Pediatric Otolaryngology Disorders for Primary Care

Transcription

1 Pediatric Otolaryngology Disorders for Primary Care A SHOK N. REDDY, MD C O N C O R D O T O L A R Y N G O L O G Y H E A D A N D N E C K S U R G E R Y C O N C O R D, N H

2 Otolaryngology Pathology in Children Head and Neck Masses Sleep Disordered Breathing/OSA Pharyngitis Otitis Media/Cholesteatoma Sinusitis Airway Dysphonia

3 Head and Neck Masses Inflammatory masses Congenital masses Branchial Cleft Cyst Thyroglossal Duct Cyst Teratoma Lymphangioma (Cystic Hygroma) Hemangioma AVM Neoplasms Cancer Thyroid goiter/nodule

4 Head and Neck Masses Work Up History Duration Size trend Pain Fever Constitutional Symptoms Dysphagia Difficulty breathing Physical Size Erythema Tenderness Firmness Location

5 Head and Neck Masses Work Up Radiology Ultrasound Cons: Less illustrative of anatomy CT scan of neck with contrast Cons: Radiation exposure MRI with gadolinium Cons: May need general anesthesia Laboratory tests CBC ESR Bartonella titers PPD FNA biopsy

6 Inflammatory/Infectious Masses Palpable LNs in children are common. Differential Diagnosis Reactive LN Lymphadenitis (Strep, Mono) Suppurative lymphadenitis Lymphoreticulosis - Cat scratch disease Retropharyngeal or parapharyngeal space abscess Atypical Mycobacterium

7 Inflammatory/Infectious Masses Reactive LNs Palpable without fixation, redness, tenderness, fluctuance. Management - Watch and wait. Lymphadenitis Rubor, Calor, Dolor, Tumor Consider treating with a strong PCN analog such as Augmentin. Close followup. Consider referral to Otolaryngologist if not improving or appears unwell.

8 Inflammatory/Infectious Masses Symptoms of Suppurative Lymphadenitis/Neck Abscess Large, red, fluctuant. Symptoms of being sick Torticollis Management Options Aspiration Incision and Drainage Consider admission to Hospital for IV antibiotics

9 Congenital Neck Masses Branchial Cleft Cyst Incomplete obliteration of a branchial cleft. Lateral Neck mass anterior to SCM. Generally presents with infection. DDx - Suppurative lymphadenitis. Work up - Ultrasound or CT scan. Referral to Otolaryngologist for excision. Thyroglossal Duct Cyst Incomplete obliteration of tract as thyroid descends from base of tongue to base of neck. Midline Neck mass. Passes through middle of Hyoid bone (above thyroid cartilage). Moves with swallowing. Work up Ultrasound Normal thyroid? Sistrunk procedure Body of hyoid bone removed.

10 Congenital Neck Masses Teratoma Germ cell tumor Three germ cell layers (Ectoderm, Endoderm, Mesoderm) Midline mass generally May have hair or teeth in it. Rarely malignant AVM (Blue) Tumors with arterial venous connection CHF, Deformity Treated with sclerotherapy or ligation

11 Congenital Head and Neck Masses Hemangioma (Red) Capillaries and small vessels Involves skin and mucosa surfaces Rapid growth to 18 months Gradual involution Airway compromise, Affect vision, Deformity Treatment Propranolol Steroids Laser surgery Open surgery

12 Head and Neck Cancers in Children No. 1 fear of a parent Rare - 5% of pediatric cancers. Most common Pediatric H&N cancers Lymphoma >50% Rhabdomyosarcoma Thyroid cancer (PTC) Less common Nasopharyngeal Malignancy Salivary gland Malignancy Malignant Teratoma Other Sarcoma Neuroblastoma Signs and Symptoms Lack of response to treatment. Rapid growth Duration Multiple masses Involve multiple nodal basins Malaise Weight loss Loss of Appetite No signs of infection

13 Lymphoma Non Hodgkin's Lymphoma Hodgkin's Lymphoma More common Peak incidence 7-11 yo Tonsil asymmetry, neck mass Fever Weight loss Night sweats Malaise Less common Peak incidence yo Firm, rubbery neck mass Fever Weight loss Night sweats Malaise

14 Sleep Disordered Breathing (SDB) Spectrum Snoring to Obstructive Sleep Apnea (OSA) Abnormal respiratory patterns while sleeping Choking, Gasping, Breath holding, Loud snoring Snoring: 10%-20% of children OSA: 2%-4% of children

15 Sleep Disordered Breathing (SDB) Children who snore vs. non-snorers have lower scores on tests of * Attention Verbal skills Academic and Executive function Children with OSA have even worse scores.* Negative effects of SDB in children without OSA* Increased Anxiety Increased Depression scores Increased Social problems *Owens JA. Neurocognitive and behavioral impact of sleep disordered breathing in children. Pediatr Pulmonol. 2009;44(5): *Holbrook CR, et al Neurobehavioral implications of habitual snoring in children. Pediatrics. 2004;114(1):44-49

16 Signs & Symptoms of OSAS (AAP Guideline) History Snoring > 3 nights/week Labored breathing while asleep Gasping, snorting, witnessed apneas Secondary sleep enuresis Abnormal sleep positions Cyanosis ADHD Learning difficulties Physical Exam Over or underweight Tonsil hypertrophy High-arched palate Hypertension Micrognathia/Retrognathia Mouth breathing

17 OSAS Workup Primary Referral to an otolaryngologist or sleep medicine specialist Attended, overnight sleep study in a sleep lab Secondary (Only if Primary options not available) Nocturnal video recording Nocturnal oximetry Daytime nap polysomnography Ambulatory polysomnography * AAP OSAS Guideline 2012

18 Sleep Disordered Breathing (SDB) Sleep study is not necessary unless (AAO guidelines) Moderate to severe OSA suspected Age <3 Craniofacial anomalies Down syndrome Adenotonsillectomy is highly effective in children EXCEPT Moderate to severe OSA Overweight Craniofacial anomalies Down syndrome Consider repeating sleep study post surgery. CPAP

19 Tonsillectomy and Adenoidectomy (OSAS) Outpatient procedure except for children with risk factors Risks Bleeding (delayed between Days 5-14) Velopharyngeal insufficiency Nasopharyngeal stenosis Anesthetic complications Risk Factors Age <3 yo Moderate to severe OSA Obesity Neuromuscular disorders

20 Postop recovery 2 weeks recovery (out of school, parents take time off) Soft diet x 2 weeks Acetaminophen and/or ibuprofen for pain control FDA Black label warning on use of codeine for postop pain management after T&A in pediatric patients with OSA. Vast majority of kids do well. Slight voice change postop.

21 Recurrent Acute Pharyngitis Natural History will resolve on its own Paradise Criteria for Tonsillectomy 7 episodes in one year 5+ episodes in each of last two years 3+ episodes in each of last three years Clinical features of an episode: Sore throat + one of below features: Temp >100.9 degrees F Cervical adenopathy (tender LN or LN>2cm) Tonsillar exudate Culture positive for group A B- hemolytic streptococcus

22 Recurrent Acute Pharyngitis Modifying factors Earlier tonsillectomy Multiple antibiotic allergies Episodes are severe or poorly tolerated PFAPA (Periodic Fever, Aphthous stomatitis, Pharyngitis, Adenitis) Peritonsillar abscess PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Assoc. with Strep.) Other indications (Must weigh against risks of surgery) Malocclusion Halitosis Tonsillithiasis Febrile seizures

23 Peritonsillar Abscess Symptoms Muffled (Hot Potato) voice Uvular deviation (Asymmetric oropharynx) Trismus Treatment Drainage Oral antibiotics Steroids Tonsillectomy after 2 nd episode

24 Ear Pathology Otitis Media Acute Otitis Media Recurrent Acute Otitis Media Chronic Otitis Media Complications of Otitis Media Tympanic Membrane Perforation Spontaneous rupture with AOM Chronic Cholesteatoma Hearing loss

25 Otitis Media Definitions Acute Otitis Media Recurrent AOM >3 separate AOM episodes within 6 months. >4 separate AOM episodes within 12 months with 1 in the past 6 months. Otitis Media with Effusion (OME) Presence of serous or mucoid effusion No AOM Chronic Otitis Media (COM) OME > 3 months

26 AOM Complications Acute Mastoiditis Coalescent Mastoiditis Bezold s Abscess Intracranial Complications Sigmoid Sinus Thrombosis Picket Fence Fevers Meningitis Intracranial Abscess

27 Recurrent Acute Otitis Media Pneumococcal Conjugate Vaccine decreases incidence. Breast feeding decreases incidence. Prophylactic antibiotic therapy not effective. Chiropractic therapy not effective. Recurrent AOM will eventually resolve. PE tube placement (AAO guidelines) Effusions present at time of evaluation. >3 separate AOM episodes within 6 months. >4 separate AOM episodes within 12 months with 1 in the past 6 months. Benefits Mean decrease of three episodes of AOM per year after PETs. Ability to treat additional episodes with antibiotic ear drops.

28 Chronic Otitis Media OME usually resolves within 3 months. Symptoms Minimal effectiveness found with using nasal balloon inflation. Hearing loss Discomfort Dizziness Poor school performance PE tubes - OME > 3 months duration with: Hearing loss Other symptoms Speech delay May elect to perform earlier in children with: Down Syndrome Congenital malformations Other risk factors.

29 Tympanostomy Review Indications: Recurrent AOM with effusion 3+ episodes in 6 months 4+ episodes in 12 months, 1 in past 6 months Chronic OM OME > 3 months At risk children Mean decrease of three episodes of AOM per year after PETs. Up to 50% of patients need a 2 nd set of tubes Adenoidectomy with 2 nd set of tubes if Age >4 yo.

30 Tympanostomy Risks Bleeding Infection Pain Tympanic membrane perforation Hearing loss Cholesteatoma

31 Post-Tympanostomy Topical therapy 1 st line - AOM Oral antibiotics 2 nd line - AOM Consider debridement by Otolaryngologist Tube Otorrhea Biofilm May need IM antibiotics May need replacement of PETs See otolaryngologist every 6 Months.

32 Tympanic Membrane Perforation

33 Not Tympanic Membrane Perforation Monomeric Tympanic Membrane Tympanic Membrane Retraction

34 Tympanic Membrane Perforation AOM with spontaneous rupture TM perforation symptoms Etiology Bloody otorrhea or blood in EAC- Not worrisome Perforation will heal easily Treat AOM Hearing loss Recurrent OM Tympanostomy, Trauma Treatment options Myringoplasty small perforations Minor procedure Fat or thin paper laid over the perforation Easier recovery Tympanoplasty large perforations Longer recovery Longer surgery Fascia or perichondrium is laid under or over the TM covering the perforation.

35 Cholesteatoma What is it? Expanding, keratinizing, squamous epithelial tumor Benign Etiology Congenital TM perforation TM retraction Congenital Asymptomatic pearl in intact TM

36 Cholesteatoma Symptoms Asymptomatic Hearing loss Recurrent OM Chronic otorrhea Aural Polyp Draining Ear Treatment Surgery Complications Hearing loss Intracranial extension Meningitis Intracranial abscess

37 Hearing Loss Sensorineural Hearing loss Tuning Fork test is heard in normal hearing ear (opposite) Humming with mouth closed opposite ear Not Reversible Conductive Hearing loss Tuning Fork test is heard in hearing loss ear (same ear) Humming with mouth closed same ear as hearing loss Largely Reversible

38 Sensorineural Hearing Loss Rare in children Congenital loss is detected via screening at birth Hereditary hearing loss Congenital Progressive Present at later ages High degree of vigilance Noise Trauma Sudden Hearing Loss

39 Sensorineural Hearing Loss Sudden Hearing Loss Prompt diagnosis Oral steroids within 4 weeks Intratympanic injection of steroids Workup for Schwannoma Hereditary Conditions Pendred syndrome Jervelle and Lange-Neilsen Syndrome Usher Syndrome Treatment options Hearing aids, FM system Cochlear implants

40 Cochlear Implant Electrode Array in cochlea Candidacy Age >12 mos. Bilateral, severe to profound HL No improvement in speech with hearing aids Implant before age 18 mos. Language skills comparable to normal hearing peers Mainstream classrooms Appreciate music

41 Conductive Hearing Loss Middle ear effusion most common Cerumen TM perforation Cholesteatoma Rare Ossicular chain discontinuity, Aural atresia Treatment options PE tubes Ossicular Chain Reconstruction BAHA Hearing aids, FM system

42 BAHA Titanium implant Processor Bone conduction Conductive hearing loss Chronic mastoiditis following surgery Aural atresia Ossicular chain discontinuity More natural hearing than cochlear implant Processor trialed on a head band

43 Sinusitis Acute Sinusitis Chronic Sinusitis More severe symptoms Fever? Some risk of intracranial/eye complications Antibiotics >10-14 days of symptoms Worsening of symptoms after initial improvement. Less severe symptoms No fever Minimal risk of severe complications > 3 Months duration Linked with Allergic Rhinitis

44 Acute Sinusitis Antibiotic Choice First Line Amoxicillin double dose (80 mg/kg) Clarithromycin Azithromycin Second Line Augmentin 2 nd or 3 rd generation Cephalosporins (Cefuroxime) Macrolides Clindamycin

45 Acute Sinusitis Complications Preseptal Cellulitis (Periorbital Cellulitis) Orbital Involvement Orbital cellulitis Orbital abscess Cavernous Sinus Thrombosis Intracranial Infection Meningitis Intracranial Abscess

46 Airway Nasal Laryngeal Esophageal Symptoms Respiratory distress Stridor, Retractions Drooling/Dysphagia Unilateral rhinorrhea Infection that does not resolve with treatment

47 Airway Obstruction Foreign body Infection URI RSV, etc. Croup Epiglottitis Trauma Neoplasm Subglottic hemangioma Teratoma Dermoid cyst Congenital Choanal atresia Laryngomalacia Laryngotracheal anomaly

48 Toddlers Foreign Body Laryngeal, Nasal, Aural, Esophageal Symptoms Sudden Stridor, Unilateral Rhinorrhea, Dysphagia, Drooling, Ear infection Unresolving Infection Suspected laryngeal FB is an EMERGENCY. Send to ER Suspected Battery FB is an EMERGENCY Send to ER Nasal/Ear FB Can be handled in office.

49 Infections Epiglottitis EMERGENCY Fever Drooling Tripodding, Respiratory distress Much less common since Hib vaccine Diphtheria Uncommon Corynebacterium diphtheria Vaccine Croup Viral Symptom management, May need admission for treatment

50 Neonatal period - Neoplasm Subglottic hemangioma May resolve as they get older. Treated with B-blockers or surgery. Lymphangioma Teratoma Dermoid cyst Endoscopy or Imaging

51 Neonatal period - Laryngomalacia Stridor feeding, lying supine Crying Thriving child Manifests at age 4 weeks Generally self-resolving by Age 2. Fiberoptic laryngoscopy is diagnostic Floppy epiglottis and larynx

52 Neonatal period - Laryngomalacia Severe Hypoxemia Cyanosis OSA May be associated with other congenital anomalies Surgical intervention 10% Referral to Otolaryngologist for endoscopy

53 Neonatal period Choanal Atresia Bilateral Life threatening Unilateral Unilateral rhinorrhea Unable to pass catheter through one or both nasal passages. CT scan of sinuses Referral to pediatric otolaryngologist

54 Laryngotracheal Anomalies Symptoms Dysphonia Dysphagia Aspiration Recurrent pneumonia Failure to thrive Workup Swallow study Fiberoptic laryngoscopy Direct laryngoscopy Vocal Cord Paralysis Laryngotracheal cleft Tracheo-esophageal fistula Treatment Swallow therapy Surgery

55 Dysphonia Symptoms Differential Diagnosis Weak Cry Breathy Voice Aspiration Recurrent Pneumonia Stridor (Bilateral VC paralysis) Allergies GERD Vocal Cord Nodules Tumors Iatrogenic Congenital Vocal Cord Paralysis Recurrent Respiratory Papillomatosis (RRP)

56 Recurrent Respiratory Papillomatosis Rare Presents Age <5 yo. Dysphonia Fiberoptic laryngoscopy shows papillomas of larynx HPV Peripartum transmission Risk factors First Born Mother Age <20 yo Vaginal Delivery

57 Recurrent Respiratory Papillomatosis Suspect abuse presents at age >5 yo Malignant transformation 3% Treatment Repeat Surgery Cidofivir May resolve or may persist

58 Other Vocal Cord Lesions Vocal Cord Nodules Vocal cord