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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 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 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 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: Poor growth and development High blood pressure Lung injury (Cor pulmonale) Heart failure Premature death Diagnosis Symptoms suggestive of OSA Snoring Witnessed apnea Mouth breathing Frequent awakenings Daytime somnolence Behavior problems Headaches/ Irritability Poor school performance Diagnosis Signs 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 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 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 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