Paediatric ENT Update for General Practice PPG

Transcription

1 Paediatric ENT Update for General Practice PPG Mr Daniel Tweedie MA FRCS(ORL-NHS) DCH Consultant Paediatric ENT, Head and Neck Surgeon Evelina London Children s Hospital

2 Evelina London Children s Hospital Dedicated tertiary paediatric hospital in central London (St Thomas site) Completed in 2004 Built around children s requirements State of the art facilities Innovative management

3 Paediatric ENT Service Five consultants Among the largest specialist children s ENT units in the UK All aspects of paediatric ENT Very large airway practice Excellent links with adult ENT and other specialities

4 My practice Trained in SW Thames, fellowship training at Great Ormond Street Hospital All aspects of paediatric ENT- including airway, otology and head and neck surgery Training programme director for South London Council member of BAPO and Children s Surgical Forum at the Royal College of Surgeons Individualised patient care Latest evidence-based management and techniques

5 Today s objectives Clinical scenarios in paediatric ENT Common problems Diagnosis and management Interactive Question and answer opportunities

6 Scenario 1

7 Obstructive sleep apnoea in children Very common 12-15% snore 2% have OSA cases/year in UK Major public health problem Greatly under-recognised Treatment delays common

8 Causes of OSA in children Large tonsils and adenoids Adenoids more so in infants Other factors: ethnicity, C-F geometry, obesity, syndromes, poor tone Also consider rarer cases of central apnoeasin some syndromes, +/- neurological or developmental delay

9 Clinical effects of OSA in children Not necessarily as for adults: more variable Tiredness and lethargy or may be hyperactive Neurocognitive impairment/ IQ Poor concentration Poor appetite, poor weight gain Cardiopulmonary effects Many of these are reversible with prompt treatment

10 Diagnosis (1) Not always easy May be obvious from history- but may not be Snoring, apnoeas despite respiratory effort Head-extended position, mouth open Restlessness, frequent waking, bed wetting etc Daytime effects But parental history not always reliable- anecdotally low negative predictive value Size of tonsils and adenoids not always predictive

11 Diagnosis (2) History and clinical examinationaccepting limitations Sleep study- recorded domiciliary SaO 2 * Very fast turnaround at Evelina sleep centre One stop pick up; posted back; results in 5 days Polysomnography: gold standard, selected cases only

12 Treatment of childhood OSA Adenoidectomy Tonsillectomy Generally curative, some have residual or recurrent symptoms Other options including CPAP, and tracheostomy (rarely)

13 Scenario 2

14 Tonsillitis Very common Often viral Sometimes bacterial Glandular fever Management options

15 Tonsillitis: viral or bacterial? Centor criteria- score out of 5 Likelihood of group A Streptococcal pharyngitis 1. Fever 2. Tonsil exudates 3. Anterior cervical lymphadenopathy 4. Absence of cough 5. Age <16 add 1 point; age >44 subtract 1 point All 4: PPV 40-60% for Group A Strep None: NPV 80% Original study in adults-? applicability to children

16 Tonsillitis: management Management according to the SIGN guidelines 2010 Severe attacks: emergency referral No routine throat swabs Simple analgesia Antibiotics according to clinical picture (Centor) Penicillin V QDS for 10 days

17 Recurrent tonsillitis SIGN recommendations Empirical treatment of each episode No great evidence for prophylactic antibiotics* Tonsillectomy if severe 7 attacks/ 1year; 5 attacks per year for 2 years; 3 attacks per year for 3 years Additional clinical judgement

18 Tonsillectomy Ancient procedure Numerous methods Traditionally extracapsular Cauterisation thermal injury Muscle exposed painful Vessels exposed risk of bleeding High rates of delayed discharge, readmission and post-operative haemorrhage (3-5%) Mortality risk

19 Coblation intracapsular tonsillectomy An alternative approach Cold radiofrequency ablation C Dissection within the tonsil capsule Underlying muscle and vessels not exposed

20 Coblation intracapsular tonsillectomy

21 Experience at Evelina Largest prospective series in the UK >430 cases since Spring 2013 All children: OSA and/or tonsillitis Very rapid recovery: 5-6 days Minimal analgesia No phone calls from parents No readmissions with pain 2 cases of bleeding (0.47%) Symptomatic improvement Excellent feedback: > 99% of parents would recommend

22 Scenario 3

23 Acute otitis media Commonest reason for under-5s to see their GP (70% affected by 2 years) Similar risk factors to glue ear- age, winter, male sex, family history, reflux Plus: low birth weight, poor immunity (incl. PCV), dummy use, bottle feeding

24 AOM: pathophysiology Viral URTIs /year in young children Generalised mucosal inflammation Impaired mucociliary clearance Short, horizontal Eustachian tubes- may allow bacterial ingress Limited immunity Bacterial supra-infection is common following initial viral infection Pneumococcus, Haemophilus, Moraxella

25 AOM: diagnosis Not always easy Variable history, especially in younger children (may not be febrile or in pain, may or may not have discharge) Softer symptoms, eg reduced appetite and play, restlessness at night etc Difficult otoscopic view +/- crying-induced vasodilatation of tympanic vessels

26 AOM: management 2013 AAP guidelines Single episodes Recurrent AOM Antibiotics Grommets Other measures Some differences vs equivalent Cochrane recommendations NICE CKS available (2009) but not formal guidelinessimilar to AAP

27 Single episodes of AOM Supportive measures: fluids, rest, regular analgesia (ibuprofen > paracetamol) Low threshold for admission of very young or toxic children Immediate or delayed antibiotic prescribing policy (see again at hours) Consider early antibiotics for certain cases: 3 months or younger, symptoms >4 days, bilateral infection in under 2s, perforation and discharge, comorbidities

28 Benefits of antibiotics Reduced mean duration of symptoms by a small amount Reduced risk of complications eg mastoiditis, meningitis etc

29 Which antibiotic? Both AAP and NICE recommend amoxilicillin as first line (clarithromycin or erythromycin if allergic) No consensus regarding duration (?5-10 days) Consider co-amoxiclav or cefuroxime in resistant casesexpect improvement by hours

30 What dose of amoxicillin? NICE: 40mg/kg/day in divided doses for 5 days (ie 13mg/kg TDS) But evidence from US CDC supports 80-90mg/kg/day, given high prevalence of resistant organisms Consider doubling the dose

31 Recurrent AOM AAP- 3 or more episodes in six months, or four in a year, with at least one in the past six months Particular risk factors: First infection < 3 months of age Persistent previous AOM > 10 days Winter months Male gender Passive smoking

32 Recurrent AOM- management Manage each episode Wait for resolution with time Address reversible risk factors (incl.pcv) Prophylactic measures

33 Recurrent AOM- prophylaxis Antibiotics- limited evidence to support low dose prophylaxis. Cochrane review mildly supportive, AAP does not recommend Options include trimethoprim (1-2mg/kg nocte), amoxicillin or azithromycin (10mg/kg M,Tu,W then off for 11 days) Grommets- more evidence to support these, but risks of persistent discharge and permanent perforation No evidence to support adenoidectomy

34 Complications of AOM Outer ear- otitis externa Middle ear- perforation, ossicular erosion, tympanosclerosis, adhesions, facial palsy Inner ear- toxicity to cochlea and labyrinth Intratemporal- mastoiditis Press on the cymba conchae Intracranial- meningitis, abscess, venous sinus thrombosis

35 Scenario 4

36 Glue ear Extremely common in pre-school children 40-60% affected at some point Inflammation of middle ear mucosa associated with non-purulent effusion and conductive hearing loss Variable clinical effects: poor listening skills, speech delay, frustration, withdrawn behaviour- or may have minimal effects

37 Glue ear- risk factors Individual Age- peaks at 2 and 5 Male sex Family history Nasal allergy/ adenoiditis Reflux Environmental Winter months Passive smoking Daycare with >4 children

38 Glue ear- management framework Nice guidelines 2008 Generally evidence based Some limitations

39 Glue ear-diagnosis Clinical suspicion Otoscopic examination Tympanometry Audiometry

40 Free field audiometry

41 Hearing tests for children Visual reinforcement Toy test Conditioned play

42 Glue ear- general steps Maximise listening opportunities School or nursery should be aware Care with crossing road etc Parental advice and reassurance Benign condition Active monitoring in the first instance- 3 months Short/medium term sequelae, less likely to produce long term problems

43 Glue ear- autoinflation Either self-valsalva or using Otovent balloon Not easy for younger children Some evidence to support use in parallel with active monitoring (Cochrane) Can be prescribed, or available online for about 6-8

44 Glue ear- after 3 months Options include further active monitoring Particularly if parents are happy and child is doing well Hearing aids- no complications, effective increase in volume with normal underlying sensorineural hearing (especially those with cleft palate or Down s syndrome) Surgery- grommets +/- adenoidectomy Other measures eg steroids, antibiotics, osteopathy etc- not recommended by NICE

45 Grommets Reasonable option for hearing loss 25-30dB in the better hearing ear for 3 months Remain in situ for 6-18 months before extruding Consider adenoidectomy: prolongs benefits of grommets

46 Grommets- problems Limited duration of benefit 6-8 months on average Adenoidectomy at the same time is known to prolong the beneficial effects of grommets Difficult to demonstrate long-term benefits of surgical intervention for glue ear Risks of recurrence, discharge (5-10%) and persistent perforation (1-2%)

47 Grommets FAQs/ answers OK to swim after 6 weeks- no proven benefit of keeping the ears dry Avoid immersion in bath water + avoid diving deep under water Treat discharge with water precautions +/- topical medication OK to use antibiotic drops if the ear is infected- I tend to use ciprofloxacin eye drops: 3 drops BD for 10 days

48 Thank you ENT patient information and resources for doctors at danieltweedie.com