2.2.1 The Waiting Area
The clinic experience for the family starts well before they see you. Easy road access, car parking, a bright and friendly environment with adequate facilities for food and drinks, baby-feeding facilities, wheelchair-friendly access, and an environment where children and parents feel safe and welcome not only contribute greatly to parental and child satisfaction with their visit but also probably influence outcomes. Planning modern children’s hospitals is a highly skilled endeavor and ideally will involve close liaison between the building architects and their design team, clinicians, hospital staff, children and their advocates, and planning authorities ( ▶ Fig. 2.1).
Fig. 2.1 The entrance foyer, Royal Liverpool Children’s Hospital, Alder Hey.
A bright, spacious waiting room well stocked with toys, pens, paper, crayons, and computer games and able to withstand the rough and tumble that is inevitable in a group of children will make for a far happier experience than a cramped shared facility ( ▶ Fig. 2.2). Play therapists are invaluable, and if the hospital authorities can be persuaded to hire a professional clown, better still.
It goes without saying that easy access to bathrooms, baby-change facilities, and adequate space for breast-feeding mothers is essential.
Fig. 2.2 The ENT waiting area.
2.2.2 The Clinic Room
One of the paradoxes of caring for children is that despite their small size they need far more space than adults. A clinic room needs to accommodate two parents, the child—sometimes in a Moses basket or a pushchair—one or more siblings, equipment such as oxygen cylinders or a ventilator, the doctor, a nurse, and often one or more medical students or trainee surgeons. This is in addition to the equipment required for ear, nose, and throat (ENT) examination and treatment. Ideally, each clinic room will have a microscope, suction apparatus, a camera, a light source and stacker system with a monitor for nasal and airway endoscopy, image capture facilities, and a range of flexible and rigid endoscopes ( ▶ Fig. 2.3). Discreetly put away as many sharp instruments, such as hooks, picks, and needles, as you can so they are not on display. They are better stored on a shelf out of view as they can be extremely intimidating to young children. Hand-washing facilities are, of course, mandatory. The physical environment needs to be safe with no sharp or pointed corners, spirit lamps, or loose cables.
Audiological testing rooms are an integral part of an ENT consultation and should be adjacent to the clinic so that the child can easily move from one room to the other.
The preceding represents an ideal state of affairs and many ENT surgeons have to see children in less than optimum circumstances, but it is important that we as clinicians advocate as robustly as we can for the best facilities for our pediatric patients.
Fig. 2.3 Examining a child’s ear using the otoendoscope. The parent can see the screen image, which can be recorded and kept.
2.2.3 Support Staff
Reception staff and care assistants who have had training and experience in dealing with parents and children help to make for a better clinic experience. Best practice is that a registered children’s nurse should ideally be available “to assist, supervise, support, and chaperone children,” 1, 2 but clearly arrangements will vary in different jurisdictions and in different health care settings.
Audiological professionals are an integral part of pediatric ENT practice, and as a minimum, a fully registered audiology technician with appropriate facilities for audiometry and tympanometry should be available for all children’s ENT clinics.
Other professionals may be needed depending on the nature of the clinic, for example, a speech and language therapist for voice disorders or cleft palate, or specialist audiological personnel for children with bone-anchored hearing aids or cochlear implants.
Trained specialist nurses who liaise with families outwith the clinic, for example, in supporting home tracheostomy care, greatly enhance the clinical experience for parent and child. Some units arrange a “preadmission” clinic so that when a child is scheduled for surgery, he/she can have preoperative checks in advance of the day of admission. A dedicated nurse usually runs these clinics, and it can be useful for the family to meet her/him at the first clinic visit so that they can plan ahead. If the family does not speak the same language as the doctor and clinic staff, an interpreter may be needed, and this should, of course, be arranged well in advance of the visit.
Many ENT surgeons run “specialist” clinics with a focus on multidisciplinary care, for example, an allergy clinic will require an ENT surgeon and a specialist in pediatric allergy. It is important to strike a good balance between involving the required staff and overwhelming the child with a surfeit of adults in a single room.
2.2.4 Preparing for the Consultation
A visit to the hospital is a routine event for the doctor. It is a major episode in the life of the child and parent.
The parents may have had to book time off work, child care for siblings, a day off school for the child, and transport for the trip. Ideally, the children’s clinic must be separate from the adult clinic. If it is not possible to have a clinical area and a set of consulting rooms that are used exclusively for children throughout the working week, they should be scheduled for a dedicated pediatric session; children should no longer be seen in a “mixed” adult and pediatric setting. It can be very uncomfortable for children and their parents—and for adult patients and their relatives—if they are allocated the same clinic and have to share a waiting area. Parents or children must not feel rushed in clinic; if you have to hurry them along, the clinic has not been properly planned.
Take time to read the case notes, including the results of investigations, if applicable, before the child enters the room. If the child has a chronic medical condition or a syndrome, read up on it in advance if you can. This should be relatively easy in most settings nowadays as so much information is available online. Parent and child will appreciate continuity, and if you are seeing a child for repeat visits, it is ideal if the same doctor sees them each time.
2.3 The Consultation
2.3.1 The History
Greet the child by name, make eye contact, and introduce yourself and any other staff in the room. Establish who is with the child—it may be a parent, a carer, or a grandparent. Be clear on who is going to give you the history and make sure the child gets an opportunity to speak if she is old enough. Doctors are taught to take very focused histories, but in a pediatric setting it is often better to ask an open question such as, “What are your worries about Kirsten?,” rather than steering the parent down a particular set of symptoms. Many doctors regard themselves as good communicators because they can explain illnesses and procedures in easy-to-follow terms, but of course communication is a two-way street and listening without interruption can be more useful than talking. It is essential that the parent, usually the mother, feels that her account has been carefully listened to and understood before you probe with more direct questions. Watch the child, look at the mother’s facial expressions, note how she interacts with the child, and pick up as much information as you can from both verbal and nonverbal clues.
Listen well and talk less until it is clear that the parent feels you have the full picture.
If the parents offer to show you the child’s growth chart, a record of their visits to the doctor, diary entries, photographs, or short video clips, do look at them. The parents will feel any record of their child’s health is important and they may give you much information, for example, about the child’s overall development or, in the case of video clips, the child’s sleep pattern. The birth and perinatal history may be important, particularly with airway pathology, it is helpful to ask the mother about the delivery, whether the baby was term or premature, whether there were any concerns about breathing and feeding as a newborn, and in particular whether there was any airway intervention, for example, an endotracheal tube or a period on the special care baby unit.
Good consultation skills can be taught, learned, and improved upon with constructive feedback and should be an important part of training and assessing surgeons as they progress toward independent practice.
Parents may be angry, upset, seeming not to listen, or challenging in a variety of ways, but unless they are overtly abusive or threatening, they should be carefully listened to and treated with the utmost courtesy.
The examination begins as soon as the child comes into the room. An astute clinician will note the child’s gait, breathing pattern, and state of alertness as he/she is taking the history. Once they have had a chance to settle in the clinic room, most young children are happy to be examined. Smaller children are best examined sitting on their mother’s knee.
Explain in an age-appropriate way what is going to happen and do not persist if the child is fractious or struggling.
It is not appropriate to restrain an older child for the purpose of an elective clinical examination, but the parent can gently but firmly hold a baby or toddler to facilitate otoscopy, examination of the nose, and examination of the neck.
Most children will tolerate otoscopy, and if there is wax or debris, it is usually possible to remove it by suction to get a better view. Use the biggest speculum that will comfortably fit in the ear canal. If you need a better view, use the microscope, which should be as well tolerated as a standard otoscope. Thin otoendoscopes with high-quality cameras and viewing monitors are becoming more widely available and represent a good opportunity to record findings, to facilitate better explanations of pathology to parents, and as an aid to teaching.
A good way to start a nasal examination is to assess the nasal airway using a cold metal spatula to look for the pattern of condensation ( ▶ Fig. 2.4). Children do not like Thudicum’s speculum; you can get a good view of the nasal cavities by simply elevating the tip of the nose and looking with a good light source, but again high-quality endoscopes have made rhinoscopy far easier and better tolerated. In a cooperative child, you should get a good view using a standard 0- or 30-degree telescope. Although some surgeons like to use a local anesthetic spray, the author has not found this useful, and, in general, if a child will not tolerate a nasendoscope, he/she will tolerate a spray even less so, and you are better getting the best view you can using a headlight.
To examine the pharynx, use a standard headlight. Children dislike tongue depressors; the author very rarely uses them. You can get a good view of the nasopharynx using a telescope with an angled lens gently placed between the tonsils.
Examining the larynx can be difficult in an older child, but flexible transnasal endoscopy will give you a very good view in a cooperative older child or in the case of a baby who is gently but firmly held by the mother. As with nasendoscopy, the author has not found local anesthesia very helpful as it can cause as much distress as the endoscope. Clearly, if a child is anxious or distressed, it is inappropriate to proceed, and if you have to get a view of the larynx, then you may need to arrange admission for a general anesthetic.
Neck examination should focus on observation for lumps, bumps, sinuses, and asymmetry, gently palpating to assess for lymph nodes. “Lymphadenopathy” is probably a misnomer in children as some degree of lymph node enlargement is physiological and should cause no alarm (see ▶ 25).
Fig. 2.4 Testing the nasal airway.
Few, if any, investigations are needed for most common ENT presentations in children.
Pure-tone audiometry (provided the child is old enough) and tympanometry are essential components of a full ENT examination. Radiological imaging may be needed depending on the pathology, and ultrasonography is commonly used to quickly assess neck swellings. Some ENT surgeons are now skilled at getting good ultrasound images in clinic. If the child needs blood tests, then he/she should have local anesthetic cream (e.g., EMLA cream, an emulsion containing lidocaine and prilocaine) before being sent for phlebotomy. Photography can be useful, for example, for facial and neck lesions, and close liaison with a skilled medical photography department will make for a much better pediatric ENT service.
2.3.4 Management Plan
The parents have come to see you to hear your opinion on their child’s condition and to discuss management options with you. In most cases, you should be able to make a plan having taken a history and conducted the examination.
This part of the consultation is vital and must not be rushed.
Very often there will be more than one option, including and perhaps most important avoiding any intervention, and it is essential that you present each of the options and get a feel for how the parents want to proceed. Diagrams, models, and wall charts can be very helpful in trying to explain pathologies and interventions, and it is good practice in writing to the referring clinician to copy in the parents, using this as an opportunity to reinforce and amplify any explanations you may have given. If a decision is made to admit the child for surgery, it is ideal if a date can be agreed with the parents, but this is not always possible and practice will vary in different settings. The more information parent and child have about the admission process the better. Many units run a “preadmission” clinic when the child and family can visit the ward and meet the staff. Parents greatly appreciate information leaflets and some surgeons maintain good quality websites with video clips and explanations of common ENT conditions and interventions.
2.4 Normal Growth, Development, and Child Health Promotion
Otolaryngologists are not experts in assessing and monitoring child development, but all health care professionals who deal with children need to acquaint themselves with the major events in children’s normal progression and to be alert to signs that all is not well. Some important milestones are shown in ▶ Table 2.1, but of course children develop at different rates, and it is the overall pattern of progress that is important.
The otolaryngologist may be the first specialist the parents see if a child is slow to speak, develops obstructive sleep apnea related to muscle hypotonia, or presents with suspected earache or hearing loss when a neurodevelopmental disorder is to blame. Parents who worry about their child’s progress need to have their concerns taken seriously, and if you are in any doubt or have concerns about a child’s overall growth and development, seek the opinion of a general pediatrician.