The 12 Days of Pediatric Otolaryngology | Holiday Pearls for Practice: Part 2

Lyndy J. Wilcox, MD, MMHC, on behalf of the Pediatric Otolaryngology Committee

This article, begun earlier this month, offers a lighthearted yet evidence-based look at some common pediatric otolaryngology issues that may appear in your clinic or emergency room this season. From a peanut in a bronchial tree to 12 TikToks Tokking, these 12 vignettes reflect the breadth of our field—from newborn airway emergencies to adolescent tinnitus, and everything in between. Each “day” highlights a familiar question, a best-practice approach, and a reminder that even in the bustle of the holidays, there’s joy in what we do: helping children breathe, speak, and hear their way into the New Year.

Here, in Part 2, we pick up with Day Seven …

Seven Swans a-Swimming

Do children with tympanostomy tubes need water precautions? 

The short answer: usually not. The 2022 AAO-HNSF clinical practice guideline on tympanostomy tubes clearly states that routine water precautions are not necessary for most children. Studies demonstrate that swimming in chlorinated or clean, treated water does not significantly increase rates of otorrhea or infection. Exceptions may include children with recurrent otorrhea, persistent drainage, tympanostomy tubes placed for chronic otorrhea, or exposure to heavily contaminated water such as lakes, rivers, or hot tubs.¹⁶

If drainage occurs, ototopical fluoroquinolone drops remain first-line therapy and are typically more effective and better tolerated than systemic antibiotics. Combination steroid-antibiotic drops may be used for more significant inflammation. Persistent or recurrent otorrhea should prompt evaluation for granulation tissue, biofilm formation, or concurrent sinus or adenoid disease.

For ear discomfort during swimming, soft silicone earplugs or a snug swim band can be offered, though these are optional and primarily for comfort rather than infection prevention. Diving and deep submersion may still increase water pressure and the risk of reflux through the tube, so gentle surface swimming is preferred.

As for the “swans,” parents can rest assured that most children with tubes can return to the pool, bathtub, and splash pad without worry. After all, keeping their ears dry year-round isn’t the goal—keeping their middle ears healthy and infection-free is what truly helps them swim through the season in peace. 

Eight Moms a-Nursing (But Struggling To)

When do oral ties need intervention?

Feeding concerns in newborns often lead to the familiar question, “Does this baby need a frenotomy?” The answer should always begin with function, not form. Frenotomy is appropriate when ankyloglossia causes demonstrable functional impairment—ineffective latch, maternal nipple pain or trauma, or poor weight gain—that persists despite skilled lactation support and optimized feeding techniques. Collaboration with lactation consultants and pediatric speech-language pathologists (SLPs) helps identify other contributors, such as reflux, neuromuscular tone differences, palatal anomalies, or oral-motor discoordination.¹⁷

In a large multicenter study, infants who underwent feeding evaluation by SLP or lactation specialists prior to surgical referral had significantly lower rates of frenotomy, with many achieving successful feeding through conservative management alone.¹⁸ These findings highlight the importance of multidisciplinary evaluation before proceeding to surgical release.

There is no clear consensus on how to define a “posterior” tongue-tie or whether it directly impacts feeding. Similarly, evidence for releasing “buccal ties” or for performing frenotomy to prevent future speech issues remains weak. Labial (upper lip) frenula are also common normal variants; their role in feeding difficulty is unproven, and surgical release is rarely indicated. The use of lasers for frenotomy also lacks evidence of superiority and introduces unnecessary cost and risk. These recommendations align with the AAO-HNSF Clinical Consensus Statement on Ankyloglossia in Children.¹⁷

When intervention is indicated, the procedure should be supported by ongoing feeding therapy. Office-based frenotomy with scissor release +/- topical or local anesthesia is generally appropriate for young infants—typically up to three to six months of age depending on infant cooperation, provider experience, and safety considerations. Frenotomy or frenuloplasty in older infants or children often require general anesthesia—an age-dependent distinction important for counseling families about risk and setting expectations. Families should be counseled regarding potential risks—minor bleeding, scarring, or recurrence—and realistic expectations, emphasizing that frenotomy may facilitate improvement but rarely serves as a complete solution.^17,19

If eight moms (and their lactation consultants) have exhausted conservative measures and feeding still falters, frenotomy can meaningfully improve function and comfort. But for many infants, time, patience, and expert support are all that’s needed to get those “moms a-milking” once again.

Nine Kids a-Snoring

When can we sleep on a child’s snoring and when does it warrant further workup?

’Tis the season when the sounds of “Deck the Halls” might compete with the rhythmic rumble of snoring from a child’s room down the hallway. But when a child’s “jingle bell rock” persists when not ill, it’s time to consider OSA, a condition associated with neurocognitive, behavioral, cardiovascular, and growth consequences.

Per AAO-HNSF and American Academy of Sleep Medicine recommendations, polysomnography (PSG) should be obtained before surgery when the diagnosis is uncertain, symptoms are discordant with tonsil size, or when children have comorbidities such as obesity, Down syndrome, craniofacial anomalies, neuromuscular disease, sickle cell disease, or mucopolysaccharidoses.^13,20 Just as with tongue-tie, appearance alone is not the indication. Function is what matters most. Big tonsils may be innocent “lumps of coal” if they aren’t obstructing airflow or affecting sleep quality.

When OSA is confirmed, adenotonsillectomy remains first-line therapy for most otherwise healthy children. Intracapsular (partial) tonsillectomy offers reduced postoperative pain and bleeding risk, with comparable short-term efficacy in resolving OSA, though carries a small risk of tonsillar regrowth.^20-22 Conversely, extracapsular (total) tonsillectomy remains the more definitive option with a lower risk of regrowth or revision surgery; however, outcomes of OSA treatment are similar in the short-term.^21,22 Postoperative overnight observation is advised for children younger than three years, those with severe OSA (apnea–hypopnea index ≥ 10 or oxygen saturation nadir < 80%), or those with significant medical comorbidities. Careful airway monitoring and multimodal pain control are essential, as most complications occur within the first 12 hours.¹³

Repeat PSG, if needed, should be delayed until eight to 12 weeks postoperatively to allow for full healing and stabilization of airway dynamics. Indications include persistent symptoms, obesity, high-risk medical conditions, severe preoperative OSA,²³ or an elevated central apnea index, suggesting neurologic or ventilatory control abnormalities. Beyond the apnea–hypopnea index, clinicians should also review less common findings such as elevated periodic limb movement index or persistent hypoventilation, which may warrant further neurologic or pulmonary evaluation.

With thoughtful preoperative assessment, evidence-based surgical planning, and postoperative vigilance, those “nine kids a-snoring” can return to dreaming of sugarplums—in silence this time.

10 Ear Pipes Popping—Pediatric Ear Pain and Air Travel

How should we counsel families about ear pain and pressure with flying?

Few holiday questions are more common in pediatric otolaryngology than, “Can my child fly with ear tubes?” The winter season brings not only “pipers piping,” but families jetting off to see loved ones—often accompanied by anxious questions about how to prevent ear pain in the air. The culprit behind most in-flight discomfort is Eustachian tube dysfunction (ETD), when poor middle ear ventilation during ascent or descent prevents pressure equalization across the tympanic membrane. 

Fortunately, children with tympanostomy tubes are the best equipped for air travel—their tiny “pressure equalization” devices do exactly what their name implies. For everyone else, chewing, swallowing, or drinking during ascent and descent remains the simplest and most effective preventive measure. In older children, pressure-equalization devices or autoinflation techniques (such as blowing gently against a closed nose after pinching the nostrils) can also help when used correctly.²⁴

The role of decongestants is less clear. Evidence supporting oral pseudoephedrine in children is limited and inconsistent, and potential side effects—irritability, tachycardia, and insomnia—often outweigh modest benefit.^25-27 Similarly, topical nasal decongestants such as oxymetazoline or phenylephrine may provide transient relief if used 30 to 60 minutes before takeoff and landing, but their efficacy in children has not been proven, and overuse risks rebound congestion. Current expert consensus discourages routine use of either oral or topical agents for prevention, reserving them for older, cooperative children with recurrent barotrauma or chronic ETD.²⁹ 

Beyond medication, preventive strategies center on nasal hygiene, allergy management, and treating underlying sinus or adenoid disease. In children with chronic effusion, tympanostomy tubes can be protective against pressure changes, allowing passive middle ear ventilation.

When “10 pipers” are preparing for takeoff, a little anticipatory counseling goes a long way: focus on hydration, gentle autoinflation, and conservative use of decongestants when appropriate. With that, most young travelers can enjoy their flight with ears popping only to the rhythm of the season’s songs.

11 Lords a-Leaping to the OR for a Button Battery

What’s the urgency in suspected button battery ingestion or nasal foreign body?

Some pediatric calls make even the most seasoned otolaryngologist “leap” out of their chair, and few faster than the report of a button battery lodged in the esophagus or nose. Button battery injuries represent true otolaryngologic emergencies: tissue injury begins within minutes, and transmural necrosis can occur within two hours. The 2021 National Button Battery Task Force guidelines emphasize immediate removal for esophageal or nasal button batteries and urgent evaluation for any child with unexplained drooling, dysphagia, stridor, nasal discharge, or refusal to eat.²⁸

Whether the ingestion time is known or uncertain, anteroposterior and lateral neck, chest, and abdominal radiographs should always be obtained to confirm location, orientation, and number of batteries. Esophageal batteries show a characteristic “double ring” or “halo” sign on imaging. If ingestion occurred within 12 hours and the battery remains in the esophagus, administration of honey (for children >1 year) or sucralfate suspension may help neutralize local pH and limit mucosal injury while en route for removal, provided the child can swallow safely and has no airway compromise.²⁸

Immediate endoscopic removal in the operating room is required for esophageal batteries, with airway protection and careful esophageal inspection after retrieval. Irrigation with 0.25% acetic acid and meticulous documentation of mucosal injury are recommended. If injury extends beyond the mucosa, early consultation with interventional radiology, pediatric surgery, and cardiothoracic surgery is warranted to evaluate for perforation, mediastinal involvement, and/or vascular compromise.

For nasal button batteries, removal should occur emergently in the clinic or operating room, as even short dwell times can cause septal perforation and turbinate necrosis. Saline irrigation should be avoided prior to removal to prevent ion activation and further injury.²⁹

Although button batteries are the most urgent offenders, other nasal and esophageal foreign bodies—coins, beads, food boluses—also deserve prompt but calm intervention. The key is recognizing that with these cases, as the carol reminds us, everyone should “leap” into action. Quick diagnosis, multidisciplinary coordination, and timely removal can prevent long-term harm and turn a potential disaster into a holiday success story.

After removal, delayed complications such as tracheoesophageal fistula, esophageal stricture, or vocal fold immobility may develop days to weeks later. Repeat esophagram or endoscopy should be obtained for deep injuries, circumferential burns, or persistent symptoms. Long-term follow-up with multidisciplinary teams—including otolaryngology, gastroenterology, pulmonology, and rehabilitation specialists—ensures recovery of safe swallowing, airway protection, and quality of life.

12 TikToks Tokking

How should we approach tinnitus and hearing concerns in children and teens?

As the holidays crescendo with “12 drummers drumming,” it’s not just the percussion section that’s raising the volume. Between holiday concerts, new headphones, and the irresistible pull of TikTok, children and adolescents may be exposed to sound levels that rival the marching band’s finale. Increasingly, pediatric otolaryngologists are seeing noise-related tinnitus and transient threshold shifts that masquerade as hearing loss—or, in younger children, simply as a tendency to turn the music up louder.

The differential diagnosis for tinnitus or perceived muffled hearing in a child includes ETD, middle ear effusion, and temporary threshold shift from excessive sound exposure. ETD remains particularly common during the winter months, when upper respiratory infections and allergic congestion peak. Children may crank up their earbuds or devices not from defiance but from diminished sound transmission. A thorough otoscopic and audiologic evaluation helps differentiate conductive from sensorineural causes before assuming “selective hearing.”

When true tinnitus or noise sensitivity is identified, counseling should include safe-listening strategies: limiting headphone use to 60 minutes at ≤60% of maximum volume, avoiding deep insertion of earbuds, and favoring over-the-ear headphones when possible. The World Health Organization and American Speech-Language-Hearing Association both emphasize these simple habits as key to preventing long-term noise-induced hearing loss.^30-32

In adolescents, chronic tinnitus warrants audiometric testing and discussion about sound exposure history, sleep quality, and mental health, as anxiety often amplifies tinnitus perception. For younger children, reassurance and management of ETD often resolves the complaint. Persistent or asymmetric symptoms merit a full audiogram and possible imaging.

Although it may feel impossible to tell some teens to “turn it down,” gentle counseling—sometimes with a little help from their favorite artist—can go a long way. After all, as Taylor Swift reminds us, “You can’t spell ears without eras.” Encouraging moderation, good listening habits, and awareness of early symptoms help preserve both hearing health and harmony so they can keep enjoying the music for many years (and concert tours) to come.

Conclusion

As the 12th verse draws to a close, we’re reminded that pediatric otolaryngology, much like the holidays themselves, blends urgency with wonder. Across a full 12-verse symphony of seasonal challenges, each case offers a moment to restore comfort, confidence, and connection, from the tiniest airway to the loudest drummer. 

The rhythm of our work may change with the season, but its melody remains constant: helping children breathe easier, speak more clearly, and hear the world around them. Whether managing airway emergencies or simply clearing “two snotty nares,” may your operating rooms stay merry, your tympanic membranes intact, and your call nights silent and bright. Because caring for children is, in any season, the gift that keeps on giving.

If you missed The 12 Days of Pediatric Otolaryngology | Holiday Pearls for Practice: Part 1, you can read it here.

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