1. The ABC’s of Pediatric ENT
Charles M. Bower, M.D.
Chief Pediatric Otolaryngology
Arkansas Children’s Hospital

2. Disclosures
None

3. Summary Hearing loss Stridor Otitis media Tonsillectomy Sinusitis
Epistaxis

4. Infant hearing screening

5. 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

6. 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.
Incidence per 10,000 births

7. Reading Comprehension Scores of Hearing and Deaf Students
Grade Equivalents
Age in Years
Schildroth, A. N., & Karchmer, M. A. (1986). Deaf children in America, San Diego: College Hill Press.

8. 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

9. 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
ENT
Audiology
Genetics
Ophthalmology

10. 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

11. Stridor

12. Definitions Stridor--high pitched laryngeal noise
Congenital or acquired
May be associated with respiratory distress
Requires evaluation

13. Airway symptoms/signs
Stridor
Biphasic = subglottic
Inspiratory = supraglottic
Expiratory = Intrathoracic
Retractions
Feeding difficulties
Blue spells
FTT
OSA

14. Differential Diagnosis-Congenital Stridor
Laryngomalacia
Vocal cord paralysis
Subglottic stenosis
Tumors (hemangioma, papilloma)

15. Laryngomalacia Most common cause of inspiratory stridor (80%)
FTT, blue spells, dysphagia
Diagnosis
NP scope
MLB for secondary lesions
Treatment
Observation in 90%
Monitor weight
Rx GER, dysphagia, rhinitis
Epiglottiplasty

16. Subglottic stenosis Biphasic stridor Croupy cough
History of intubation
Diagnosis
NP scope
Plain films
ML and B

17. Tumors (hemangioma, papilloma)
Biphasic stridor
Progressive
Hoarse (papilloma)
Cutaneous hemangioma
Diagnosis
NP scope
Plain films
ML and B

18. AOM Recurrent AOM Chronic Otitis Media with Effusion (COME)

19. New Guidelines AAO/AAP/AAFP

20. 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:

21. Definitions Acute Otitis Media AOM) Otitis Media with Effusion (OME)
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.

23. Acute otitis media

24. Otitis Media
OME
Acute

25. Surgical indications Recurrent Acute Otitis Media
3 episodes in 6 months or in one year
With evidence of OME in at least one ear

26. 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

27. Otitis media – Treatment Surgical Options
Tympanocentesis/myringotomy for acute otitis media
Tube insertion for chronic otitis media
Adenoidectomy

28. Tympanocentesis Diagnostic importance May decrease pain
No significant impact on clinical resolution of AOM.
No randomized data

29. Tube insertion

30. Tympanostomy and Tube Insertion

31. 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

32. 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

33. 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

34. Tonsillectomy

35. 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,

36. 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

37. 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

38. 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 Nov 15;55(10):

39. Tonsillectomy and Adenoidectomy

40. Tonsillectomy - Indications
Recurrent tonsillitis >7 episodes in 1 year
>5 episodes/yr for 2 yr
>3 episodes/yr for 3 yr
Paradise criteria

41. Tonsillectomy – Indications
Obstructive sleep apnea
Snoring
Restless
Pauses
Arousal
EDS
Behavior
Enuresis

42. Tonsillectomy – Indications
Complicated Recurrent
Peritonsillar abscess
Tonsillitis
Acute airway obstruction
PANDAS?
Chronic tonsillitis
Obstructive Tonsil hyperplasia
Neoplasia

43. 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

44. 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

45. Obstructive Sleep Apnea
Serious consequences of sleep apnea:
Poor growth and development
High blood pressure
Lung injury (Cor pulmonale)
Heart failure
Premature death

46. Diagnosis Symptoms suggestive of OSA Snoring Witnessed apnea
Mouth breathing
Frequent awakenings
Daytime somnolence
Behavior problems
Headaches/ Irritability
Poor school performance

47. Diagnosis Signs Nasal obstruction Adenotonsillar hypertrophy
Macroglossia
Craniofacial anomalies
Weight (<10, 10-90, >90 percentile)
Pulmonary hypertension
Cor pulmonale

48. Diagnosis • Adenotonsillar hypertrophy size • 0 Prior tonsillectomy
• + No extrusion
• ++ Extrude partially out of tonsil fossa
• +++ Fill oropharynx
• ++++ Kissing tonsils

49. Testing Overnight Pulse oximetry 4 channel sleep studies
Polysomnography
Refer for PSG
Refer for consultation
Sleep Tape
Xray
Testing

50. 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%

51. 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

52. Treatment- OSA Surgical
T and A– 60-90% cure rate
UPPP
Septoplasty
Hyoid advancement/expansion
Tongue reduction
Lingual tonsillectomy
Maxillary/mandibular surgery
Tracheotomy

53. Sleep apnea after T and A
Complete reassessment
PSG important
Medical management
Treat the nose
Weight loss
CPAP
Further surgery

54. Sinusitis

55. Pediatric Rhinosinusitis
S’not snot s’mucous!
Signs and symptoms
Overlap with URI
Overlap with Allergic Rhinitis
Overlap with other conditions

56. Sinusitis Average infant has 6 colds per year
Average infant in daycare has 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

57. Duration of Symptoms in URI’s
% of Patients with Symptom 70
Fever 60
Sore Throat 50
Cough
Nasal Drainage 40 30
After a common viral respiratory tract infection, symptoms related to the illness gradually subside.
The viral stage usually lasts for about 5-7 days, and after this time period, the likelihood of a bacterial infection rises. It is not until this period of thime that antibiotics are recommended to treat the bacterial phase of the inflammation. 20 10 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Day of Illness

58. Allergic rhinitis incidence
Percent with
Allergic Rhinitis
Broder 1974

59. Sinusitis Progression to sinusitis Inflammation (URI, allergy)
Mucosal edema
Mucociliary dysfunction
Sinus ostia occlusion
Sinusitis (empyema)

60. Pediatric Sinusitis Symptoms
Chronic nasal obstruction 100%
Purulent nasal discharge 90%
Headache %
Cough %
Fetid breath %
Postnasal drainage 63%
Behavior changes 63%
Parsons Phillips 93

61. 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

62. Sinusitis Diagnostic challenges
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)

63. 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

64. Sinusitis Adjunctive measures Clinical response at two weeks:
Nasal steroids
Decongestants
Nasal hygiene
Social factors
Clinical response at two weeks:
Placebo effect 60%
Antibiotic treatment effect %

65. Sinusitis Treatment Antibiotic selection Duration of treatment
Like AOM
Reduce symptoms
Reduce risk of complications
Duration of treatment
10 days
Consider up to 3 weeks in non-responders

66. 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

67. Sinusitis Surgical Management Irrigations/windows Adenoidectomy FESS
Diagnostic
Cultures
Severe disease, immune compromise
Adenoidectomy
60% improvement
First surgery in young children
FESS
80-90% improved
Other

68. Sinusitis Summary Diagnosis Evaluation
Clinical (Severity or duration rules)
Sparing use of x-rays
Evaluation
Allergy, if older or positive family hx
Other disease

69. Epistaxis Nose bleeds are common with URI’s Mucosal inflammattion
Frequent nose bleeds
Anterior nasal septum vessels
Poor nasal hygiene
Low humidity

70. Epistaxis Treatment Nasal hygiene
Saline irrigations
Topical lubricants (Vasoline, Polysporin)
Nasal cautery
Silver nitrate

71. Frenulotomy Short lingual frenulum Consequences Treatment
Breast feeding
Speech?
Treatment
Elective frenulotomy

72. 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

73. 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

74. Bibliography
Screening children's hearing. Haggard M. Br J Audiol Aug;26(4):
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 Mar;131(3):e
Casselbrant ML, Mandel EM. Epidemiology. In: Rosenfeld RM, Bluestone CD, eds. Evidence-Based Otitis Media. 2003:
Clinical practice guideline: Tympanostomy tubes in children. Rosenfeld RM, Schwartz SR, et al Otolaryngol Head Neck Surg Jul;149(1 Suppl):S1-35. doi: /
Clinical practice guideline: Otitis media with effusion. Rosenfeld RM1, Culpepper L, Otolaryngol Head Neck Surg May;130(5 Suppl):S
Middle ear disease in young children with sensorineural hearing loss. Brookhouser PE, Worthington DW, Kelly WJ. Laryngoscope 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 May;126(5):

75. 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 Nov 15;55(10):
Clinical practice guideline: tonsillectomy in children.Baugh RF1, Archer SM, et al Otolaryngol Head Neck Surg Jan;144(1 Suppl):S1-30. doi: /
Polysomnographic and clinical findings in children with obstructive sleep apnea. Leach J, Olson J,et al Arch Otolaryngol Head Neck Surg Jul;118(7):741-4.
Diagnosis and management of childhood obstructive sleep apnea syndrome. Marcus CL, Brooks LJ, et al Pediatrics Sep;130(3): doi: /peds 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 Jul;145(1 Suppl):S1-15

76. 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 Mar;53(3):
Functional endoscopic surgery in children: a retrospective analysis of results. Parsons DS1, Phillips SE. Laryngoscope Aug;103(8):
Comparative effectiveness of amoxicillin and amoxicillin-clavulanate potassium in acute paranasal sinus infections in children: a double- blind, placebo-controlled trial. Wald ER, Chiponis D, Ledesma- Medina J. Pediatrics Jun;77(6):
Treatment of acute maxillary sinusitis. A comparison of four different methods. Axelsson A, Chidekel N, et al Acta Otolaryngol Jul;70(1):71-6