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The ABC’s of Pediatric ENT

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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

4 Infant 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

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