Paediatric Otolaryngology

Transcription

1 Paediatric Otolaryngology Antony A Narula MA FRCS FRCS Ed Consultant St Mary s & Ealing Hospitals Hon. Professor, Middlesex University 17 th July 2004

2 Otology Acute Otitis Media Otitis Media with Effusion (glue ear) Chronic Suppurative Otitis Media Trauma, Foreign Bodies Otitis Externa

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4 Acute Otitis Media Pre-school children; 85% settle spontaneously within 24 hrs After 24hrs antibiotics do influence natural history Repeated episodes of acute otitis media in 12 months: Adenoidectomy + Grommets

5 Complications Perforation Facial palsy Mastoiditis Lateral Sinus Thrombosis Intracranial meningitis, abscess

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7 Mastoiditis masked variety Swelling of the postero-superior meatal wall Systemic upset, swinging pyrexia CT scanning Aggressive treatment; IV ABiotics +cortical mastoidectomy

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9 Otitis Media with Effusion - Glue Ear Eustachian tube dysfunction Symptoms - speech and language delay, behavioural, imbalance No otalgia : silent otitis Natural history: peak incidence 2-6 years

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11 Treatment Oral steroids - only medication shown to clear fluid Antibiotics, antihistamines, decongestants do not alter the natural history Bilateral 30dB loss for 3 months with symptoms Grommets Adenoidectomy Treat coexisting chronic rhinitis

12 The Problem OME affects 20% of children Often short-lived Possible effects on speech / education Thousands of operations each year Very poor evidence base

13 Follow Up Details All children followed up for min 2 years Analysed on intention to treat basis 550 children entered in 7 centres Numerous measures inc. social functioning Case notes monitored thereafter

14 Main Outcomes Moderate OM history is relevant Hearing level alone is an inadequate surrogate measure of disability Speech and language development Anti-social behaviour Social immaturity

15 Spontaneous Improvers season initial hearing level referral route passive smoking +ve sibling history

16 Hearing Levels >20 db on two occasions = entry criterion These are severely affected children Up to 50% still consulting in year 4

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18 Adenoidectomy Respiratory health Sleep patterns Hearing levels Lasts beyond 2 years with reduced repeat consultations

19 Other Outcomes Grommets reduce acute otitis media Surgical treatment is cost-effective in QALYs

20 TARGET Results Grommets do work Adenoidectomy offers added value Applicable to children over 3.5 years

21 Chronic Suppurative Otitis Media CSOM Otorrhoea and deafness +/- pain Classify as SAFE or UNSAFE SAFE :Reconstructive - Myringoplasty, Tympanoplasty, Ossiculoplasty UNSAFE : Establish a safe ear - Modified/radical mastoidectomy Combined approach tympanoplasty

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25 Complications of unsafe disease Facial palsy Semicircular canal fistula Dead ear Meningitis Brain abscess

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27 Rhinitis Increasing incidence Treat both the upper and lower airways?environmental pollution, dust mite faeces Treatment is environmental and medical Nasal steroids are the mainstay of treatment Antihistamines also helpful Mast cell stabilizers, leukotriene receptor antagonists disappointing

28 Engorged Turbinate

29 Polyps

30 Infective Rhino-sinusitis Children- Ethmoiditis Periorbital cellulitis Complications - orbital and intracranial Emergency referral

31 Peri-orbital Cellulitis

32 Fractured Nose Rare in childhood Exclude a septal haematoma No Xrays If too swollen to assess see in 7 days Refer if cosmetic displacement

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34 Tonsillitis Penicillin is still the antibiotic of choice Quinsy uncommon in children Tonsillectomy for recurrent acute tonsillitis - 5 episodes each year for two years in association with adenoidectomy in adenotonsillar hypertrophy

35 Indicators for inpatient stay following Ts&As (1) Age <36 months Significant pre-operative apnoea Medical co-morbidities asthma, cardiac disease Narrow pharyngeal airway: mandibular hypoplasia eg. Treacher-Collins / Down syndromes; mucopolysaccharidoses

36 Indicators for inpatient stay following Ts&As (2) Respiratory distress in the immediate postoperative period Social factors - distance from hospital lack of telephone or car poor carer reliability

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38 Tonsillar hypertrophy can compromise the oropharyngeal airway significantly (especially during URTI)

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42 Paediatric Airway Neonate obligate nasal breather Highly placed larynx Feeding Difficulties/Reflux Dysphonia / abnormal cry Stertor & Stridor

43 INFECTION Epiglottitis, Laryngotracheobronchitis (croup) Airway oedema and narrowing May need intubation Extubation after MLB

44 Epiglottitis H.influenzae (cf HiB vaccine) 2-6 years, boys > girls Rapid onset - 24hr history Systemic upset with severe pain on swallowing, sitting up,drooling Do not place instruments in the mouth

45 Croup Parainfluenza virus Insidious onset Barking cough No pain on swallowing Biphasic stridor?measles

46 Tracheostomy Morbidity and Mortality Huge social consequences for parents However, almost all will be ultimately decannulated

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49 Foreign Bodies History of coughing, choking +/- cyanosis Unilateral wheeze Signs of paradoxical respiration Early diagnosis important Treatment - MLB

50 Importance of E.N.T. Commonly performed procedures Large % of procedures in children Day case scenario High level of morbidity thus requiring vigilance

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