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The ABC’s of Pediatric ENT

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.

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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 • 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. Incidence per 10,000 births 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.

  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: audiologicaleval • 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. AOMRecurrent AOMChronic Otitis Media with Effusion (COME)

  19. New GuidelinesAAO/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. 2003:147-162.

  21. 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

  22. Acute otitis media

  23. Otitis Media OME Acute

  24. 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

  25. 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

  26. Otitis media – TreatmentSurgical Options • Tympanocentesis/myringotomy for acute otitis media • Tube insertion for chronic otitis media • Adenoidectomy

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

  28. Tube insertion

  29. 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

  30. 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

  31. 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

  32. Tonsillectomy

  33. 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,

  34. 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

  35. 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

  36. 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 BenedenC. Clin Infect Dis. 2012 Nov 15;55(10):1279-82.

  37. Tonsillectomy and Adenoidectomy

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

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

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

  41. 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

  42. 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

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

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

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

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

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

  48. 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%

  49. 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

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