ENT Potpourri. Stuart Morgenstein, D.O Pediatric Otolaryngology

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1 ENT Potpourri Stuart Morgenstein, D.O Pediatric Otolaryngology

2 None to Disclose Conflict of Interest

3 External Otitis Media Occluded canal/ exquisite pain touching EAC and auricle. Canal skin swollen, weeping Place wick and drops. No po abx unless auricle inflamed. Pain management.

4 Foreign Body Ear Make limited attempt to remove. Inform family may fail, child will cry and there can be some bleeding (canal skin bleeds easily) Only urgency: Battery Family upset ( dissatisfied ) if perceive you are hurting their : crying, bleeding and, worse, fail to remove foreign body.

5 Nasal Foreign Body Limited attempt to remove Could risk pushing foreign body into nasopharnx and aspirated (bead) Only urgency: battery

6 Acute Otitis Media?? Observe 48 hours : 6mo-23 month or older, non severe symptoms Consensus against: reduced suppurativecomplications cannot predict complications improved patient outcomes (? Satisfaction)

7 Treatment Acute Otitis Media Amoxicillin if no prior Rx 30d. Erythromycin/sulfisoxazole if PCN allergy Resistant strains or prior Amox RX: augmentum or cephalosporin or trimethoprim-sufamethoxazole

8 Cholesteatoma Definition: epithelial lined sac that contain enzymes that, over time, will destroy ossicles, erode into middle fossa tegmen(roof), facial nerve, inner ear Presentation: chronic draining ear, polyp on exam, hearing loss, vertigo etc. Refer

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11 Otitis Media with Effusion 90% will resolve within 3-4 months No benefit abx, steroids, decongestants, etc After 4 months consider referral

12 Ventilation Tube Insertion Guidelines No tubes after single episode of acute otitis media < 3 months duration No tubes kids with recurrent otitis media who DO NOT have middle ear fluid at time of initial ENT physician exam Consider tubes if history of recurrent otitis media 3 months or longer with documented hearing difficulties

13 Guidelines (cont d) Consider tubes if history of recurrent otitis media 3 months or longer with fluid NOTED on initial exam by ENT Hearing loss on audiogram

14 Otalgia Acute / Ext otitis media TMJ Tonsillitis/ tonsil abscess ( referred Pain) Hypopharyngeal cancer Sternocleidomastoid mm tendonitis

15 Sudden Sensornieural Hearing Loss Def: Rapid onset hearing impairment over 72 hours or less (30db 3 frequencies) Etiology: 85% idiopathic. infection(acute otitis media), vascular,(stroke),trauma, autoimmune, neoplasm drugs Incidence: 5-20 per 100,000 Symptoms: Hearing loss, aural fullness, tinnitus, vertigo Prednisone 1mg/kg x 1 week and taper??helps Tx: 65 % spontaneous resolution but Refer!!!!!

16 Facial Nerve Palsy Rapid onset 24-48hrs Symptoms: facial weakness, pain mastoid, numbness around ear, hyperacusis, dysgeusia Tx: 85% spontaneous resolution 3 months Prednsione 1mg/kg taper 2-3 weeks, oral antiviral (ie: valacyclovir 500mg tid 7 days Eye care : drops/ointment Progression over 3 months, recurrence or persistent think neoplasm!!! Imaging Refer

17 Large Tonsils Tonsil maximize size about age 6-8 yo In kids can often fluctuate in size since active part of immune system with frequent URI s in this age group. Contract as they enter adolescence. Size of tonsils often does not correlate with degree of snoring or OSA!!!

18 Asymetric Tonsils Common in peds Uncommon adults and more concern ENT opinion if unsure Bx would require tonsillectomy

19 Tonsillectomy Guidelines 3 documented and treated infections/year for 3 years 5 documented and treated infections/year for 2 years 6-7 documented and treated infections in 1 year

20 Pertonsillar Abscess Symptoms duration 3-5 days or so Drooling, odynophagia,referred ipsilateral otalgia, trismus, unilateral tonsil swelling, muffled voice, uvula edematous and shifted off midline Treatment (my preference) Call ENT and discuss. Often can respond to po Abx and steroids. If needed may be able to drain in office if adult. Avoid imaging.

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24 Sleep Studies I prefer to evaluate first or call Expensive: $

25 CT vs MRI vs Ultrasound CT: 2% peds cancer? Related to dx radiation MRI: No radiation, requires sedation, more expensive, Ultrasound : cheaper, faster, no sedation, no radiation If not sure, talk to your radiologist or ENT

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28 Battery Ingestion Most common: 3V 20 millimeter Found: remote control devices, thermometers,calculators,key fobs, flashing shoes, toys etc If suspect, do plain xrays ( double rim vs coin) Damage stomach 2-4 hours Esophageal perforations, tracho-esoph fistula Erosion aorta : exsanguination National Battery Hotline:

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30 Acute Sinusitis 80% viral 5-13 % secondary bacterial infection Viral vs bacterial: color, pain, fever not dx?tx: Benefits: decrease duration of illness, symptoms,? Prevent complications Rx: DOC: Amoxicillin 45-90/mg/kg/d divided 2 Allergy Pcn: cephalosporin, clarithromycin Failed amoxicillin: augmentum No imaging

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35 Dysphonia/Hoarseness Causes: misuse, PND, GERD, cord polyps, granuloma, cord paresis, cancer, etc Treatment: voice rest (no whispering ), increase fluids.?? PO steroids Empiric tx PPI: NO!! Kidney dz, low bone mineral density, etc,. Rarely helpful. After about 2 weeks: Refer!! For direct visualization of cords

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40 Conclusion Develop relationship with your favorite ENT Call for advice / information 24/7 Remember: No one will send you a thank you note for saving them money. They will, however, send you a subpoena

41 Questions?? Thank You