Transcript The ABC’s of Pediatric ENT - Arkansas Academy of Family

The ABC’s of Pediatric ENT
Charles M. Bower, M.D.
Chief Pediatric Otolaryngology
Arkansas Children’s Hospital
Disclosures
 None
Summary
 Hearing loss
 Stridor
 Otitis media
 Tonsillectomy
 Sinusitis
 Epistaxis
Infant hearing screening
UNIVERSAL HEARING
SCREENING
 The main premise of hearing screening in young children is
that early detection and intervention are beneficial to the
development of speech, language, reading, and cognition
Haggard 92
Why is Early Identification of Hearing Loss so Important?
 Hearing loss occurs more frequently than any other
newborn condition that may cause significant
developmental delays.
40
30
Incidence per 10,000
births
30
20
10
0
12
11
6
5
5
2
1
Grade Equivalents
Reading Comprehension Scores of
Hearing and Deaf Students
10.0
9.0
8.0
7.0
6.0
Deaf
Hearing
5.0
4.0
3.0
2.0
1.0
8
9
10
11
12 13
14
15 16
17
18
Age in Years
Schildroth, A. N., & Karchmer, M. A. (1986). Deaf children in America,
San Diego: College Hill Press.
Early Hearing Detection and
Intervention (EHDI) Timetable
 0-3 days old: birth admission screen
 Up to 1 month old: follow-up rescreen
 1- to 3-months old: audiological eval
 3- to 6months old: early intervention
• Hearing can be tested at any age
• Hearing aids can be fit at any age
Lost to fu
 30% rate of lost to fu in Arkansas
 PCP may be first access after failed screen
 Must know hearing screening results
 Should always assess for hearing loss and language
development
 If suspected hearing loss, need to test and refer
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ENT
Audiology
Genetics
Ophthalmology
Ongoing hearing screening
 Objective hearing screening at birth,4,5,6,8,10 years
 Assess for hearing loss, speech and language delays
at every visit
 Screen hearing if available
 Refer to audiology if failed screen for objective test
 ENT if hearing loss
 Ophthalmology, genetics, etc if permanent SNHL
Stridor
Definitions
 Stridor--high pitched
laryngeal noise
 Congenital or acquired
 May be associated with
respiratory distress
 Requires evaluation
Airway symptoms/signs
 Stridor
 Biphasic = subglottic
 Inspiratory = supraglottic
 Expiratory = Intrathoracic
 Retractions
 Feeding difficulties
 Blue spells
 FTT
 OSA
Differential DiagnosisCongenital Stridor
 Laryngomalacia
 Vocal cord paralysis
 Subglottic stenosis
 Tumors
(hemangioma,
papilloma)
Laryngomalacia
 Most common cause of
inspiratory stridor (80%)
 FTT, blue spells, dysphagia
 Diagnosis
 NP scope
 MLB for secondary lesions
 Treatment
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Observation in 90%
Monitor weight
Rx GER, dysphagia, rhinitis
Epiglottiplasty
Subglottic stenosis
 Biphasic stridor
 Croupy cough
 History of intubation
 Diagnosis
 NP scope
 Plain films
 ML and B
Tumors (hemangioma,
papilloma)
 Biphasic stridor
 Progressive
 Hoarse (papilloma)
 Cutaneous hemangioma
 Diagnosis
 NP scope
 Plain films
 ML and B
AOM
Recurrent AOM
Chronic Otitis Media with
Effusion (COME)
New Guidelines
AAO/AAP/AAFP
The Problem: Otitis Media
 75% of young children will have at least one AOM
 17% of children will have >3 / 6 months
 AOM is 2nd most common reason for office visits
 Annual Cost of US treatment $3-5 billion
 Emergence of resistant organisms
 Casselbrant ML, Mandel EM. Epidemiology. In: Rosenfeld RM, Bluestone CD, eds.
Evidence-Based Otitis Media. 2003:147-162.
Definitions
 Acute Otitis Media AOM)
 Rapid onset of middle ear inflammatory process
 Fluid: Color change, non mobile, thick
 Inflammation: fever, irritability, hyperemia, bulging
 Otitis Media with Effusion (OME)
 Middle ear fluid without inflammation.
 Fluid: Color change, non mobile, thick
Acute otitis media
Otitis Media
Acute
OME
Surgical indications
 Recurrent Acute Otitis Media
 3 episodes in 6 months or 4 - 5 in one year
 With evidence of OME in at least one ear
Surgical Indications
 Chronic Otitis Media with Effusion (COME)
 Persistent effusion for more than 3 months
 And evidence of hearing loss, speech/language delays,
other risk factors
Otitis media – Treatment
Surgical Options
 Tympanocentesis/myringotomy for acute otitis media
 Tube insertion for chronic otitis media
 Adenoidectomy
Tympanocentesis
 Diagnostic importance
 May decrease pain
 No significant impact on clinical resolution of
AOM.
 No randomized data
Tube insertion
Tympanostomy with tube
insertion-outcome
 Pre PET patients had
4.8 episodes in 6
months, versus 0.9
episodes / 6 mo after
PET
 No difference with
season or age
 Pat Brookhouser
March 1993
Tympanostomy with tube
insertion-outcome
 Impact of Tympanostomy
Tubes on Quality of Life
 Improvement in quality of
life scores noted in 79% of
patients after PET
(p<.00001)
 Poorer quality of life (4%)
predicted by otorrhea.
 Rosenfeld,Bhaya,Bower et
al.1999
Adenoidectomy reduces risk of OM 50%
Consider adenoidectomy as
an adjunct to PET
placement if
Age 4 to 8 at the time of
tube insertion
Recurrent disease after
tube extrusion
Primary adenoid disease
Non otologic disease
secondary to adenoids
Tonsillectomy
Tonsillitis
 3rd most common diagnosis of US pediatricians, after
cold and otitis media
 High impact on patient & family
missed school days, cost of missed work,
Tonsillitis - Microbiology
 majority of infections are viral
adenovirus, Epstein-Barr virus common
 Group A beta-hemolytic streptococcus
 Anaerobic bacteria, esp. Bacteroides
 polymicrobial infections with mixed
aerobes and anaerobes
Acute Tonsillitis - Diagnosis
 Clinical signs and symptoms of strep
extreme sore throat, odynophagia, fever,
pharyngeal exudate, tender cervical
adenopathy, elevated WBC
 Throat Culture - gold standard
 Don’t test under age 3…..low probability of complications
 Antigen detection tests - rapid strep test
latex agglutination vs. Elisa technique
5. Diagnostic studies for GAS pharyngitis are not indicated
for children <3 years old because acute rheumatic fever is rare in
children <3 years old and the incidence of streptococcal pharyngitis
and the classic presentation of streptococcal pharyngitis are
uncommon in this age group. Selected children <3 years old
who have other risk factors, such as an older sibling with GAS
infection, may be considered for testing (strong, moderate).
Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Van
Beneden C. Clin Infect Dis. 2012 Nov 15;55(10):1279-82.
Tonsillectomy and
Adenoidectomy
Tonsillectomy - Indications
 Recurrent tonsillitis >7 episodes in 1 year
>5 episodes/yr for 2 yr
>3 episodes/yr for 3 yr
Paradise criteria
Tonsillectomy – Indications
 Obstructive sleep apnea
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Snoring
Restless
Pauses
Arousal
EDS
Behavior
Enuresis
Tonsillectomy – Indications
 Complicated Recurrent
 Peritonsillar abscess
Tonsillitis
Acute airway obstruction
PANDAS?
 Chronic tonsillitis
 Obstructive Tonsil hyperplasia
 Neoplasia
Peritonsillar Abscess
 complication of acute or chronic tonsillitis
 collection of pus between tonsil and
pharyngeal constrictor muscle
 Sx - fever, odynophagia, trismus, uvular
deviation, hot-potato voice
 Rx - Needle aspiration vs. I & D
“Hot” vs. Interval Tonsillectomy
Incidence of OSA
About 2% of US children have OSA
More than 500,000 affected children in the US.
Ali N et al Am Rev Respir Dis 1991
Leach J, et al Otolaryngol Head Neck Surg 1992
Obstructive Sleep Apnea
 Serious consequences of sleep apnea:
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Poor growth and development
High blood pressure
Lung injury (Cor pulmonale)
Heart failure
Premature death
Diagnosis
 Symptoms suggestive of OSA
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Snoring
Witnessed apnea
Mouth breathing
Frequent awakenings
Daytime somnolence
Behavior problems
Headaches/ Irritability
Poor school performance
Diagnosis
 Signs
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Nasal obstruction
Adenotonsillar hypertrophy
Macroglossia
Craniofacial anomalies
Weight (<10, 10-90, >90 percentile)
Pulmonary hypertension
Cor pulmonale
Diagnosis
 • Adenotonsillar
hypertrophy size
 • 0 Prior tonsillectomy
 • + No extrusion
 • ++ Extrude partially out
of
tonsil fossa
 • +++ Fill oropharynx
 • ++++ Kissing tonsils
 Overnight Pulse oximetry
 4 channel sleep studies
 Polysomnography
 Refer for PSG
 Refer for consultation
 Sleep Tape
 Xray
Testing
PSG recommended before T and A:
Certain complex conditions (Obese, Down sx)
Need for surgery is uncertain
Admit post up under 3yrs
Admit post op if AHI >10 or desats < 80%
Treatment-OSA Medical
 Medication
 Antibiotics
 Resolution of sx in 10%
 Nasal steroids
 82% reduction in sx score
 reduced adenoid size all patients
 Demain 95
 50% reduction in AHI in children
 Decongestants
 CPAP
 Weight Loss
 O2
Treatment- OSA Surgical
 T and A– 60-90% cure rate
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UPPP
Septoplasty
Hyoid advancement/expansion
Tongue reduction
Lingual tonsillectomy
Maxillary/mandibular surgery
Tracheotomy
Sleep apnea after T and A
 Complete reassessment
 PSG important
 Medical management
 Treat the nose
 Weight loss
 CPAP
 Further surgery
Sinusitis
Pediatric Rhinosinusitis
S’not snot s’mucous!
Signs and symptoms
 Overlap with URI
 Overlap with Allergic Rhinitis
 Overlap with other conditions
Sinusitis
 Average infant has 6 colds per year
 Average infant in daycare has 10-12 colds per year
 0.5 to 5% of URI’s develop bacterial sinusitis
 Sinusitis may exist in 30-40% of patients referred for
ENT evaluation
Duration of Symptoms in URI’s
% of Patients with Symptom
70
Fever
60
Sore Throat
50
Cough
40
Nasal Drainage
30
20
10
0
1
2
3
4
5
6
7
8
9
Day of Illness
10 11 12 13 14
Allergic rhinitis incidence
16
14
12
10
Percent with
Allergic Rhinitis
age <1
9 yrs
adult
8
6
4
2
0
1
9 yrs
adult
Broder 1974
Sinusitis
 Progression to sinusitis
 Inflammation (URI, allergy)
 Mucosal edema
 Mucociliary dysfunction
 Sinus ostia occlusion
 Sinusitis (empyema)
Pediatric Sinusitis Symptoms
 Chronic nasal obstruction
100%
 Purulent nasal discharge
90%
 Headache
90%
 Cough
71%
 Fetid breath
67%
 Postnasal drainage
63%
 Behavior changes
63%
Parsons Phillips 93
Sinusitis
 Diagnosis
 Persistence of symptoms >10 days
 Not for allergy
 Watch for recurrence, not persistence
 Unusually severe symptoms (Temp >39.5)
 Watch for fever with viral syndrome without intranasal
purulence
Sinusitis
 Diagnostic challenges
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Frequent URI’s act like chronic sinusitis
URI’s increase the risk of URI’s
Allergy
Parent overinterpretation of disease
Misperception of benefit of treatment (esp antibiotics)
Sinusitis
 Radiology- Rarely indicated
 Waters view
 75% positive aspirates for opacification
or AF level
 50% positive for mucosal thickening
>5mm
 Non predictive under age 1
 CT scan (Surgical Planning)
 Diagnostic procedure of choice
 “Sinusitis” seen in 50% of normals
 Reserve for severe/uncertain disease
Sinusitis
 Adjunctive measures
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Nasal steroids
Decongestants
Nasal hygiene
Social factors
 Clinical response at
two weeks:
 Placebo effect 60%
 Antibiotic treatment effect
40-80%
Sinusitis Treatment
 Antibiotic selection
 Like AOM
 Reduce symptoms
 Reduce risk of complications
 Duration of treatment
 10 days
 Consider up to 3 weeks in non-responders
Acute sinusitis- Antibiotic
effect
 Clinical response in children was 79% for antibiotic
treated patients, and 60% for placebo
 Wald ER, Chiponis D. Pediatrics 1986
 In adults, antibiotic plus irrigation clinical response rate
was 80% vs 75% for placebo.
 Axelsson A, Chidekel N. Acta Otolaryngol 1970
Sinusitis
 Surgical Management
 Irrigations/windows
 Diagnostic
 Cultures
 Severe disease, immune compromise
 Adenoidectomy
 60% improvement
 First surgery in young children
 FESS
 80-90% improved
 Other
Sinusitis Summary
 Diagnosis
 Clinical (Severity or duration rules)
 Sparing use of x-rays
 Evaluation
 Allergy, if older or positive family hx
 Other disease
Epistaxis
 Nose bleeds are common with URI’s
 Mucosal inflammattion
 Frequent nose bleeds
 Anterior nasal septum vessels
 Poor nasal hygiene
 Low humidity
http://epistaxiss.blogspot.co
m
Epistaxis
 Treatment
 Nasal hygiene
 Saline irrigations
 Topical lubricants (Vasoline, Polysporin)
 Nasal cautery
 Silver nitrate
Frenulotomy
 Short lingual frenulum
 Consequences
 Breast feeding
 Speech?
 Treatment
 Elective frenulotomy
Frenulotomy
 Refer early if question on breast feeding
 Frenulotomy in clinic
 Topical lidocaine
 Sweeteze
 Scissor divided
 Frenulotomy in OR
 If older/teeth
 Consider deferring until other procedures or age of
tolerance in clinic
Summary
 Remember 1 3 6
 Stridor should be assessed
 Bulging TM is critical
 3 in 6 or 4 in 12 (with effusion)
 7/yr, 5/yr for 2, 3/yr for 3
 OSA
 URIs prevail
Bibliography

Screening children's hearing. Haggard M. Br J Audiol. 1992 Aug;26(4):209-15.

Schildroth, A. N., & Karchmer, M. A. (1986). Deaf children in America, San Diego: College Hill Press.

The diagnosis and management of acute otitis media. Lieberthal AS, Carroll AE, et al. Pediatrics. 2013
Mar;131(3):e964-99.

Casselbrant ML, Mandel EM. Epidemiology. In: Rosenfeld RM, Bluestone CD, eds. Evidence-Based Otitis
Media. 2003:147-162.

Clinical practice guideline: Tympanostomy tubes in children. Rosenfeld RM, Schwartz SR, et al Otolaryngol
Head Neck Surg. 2013 Jul;149(1 Suppl):S1-35. doi: 10.1177/0194599813487302.

Clinical practice guideline: Otitis media with effusion. Rosenfeld RM1, Culpepper L, Otolaryngol Head Neck
Surg. 2004 May;130(5 Suppl):S95-118.

Middle ear disease in young children with sensorineural hearing loss. Brookhouser PE, Worthington DW, Kelly WJ.
Laryngoscope. 1993 Apr;103(4 Pt 1):371-8.

Impact of tympanostomy tubes on child quality of life. Rosenfeld RM1, Bhaya MH, Bower CM, et alArch Otolaryngol
Head Neck Surg. 2000 May;126(5):585-92.
Bibliography

Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal
Pharyngitis. Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin
JM, Van Beneden C. Clin Infect Dis. 2012 Nov 15;55(10):1279-82.

Clinical practice guideline: tonsillectomy in children.Baugh RF1, Archer SM, et al
Otolaryngol Head Neck Surg. 2011 Jan;144(1 Suppl):S1-30. doi:
10.1177/0194599810389949.

Polysomnographic and clinical findings in children with obstructive sleep apnea. Leach
J, Olson J,et al Arch Otolaryngol Head Neck Surg. 1992 Jul;118(7):741-4.

Diagnosis and management of childhood obstructive sleep apnea syndrome. Marcus
CL, Brooks LJ, et al Pediatrics. 2012 Sep;130(3):576-84. doi: 10.1542/peds.2012-1671.
Epub 2012 Aug 27.

Clinical practice guideline: Polysomnography for sleep-disordered breathing prior to
tonsillectomy in children. Roland PS, Rosenfeld RM, et al. Otolaryngol Head Neck Surg.
2011 Jul;145(1 Suppl):S1-15
Bibliography
 Epidemiology of asthma and allergic rhinitis in a total community,
Tecumseh, Michigan. 3. Second survey of the community. Broder I,
Higgins MW, et al J Allergy Clin Immunol. 1974 Mar;53(3):127-38.
 Functional endoscopic surgery in children: a retrospective analysis of
results. Parsons DS1, Phillips SE. Laryngoscope. 1993
Aug;103(8):899-903.
 Comparative effectiveness of amoxicillin and amoxicillin-clavulanate
potassium in acute paranasal sinus infections in children: a doubleblind, placebo-controlled trial. Wald ER, Chiponis D, LedesmaMedina J. Pediatrics. 1986 Jun;77(6):795-800.
 Treatment of acute maxillary sinusitis. A comparison of four different
methods. Axelsson A, Chidekel N, et al Acta Otolaryngol. 1970
Jul;70(1):71-6