresia is a narrowing or blockage of the back of the nose that is present at birth (congenital).


The cause of choanal atresia is not known. During development of the fetus, tissue that separates the nose, throat and mouth grows abnormally and leads to complete blockage of the back of the nose. This condition can be bilateral (both sides) or unilateral (both sides). Although it is rare, it is the most common abnormality of the nose in newborns. Choanal atresia is often associated with other birth defects and syndromes.


Newborns who have bilateral choanal atresia (both nasal passages are blocked) have extreme difficulty breathing and cyanosis (turning blue) when they are born and require a breathing tube until the choanal atresia can be surgically corrected. This is because newborns can only breathe through their nose, unless they are crying, until they are about 3 months old. Children with unilateral choanal atresia (only one nasal passage is blocked) often have a chronic runny nose from that nostril. As a result, this condition can go unnoticed and can be diagnosed later in childhood.


Choanal atresia is diagnosed by examining the nasal passages with an endoscopic camera by a Pediatric Otolaryngologists. Often, a doctor will try but be unable to pass a feeding or suction tube through one or both sides of the nose. In addition, a CT scan will help to identify the exact location and severity of the blockage.


Bilateral choanal atresia must be managed immediately after birth by placing a tube into the airway to allow for breathing. Surgery is then performed with telescopes in the nose and mouth to remove the blockage. The surgery is personalized to the patients particular blockage and anatomy. Drilling is sometimes used to thing and remove bone to widen the nasal passages. After surgery, the area is at risk for developing scar that can lead to re-blockage of the nose and infants need to be closely followed to insure that they have enough space to breathe. Some children require temporary stents in the back of the nose. Unilateral atresia usually does not require immediate treatment and infants can be allowed to grow for at least a year before repair is performed, as the larger the child is, the easier it is to open the blockage.

Reasons to seek medical help:

  • Chest retractions and extreme difficulty breathing after birth that is made better by crying
  • Cyanosis (turning blue), which often improves with crying
  • Inability to nurse or bottle-feed and breathe at the same time
  • Persistent one-sided nasal discharge or blockage


Sinusitis is an infection of the sinuses near the nose. The sinuses are air-filled pockets lined with mucous membranes located inside different parts of the face. Sinus infections usually occur after a cold or allergic inflammation. Young children have immature immune systems and their sinuses are not fully developed until the age of 20. Therefore, they are more susceptible to infections of the nose, sinuses and ears, especially in the first several years of life.

Signs and Symptoms

Children with sinusitis develop different symptoms than adults with the condition, including:

  • A "cold" lasting more than 10 days or getting much worse after 5 days
  • Stuffy or runny nose with thin or thick, clear or yellow-green nasal drainage
  • A cough that lasts a long time and is worse at night
  • Additional symptoms including low-grade fever, post-nasal drip, sore throat, bad breath,
  • low energy, a puffy face or eyes, facial or tooth pain
  • Headache, usually in children age six or older


Sinusitis is usually based on the symptoms described above. In general, it can be described as cold symptoms that do not get better or the child is much sicker than is typical with a usual cold. Usually, blood work and x-rays are not needed. If your child has had sinusitis for a long time and it has not responded to medical treatment, sometimes a computerized tomography scan (CT scan) is needed. However, most children do not require a CT scan.


Acute sinusitis (symptoms for less than 3 months)
Your child's treatment will depend on the severity and frequency of episodes of sinusitis. If your child is diagnosed with sinusitis, antibiotics may be given. Symptoms should improve within the first few days of taking an antibiotic. It is very important to take the entire course of the medication and not to stop taking it as soon as the symptoms have improved. Other ways to make your child more comfortable is to use nasal saline sprays or irrigations to help keep the nasal passages clear. Medicine may be given to reduce fever or help with your child’s comfort. Your child should also get plenty of rest and fluids. Your doctor may prescribe additional medicines if your child has allergies or other conditions that worsen the sinus infections. Cough medicine and decongestants are not usually recommended and can sometimes be harmful.

Your child should begin to improve in 24 to 72 hours, but some symptoms may persist for weeks. If your child does not improve at all after 72 hours, a new antibiotic may be necessary.

Chronic sinusitis (symptoms for more than 3 months)
If your child suffers from chronic sinusitis or repeated episodes of acute sinusitis four to six times per year, he or she should be evaluated by a pediatric ear, nose and throat specialist. The specialist will order blood tests and other special evaluations to help to determine if there are any causes for the sinusitis. They may recommend medical or surgical treatment of the sinuses. Smoke is very irritating, especially for children with sinusitis and care should be taken to avoid exposing children to cigarette smoke.

Surgery is only recommended for a small number of children with severe or persistent sinusitis whose condition does not respond to medical treatments. Some patients with Cystic Fibrosis are candidates for sinus surgery as well. During surgery, your child's pediatric ear, nose and throat specialist will use an instrument called an endoscope to open and widen the natural drainage pathways of your child's sinuses. By opening up the sinuses, air is able to circulate more freely, which usually reduces the number and severity of sinus infections. Any pus or inflammatory debris can be washed out or removed as well.

Your doctor also may suggest removing the adenoid tissue from behind the nose as part of the treatment for sinusitis. The adenoid tissue does not directly block the sinuses, but infection of the adenoid tissue or obstruction of the back of the nose can cause many of the symptoms that are similar to sinusitis, such as runny nose, stuffy nose, post-nasal drip, bad breath, cough and headache.

Reasons to call your doctor:

  • If your child has not improved or worsens within 72 hours of starting an antibiotic for sinusitis
  • If your child has redness or swelling around the eyes, especially if it is only on one side
  • If your child has a severe headache, high fever, seems very ill, or is very sleepy or hard to arouse


Adenoids is a normal pad of tissue located at the back of the nose. They are similar to the lymph nodes or "glands" found in the neck, groin and armpits. Adenoids work as part of the body's immune system by filtering germs that you breathe in through your nose. Adenoids can swell when you are sick. Large adenoids may also run in families. Enlarged adenoids can block the nasal passages and lead to mouth-breathing, sinusitis, or snoring. They can also block the eustachian tube, which is the drainage system for the ear, and lead to ear infections.

An adenoidectomy may be recommended if your child has had:

  • Chronic or recurrent sinusitis
  • Inability to breathe through the nose
  • Heavy snoring with disrupted sleep affecting daytime behavior
  • Recurrent or chronic ear infections


For at least two weeks before any surgery, your child should not take any aspirin or other medications containing blood-thinners. Acetominophen (Tylenol) can be given. Your child should refrain from eating or drinking anything (including) after Midnight the night before surgery. Anything in the stomach may be vomited when anesthesia is induced, which is dangerous and can cause pneumonia or other lung problems. You will receive a phone call confirming your child’s date of surgery and any further preoperative instructions. You may also receive a phone call or have an appointment before the surgery with a nurse who works in the anesthesia department to review what to expect from an anesthesia perspective and make sure your child does not have any medical conditions that may increase his or her risks of general anesthesia.


Adenoidectomies are usually performed as an outpatient procedure for healthy children without other medical conditions. This means that your child will be able to go home the day of the surgery. When you and your child arrive at the hospital or surgery center, the anesthesiologist or nursing staff will meet with you to review your child’s history. They will discuss with you the options for your child to go off to sleep. You will decide with the anesthesiologist whether it would be best to accompany your child to the operating room as he or she falls asleep or to give a medication to your child to drink to relax him or her before the surgery. The anesthesiologist will work with you to come up with a plan that will minimize anxiety and maximize safety for your child’s anesthesia experience. Your child will then be taken to the operating room and given a general anesthetic (laughing gas). A needle (intravenous catheter) for giving medications and fluids is put in after your child is asleep so he or she won’t feel it. The I.V. generally stays in until right before your child is discharged from the recovery room.

The surgery itself usually takes about half an hour, but your child may be in the operating room longer than that, as time is needed to put your child under anesthesia and to wake him/her up after the procedure. Today, there are many different technologies available for surgeons to use to remove the adenoids. The approach used for your child will depend on a number of factors and your surgeon's experience and preference.


Following surgery, your child will go to the recovery room. Some children wake up from general anesthesia disoriented. They do not remember what happened to them and may become upset. The recovery room nurses are very used to these reactions and will be able to determine if your child is in pain and needs more medication or needs to see a familiar face. Your child may feel sick to his/her stomach and medication can be given to help with this. It may take several hours for your child to completely wake-up and for the majority of the anesthesia to leave his or her system. Your child will be able to drink liquids and have popsicles once he/she is awake. Your child will usually be able to eat a normal diet by the day following surgery.

When you get home, it is important to encourage your child to drink a lot and get lots of rest. Most children are back to normal within 24 to 48 hours after surgery. Some children take a few days longer to recover. Snoring and mouth-breathing may continue for several weeks after surgery. In addition, your child may feel more congested or have nasal drainage. Bad breath is also common and is caused by scabs that form after surgery. All of these symptoms are usually gone in 7 to 10 days. Do not allow your child to blow his/her nose but you can dab frequently with a tissue. If your child has bleeding from the nose, you should contact your child’s surgeon.

Your child can exert him/herself whenever his/her energy level has returned. He/she may return to school when he/she feels up to it, usually within a few days.

Most children have mild or no pain after adenoidectomy. Some experience a sore throat, headache or ear pain that lasts a few days. Tylenol (acetaminophen) may be used for pain relief. It is also normal to have a low-grad fever (< 101.5F) for a few days following surgery. If a fever is above this level or your child experiences a very stiff neck, you should contact your child’s surgeon.

Head and Neck: Congenital Masses, Tumors, and Salivary Glands

Benign Head and Neck Masses

Benign tumors or cysts are non-cancerous growths which can occur in your child's head and neck region.

It is common for young children to develop infections of the ear, nose, or throat. Lymph nodes, collections of infection-fighting cells, in the neck can swell during acute infections and cause a bump in the neck. Most of these will go down once the infection resolves.

Other benign growths in the face and neck include areas of fluid collection, or cysts, such as branchial cleft cysts (on the side of the face or neck) or thyroglossal duct cysts (in the middle of the neck).

Growths of blood vessels can be seen in the face and neck, such as hemangiomas, venous malformations, or lymphatic malformations/cystic hygromas. Link to UCSF Vasc Anomalies Birthmark website


Growths and cysts in the head and neck can cause a variety of symptoms based on their location. A growth in the ear may cause trouble hearing. A growth in the nose may cause trouble breathing through that side of the nose or bleeding from the nose. A growth in the throat may cause breathing or swallowing difficulties if it grows large enough.


A complete head and neck physical exam is generally the first step in diagnosis. Sometimes other diagnostic studies may be indicated such as blood tests, needle biopsies, or imaging studies such as ultrasound or MRI to get more detail of the characteristics of the growth and its relationship to surrounding structures.


Treatment is based on the diagnosis and location of the growth. Some masses or cysts may be treated with just observation or with medication. Others will require surgical drainage or excision.

Reasons to seek medical help:

  • If your child has a growth of the face or neck that is increasing in size and/or causing pain
  • If your child has a growth of the face or neck that is causing other symptoms such as breathing or swallowing difficulties
  • If your child has a growth of the face and neck and also develops fever, chills, night sweats, weight loss, or anorexia (loss of appetite)


Fig 1: Atypical Mycobacteria of the neck

Fig 2: Branchial Cleft Cyst

Fig 3: Thyroglossal Duct Cyst

Fig 4: Lymphatic Malformation

Fig 5: Parotid hemangioma

Malignant Head and Neck Masses

There are different types of cancer that can develop in the head and neck region of children. Fortunately, survival rates for pediatric cancer are generally much better than those for adults.


Malignant tumors are cancerous growths that can occur in your child's head and neck region.


There are some genetic and environmental causes of pediatric cancer in the head and neck but often, there is no identifiable cause for why a child develops cancer in the head and neck.

Signs and Symptoms

Symptoms of head and neck cancer vary depending upon which type of tumor your child has. Many of these symptoms also can be caused by benign tumors so do not necessarily signify a malignancy. However, some symptoms may include:

  • A lump or growth in the neck that does not go away, which may be an enlarged lymph node
  • A lump, growth or sore in the mouth that does not heal or go away
  • Continuous or persistent heavy nosebleed
  • Night sweats and/or weight loss associated with a lump or growth
  • Rapid onset of snoring or sleep apnea


The first step towards diagnosis is a thorough physical examination of your child’s head and neck region. Other tests may also be recommended.

Biopsy - A biopsy, which involves the removal of a sample of tissue to see whether cancer cells are present, is necessary to confirm the diagnosis. There are several kinds of biopsies. Sometimes, a needle biopsy can be performed with local anesthesia. Other times, general anesthesia may be required for a more extensive tissue sample.

Imaging - Imaging may be necessary to better characterize the tumor and understand its relationship to surrounding structures. Different types of imaging studies have advantages and disadvantages. Ultrasound does not require sedation or anesthesia but may not provide the detail necessary for surgical planning. MRI provides the greatest amount of detail, but requires a child to have an IV and be still for up to an hour so generally requires sedation or anesthesia in young children.

The most common pediatric cancers found in the head and neck include rhabdomyosarcoma and lymphoma. More rare cancers may be found in the salivary glands or thyroid glands.


All pediatric patients with head and neck cancer cared for in the Division of Pediatric Otolaryngology at UCSF are presented at a multidisciplinary Tumor Board involving specialists from radiology, pathology, medical oncology, and radiation oncology where a comprehensive state-of-the-art treatment plan can be developed for your child.

Treatment for your child's head and neck cancer will depend on a variety of factors, including the type, location, size and stage of the tumor, as well as your child’s age and general health.

Reasons to seek medical help:

  • An enlarging mass in the head or neck
  • A mass with other symptoms of illness such as persistent fevers, night-sweats, or weight loss
  • A mass with associated increased trouble with swallowing or breathing

Thyroid Tumors

The thyroid gland is a gland that helps regulate other functions of the body such as heart rate and metabolism. It wraps around the windpipe in the front of the neck halfway between the chin and the collar bones. Tumors of the thyroid gland are rare in children with less than 2% occurring in children less than 15 years of age.

There are some genetic and environmental causes of pediatric thyroid tumors such as exposure to radiation, but often, there is no identifiable cause for why a child develops a thyroid tumor.

Signs and Symptoms

  • A lump or growth in the middle of the neck that does not go away
  • Hoarseness
  • Shortness of breath


The first step towards diagnosis is a thorough physical examination of your child’s head and neck region. Other tests may also be recommended.

Biopsy - A biopsy, which involves the removal of a sample of tissue to see whether cancer cells are present, is necessary to confirm the diagnosis. There are several kinds of biopsies. Sometimes, a needle biopsy can be performed. Other times, general anesthesia may be required for a more extensive biopsy.

Flexible fiberoptic laryngoscopy (FFL) – The nerve that controls the vocal cords which help us produce sounds run near the thyroid gland. Sometimes growths can cause pressure on the nerve and therefore affect the voice. FFL is a test where a small camera is placed in your child’s nose to be able to look at his or her vocal cords to see if they are moving correctly. It is important to do this prior to any surgery since surgery can sometimes cause the nerve to stop working temporarily or in rare cases, permanently.

Ultrasound – An ultrasound is a study that be done in an awake or moving child and help distinguish whether the thyroid growth is solid (full of cells) or cystic (full of fluid)

Magnetic Resonance Imaging (MRI) -- MRI is a non-invasive procedure that uses powerful magnets and radio waves to construct pictures of the body. These images can help show better detail of the mass and its relationship to the rest of the thyroid gland and other important structures in the neck.


Treatment for thyroid tumors depends on a variety of factors, including the type, location, size and stage of the tumor, as well as your child’s age and general health. Your pediatric ear, nose and throat specialist will work closely with you and your child, as well as doctors in other specialties if necessary, to develop the best and most effective treatment plan. The goal of treating head and neck tumors and growths is generally to completely remove the tumor with as little damage as possible to surrounding structures in the head and neck region. For some tumors, treatment involves radiation therapy, surgery, chemotherapy or a combination of approaches.

Salivary Gland Disease

There are three sets of glands in the head and neck region that secrete saliva, including those in the front of the ears, called the parotid glands; below the jaw, called the submandibular glands; and underneath the tongue, called the sublingual glands. These glands may swell due to infection or obstruction of the outflow of saliva.

Rarely, children may develop stones in their saliva ducts that cause obstruction, swelling, and sometimes infection. More commonly, children can develop recurrent swelling and infection in the parotid gland without an obvious cause. This is called idiopathic recurrent juvenile parotitis. There used to be no cure for this disease. Families were told to wait until the disease burned itself out which could sometimes take until a child was reaching adolescence. In rare cases, a parotidectomy was recommended. This is a surgery where the gland is entirely removed. This procedure can be associated with some risks, however, because the nerve that helps control facial movement runs through the gland. There is a small risk of temporary or even permanent facial paralysis from this surgery which does not seem acceptable for treatment of a benign disease.

More recently, tools have been developed that allow surgeons to look into the saliva ducts to try to diagnose the problem and if a blockage is found, to remove it with the goal of decreasing the frequency of the episodes. Sialendoscopy is associated with very few complications. The procedure takes only a few hours and your child can go home the same day. Recovery is quick with most children returning to a regular diet and regular activities within a few days.

Reasons to seek medical help:

  • If your child is having frequent episodes of cheek or swelling under the jaw associated with pain and/or fevers