Training and Accreditation

The diagnosis and management of ORL conditions in children forms an integral part of the syllabus for all ENT surgeons in training. Examinations in ORL, including the European Board Examination, ¹ put much emphasis on this, and in general, otolaryngologists are well trained in the principles of looking after children with common disorders of the upper respiratory tract. Although subspecialization in ORL is largely based on “system” (otology, head and neck surgery, rhinology) rather than on age, a growing number of otolaryngologists now choose to undertake advanced training in a fellowship program in one of the major children’s hospitals with a view to taking a special clinical interest in the care of children. In addition to basic and fellowship training, it is essential that all of us who care for children have up-to-date knowledge and skills in topics such as child protection, prescribing for children, analgesia, and pediatric resuscitation, and that we continue to maintain and refresh this knowledge and skill.

1.3 History of Pediatric Otorhinolaryngology

Doctors have treated ENT disorders in children from the beginnings of medicine, centuries before otology or laryngology emerged as discrete specialties. There are references to tonsillectomy in some of the earliest clinical texts, for example, Celsus’s “De Medicina” dating from the first century. Tracheostomy for the relief of airway obstruction has been known since ancient times. ^{2,​ 3} Congenital deafness, craniofacial dysmorphia, infective disorders of the head and neck, and perinatal airway obstruction were recognized and described long before otorhinolaryngology developed. As the age of enlightenment and scientific discovery progressed throughout the 18th and 19th centuries, clinicians began not only to bring the principles of science to bear on their work, but also to focus their attention on particular body systems and, in some cases, specific diseases (medical specialization). Otology grew largely from the early endeavors of the clinics of Adam Politzer (1835–1920) and Josef Gruber (1827–1900), who treated both adults and children at the Allgemeines Krankenhaus in Vienna, Austria, where they hosted hundreds of pupils from all over Europe and North America. These pupils included Sir William Wilde (1815–1876) and Joseph Toynbee (1815–1866) in Britain, each of whom published what were to become definitive English language textbooks of the new specialty. ^{4,​ 5} Toynbee’s avowed aim was “to rescue aural surgery from the hands of quacks.” Wilde’s book includes a substantial section cataloguing and recording the etiology of deafness in children, and an impassioned essay championing the cause of improved education for “deaf mutes.” Wilde also described an early form of myringotomy ( ▶ Fig. 1.1, ▶ Fig. 1.2) and tympanocentesis for “strumous otitis” (otitis media with effusion), myringoplasty, and a surgical approach to drain the mastoid for suppurative mastoiditis in children.

Laryngology advanced in parallel, and it was well into the 20th century before the two disciplines combined as “otorhinolaryngology.” The early laryngologists—Morell Mackenzie and Sir Felix Semon, both in London—had substantial pediatric practices. Mackenzie described recurrent respiratory papillomatosis in a postmortem specimen of the larynx of a child who had died in a “home for the friendless.” Semon did much to popularize tonsillectomy; he was a laryngologist to the British Royal family and undertook the procedure on the grandchildren of Queen Victoria, making it a fashionable intervention in the drawing rooms of the aristocracy. ⁶ Laryngeal tuberculosis and congenital syphilis were common causes of laryngotracheal stenosis, and by the early 20th century, there were well-established techniques for tracheotomy and for airway dilatation in children. Diphtheria was an important and often fatal cause of airway obstruction, and acute epiglottitis became a common indication for tracheostomy.

Gustav Killian in Freiburg pioneered suspension laryngoscopy and tracheabronchoscopy, and the technique was soon extended to children. Chevalier Jackson in Philadelphia became a celebrated teacher of pediatric airway endoscopy throughout Europe and the United States.

Children’s hospitals were established in Paris (1802), Berlin (1830), St Petersburg (1834), Vienna (1837), and Great Ormond Street, London (1852). As these hospitals expanded, otologists and laryngologists joined the staff, particularly in Eastern Europe. Dr Jan Gabriel Danielewicz opened the first pediatric ENT ward in Warsaw shortly after the end of the second world war. ⁷ By the 1950s, designated children’s ENT wards were becoming commonplace in the larger children’s hospitals. Children’s health in general improved greatly after the Second World War due to improved sanitation, availability of antibiotics, and widespread adoption of vaccination programs (see ▶ 2).

Pediatric ENT surgeons are acutely aware of the debt they owe to pioneers in other scientific disciplines. Endoscopy was greatly advanced by the discovery of the rod lens optical system by physicist Harold Hopkins in the United Kingdom ⁸ and developed and refined by the Storz company in Germany. Advances in anesthesia, intensive care, and neonatology are such that many children who now come under our care are graduates of special care baby units, neonatal intensive care units, or the pediatric intensive care unit (PICU). They often have complex perinatal histories including congenital anomalies, extreme prematurity, and cardiorespiratory diseases that would have been fatal in an earlier generation.

Joseph O’Dwyer of New York ( ▶ Fig. 1.3) is credited with the first successful endotracheal intubation in a child, but the technique was not widely taken up until the 20th century when it was popularized for the management of diphtheria and croup. Modern pediatric anesthesia owes much to the early endotracheal tubes of Magill. ⁹ As anesthesia progressed, so did the new subspecialties of pediatric anesthesia and intensive care. Prolonged endotracheal intubation and management on a PICU only became commonplace from the 1960s onward. As recently as 1955, Wilson, ¹⁰ in the first English language textbook of pediatric ENT, wrote of tracheostomy in children: “these are desperate cases at best, and it may be a comfort to remember that the worst thing that will happen is that the patient will die. This is a likely event in any case.”

Pediatric airway endoscopy even in the very young is now a safe day-case undertaking, and the fear and trepidation that surrounded tracheostomy in children is happily a distant memory.

Audiology has its own history. Physicians, pediatricians, otologists, and teachers took a keen interest in the hearing impaired child from the earliest times, but the profession of audiology began in the 1920s when the first audiometers became commercially available. Early devices for measuring hearing—known as “sonometers” or “acoumeters”—were produced in the late 19th century, and a variety of trumpet devices were used as primitive “hearing aids.” Electronic hearing aids became available in the early 20th century, gradually becoming smaller and more efficient. The modern-day digital aids are highly sophisticated programmable devices. The term “audiology,” and with it a more effective organization and regulation of the specialty, came after the Second World War. Education and teaching of the deaf child progressed hugely in the 20th century. Edith Whetnall in London was a pioneer in this area. She established a network of clinics, which became a model for the assessment and treatment of hearing impaired children, and her textbook, “The Deaf Child” (1964), was the standard work for many years. ⁴ Cochlear implantation, developed in the 1970s and, refined and improved upon throughout the next 30 years, transformed the lives of hearing impaired children and their families (see ▶ 15) in the developed world.

The assessment and rehabilitation of the hearing impaired child has advanced greatly in recent years (see ▶ 13 and ▶ 15), and pediatric audiology is an important and growing medical specialty.

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