Common ENT Problems: How to evaluate and when to refer Maria C. Veling M.D. Pediatric Otolaryngology University of Kentucky April 2009 1
Objectives Identify symptoms and findings of clinically significant adenotonsillar hypertrophy Describe the current guidelines for tonsillectomy and adenoidectomy Describe the current treatment guidelines for otitis media Define indications for surgery in pediatric sinusitis Describe other emergent ENT outpatient scenarios
Clinical Indicators for T&A Patient with 3 or more infections of tonsils and/or adenoids per year despite adequate medical therapy. Peritonsillar abscess unresponsive to medical management. Chronic or recurrent tonsillitis associated with the streptococcal carrier state and not responding to beta-lactamase-resistant antibiotics. Persistent foul taste or breath due to chronic tonsillitis not responsive to medical therapy. Hypertrophy causing dental malocclusion or adversely affecting orofacial growth documented d by orthodontist. ti t Hypertrophy causing upper airway obstruction, severe dysphagia, sleep disorders, or cardiopulmonary complications. Unilateral tonsil hypertrophy p y presumed neoplastic. http://www.entnet.org/practice/indicators/tonsillectomy.html
OBSTRUCTION 4
Adenotonsillar Hypertrophy Symptoms Snoring Mouth breather Restless Sleep Apnea Difficulty swallowing solids Muffled voice Hypo nasal speech
Tonsillar Size 0 in Fossa +1 <25% +2 25-50% +3 50-75% +4 >75%
Obstructive indicators for T&A Upper airway obstruction Sleep disordersd Cardiopulmonary complications Dental malocclusion or facial growth abnormalities Severe dysphagia
OSA in Children > 400,000000 T&A s are performed per year in children mostly for OSA Most tonsillectomies are performed in children for mild OSA OSA is associated with behavioral problems and is known to significantly affect quality-of-life < 10% of Otolaryngologists request PSG prior to T&A for OSA
Pediatric OSA and Behavior Several large studies have shown that children with SDB have behavioral problems Attention Hyperactivity Aggression Irritability Emotional and peer problems Somatic complaints N. Goldstein, et al Arch Otolaryngol Head Neck Surg. 128 (2002) 770-775. 775. Mitchell RB, Kelly J. Long-Term Changes in the Behavior of Children after Adenotonsillectomy for Obstructive Sleep Apnea. Otolaryngol Head Neck Surg. 2006 Mar;134(3):374-8.
Pediatric OSA- Outcome Studies PSG normalizes in 70-80% of normal children after T&A QOL of life improves dramatically. Over 95% of caregivers report improvement Behavior improves in 50% of children Correlation between improvements in PSG, QOL and behavior is poor Mitchell RB. Adenotonsillectomy for obstructive sleep apnea in children: outcome evaluated by pre- and postoperative polysomnography. (TRIO THESIS) Laryngoscope. 2007 Oct;117(10):1844-54. 1844 4
INFECTION 11
Infectious indications for Tonsillectomy 6-8 Episodes in one year 4-5 Episodes per year for 2 years 3 Episodes per year for 3 years
Peritonsillar ill abscess Oropharyngeal asymmetry y Trismus Hot Potato voice CT scan hardly ever necessary 20% will recur
Goals of adenotonsillectomy Adenotonsillectomy for sleep disordered breathing (SDB) in children is associated with improvements in sleep, quality-of-life life and behavioral problems Approximately 20% of normal weight children and 70% of obese children have persistent SDB after adenotonsillectomy Diminished rate of infection after adenotonsillectomy
OTITIS MEDIA 15
Otitis Media Otitis media is generally defined by the presence of effusion within the middle ear without reference to its cause or pathogenesis Acute otitis media (AOM) is usually associated with the rapid onset of symptoms and signs of acute infection in the middle ear space, including fever, otalgia, inflammation or bulging of the tympanic membrane, and purulent middle ear effusion Otitis media with effusion (OME) is the presence of Otitis media with effusion (OME) is the presence of serous, mucoid, or mucopurulent fluid in the middle ear without acute symptoms.
Natural history Otitis Media After an episode of untreated AOM, spontaneous clearance of OME may be expected in approximately 75% of children within 3 months; with treatment t t of the acute episode, clearance at 3 months may be as high as 90%. Patients with effusions with duration of at least 3 months at the time of diagnosis have the poorest prognosis, with only 27% clearance at 6 months and 32% at 1 year. Rosenfeld RM: Natural history of untreated otitis media. In Evidence- Based Otitis Media. Edited by Rosenfeld RM, Bluestone CD. Hamilton, Ontario: BC Decker; 1999:157 177
Oii Otitis Media The pathogenesis is multifactorial infection impaired Eustachian tube function immature immune status allergy
Surgical treatment of Otitis Media Acute Otitis Media Most studies of myringotomy with or without antibiotic therapy for AOM suggest no significant advantage over antibiotic therapy alone. The primary value of myringotomy or tympanocentesis is for culture to guide antibiotic therapy. Rosenfeld RM: What to expect from surgical therapy. In Evidence Based Otitis Media. Edited by Rosenfeld RM, Bluestone CD. Hamilton, Ontario: BC Decker; 1999:207 221.
Surgical treatment of Otitis Media Recurrent Acute Otitis Media (raom) Studies of raom suggest a trend toward improvement with conservative management As a result, for children with raom whose episodes are nonsevere or have occurred only for a limited period, watchful waiting is often indicated. surgery for raom should be recommended only for patients with severe symptoms and a history of at least three or four episodes in a 6-month period, anticipating at best a modest reduction in the frequency of infection
Otitis Media with Effusion Management is initiated with two goals in mind Restoration of normal hearing-g Associated with conductive hearing loss causing an average threshold elevation of 25 to 30 db Avoidance of middle ear sequelae- Result from chronic or intermittent negative pressure causing tympanic membrane retraction. ti This process may result in flaccidity and atelectasis in the posterosuperior tympanic membrane and the pars flaccida, culminating in ossicular discontinuity or cholesteatoma. t
Surgical treatment of Otitis Media Otitis Media with Effussion (OME) Tympanostomy tubes are a reasonable consideration in patients with at least 3 months of bilateral or 6 months of unilateral effusion, or in patients in whom a majority of the previous year was spent with middle ear disease Patients with effusions for less time but who also have severe symptoms, severe hearing loss, or development of atelectasis or retraction pockets should also be considered Adenoidectomy may be reserved for the second set of tubes, but should be considered primarily in patients with a history of chronic nasal obstruction or adenoiditis
Adenoidectomy Many trials now demonstrate that adenoidectomy is efficacious when performed as an adjunctive procedure to tubes. Rosenfeld RM: What to expect from surgical therapy. In Evidence-Based Otitis Media. Edited d by Rosenfeld RM, Bluestone CD. Hamilton, Ontario: BC Decker; 1999:207 221. Children with adenoidectomy tend to have fewer episodes of OME and seem to require fewer repeat tube insertions. Coyte PC, Croxford R, McIsaac W, et al.: The role of adjuvant adenoidectomy and tonsillectomy in the outcome of the insertion of tympanostomy tubes. New Engl J Med 2001, 344:1188 1195. Bibliographic Links [Context t Link] Boston M, McCook J, Burke B, et al.: Incidence of and risk factors for additional tympanostomy tube insertion in children. Arch Otolaryngol Head Neck Surg 2003, 129:293 296.
Surgical indications for middle ear dysfunction Prolonged middle ear effusions Hearing loss To obtain material for culture to guide antibiotic therapy In patients with severe symptoms and a history of at least three or four episodes in a 6-month period
PEDIATRIC CHRONIC SINUSITIS 25
Pediatric Chronic Sinusitis The precise diagnosis of sinusitis in children is often difficult to make because of the overlap of symptomatology with more common conditions such as viral upper respiratory infections and adenoid infection or hypertrophy. Acute rhinosinusitis often presents as a URI with worsening of symptoms (most notably nasal discharge, cough, and halitosis) 7 to 10 days after onset Chronic rhinosinusitis (CRS) is defined as a low- Chronic rhinosinusitis (CRS) is defined as a low grade infectious process lasting more than 3 months
Pediatric Chronic Sinusitis Diagnosis Symptoms lasting more then 3 months Nasal obstruction ti Nasal discharge Cough Halitosis Headache Recurrent acute rhinosinusitis (ARS) Six or more episodes of ARS per year, each lasting at least 10 days, with persistent changes on CT at least 4 weeks after medical management and with healthy intervals between episodes
Pediatric Chronic Sinusitis Comorbid risk factors- Anything that leads to inflammation and obstruction of the sinus ostia Viral infection Allergic rhinitis Secondary exposure to tobacco smoke Daycare attendance Bacterial load of the adenoidal pad Gastro esophageal reflux disease Cystic Fibrosis Primary Ciliary Dyskinesia Immune deficiency
Pediatric Chronic Sinusitis (CS) Sobol, Steven E. MD, MSc; Samadi, Daniel S. MD; Kazahaya, Ken MD; Tom, Lawrence W. C. MD Trends in the Management of Pediatric Chronic Sinusitis: Survey of the American Society of Pediatric i Otolaryngology. l Laryngoscope. 115(1):78-80, 80 January 2005.
Pediatric Chronic Sinusitis
Pediatric i Chronic Sinusitis i i Treatment- Medical Management Amoxicillin/clavulanate, high-dose amoxicillin, cefpodoxime, or cefuroxime Recommended duration of therapy is a total of 10 to 21 days If initial therapy is ineffective, it is switched to a broader spectrum antibiotic, or combination therapy should be considered. Culture-directed therapy Identify and treat any underlying factors that may contribute to sinus disease
Pediatric Chronic Sinusitis Treatment- Surgical Management Surgery in children with CS is usually indicated only when there is failure of maximal medical management. First-line surgical management usually consists of adenoidectomy to remove the adenoid pad as a bacterial reservoir for the sinuses. Children whose symptoms persist after adenoidectomy should be referred for immune function and allergy testing and sinus CT Clary R: Is there a future for pediatric sinus surgery? An American perspective. Int J Pediatr Otorhinolaryngol 2003; 67:S213-S215. The author reviews the recent history of FESS in the pediatric population and examines current trends in the surgical management of chronic rhinosinusitis. i iti
Functional Endoscopic Sinus Surgery (FESS) Failure of maximal medical therapy, adenoidectomy, and culture-directed systemic antibiotics Anatomic abnormalities identified which predispose to chronic rhinosinusitis i iti by obstructing ti normal sinonasal drainage pathways In sinonasal polyposis, to facilitate application of topical steroids or as an adjunct to desensitization in aspirin-sensitive patients With orbital or intracranial complications of sinonasal disease In cystic fibrosis, to improve quality of life and facilitate application of topical antibiotics with activity against Pseudomonas
Management of Pediatric Chronic Sinusitis Medical treatment Antibiotics Nasal steroids Saline irrigations Identify and treat t any underlying factors that t may contribute to sinus disease Surgical treatment Adenoidectomy FESS
POTPOURRI 35
Acute otitis media complicated by facial nerve paralysis Treatment includes CSF penetrating antibiotics and consultation ASAP for wide myringotomy with possible mastoidectomy 36
Oii Otitis Externa Signs and Symptoms Severe external auditory canal swelling Drainage/debris in canal Registers high on the pain scale Periauricular adenopathy, inflammation 37
Oii Otitis Externa 38
Nasal Fractures Most common facial fracture Rule out CSF rhinorrhea Rule out septal hematoma Patient should be seen by surgeon within the first 3-5 days of injury 39
Nasal Fracture 40
Septal Hematoma Blood accumulation which separates the cartilage from the perichondrium Diagnosis Usually bilateral reddish septal swelling Severe nasal obstruction Usually painful Treatment Fluid removal and packing or plicating suture Rx should be instituted within 24 hours Sequelae can include infection, cartilage necrosis, fibrosis, i saddle nose deformity 41
Septal Hematoma 42
Auricular Hematoma
Traumatic Tympanic Membrane Perforation Usually involves the posterior quadrant Usually heals within a few days Evaluation should include hearing test Immediate referral for complaints of hearing loss, vertigo etgoor facial aca nerve e dysfunction
Foreign Bodies Most foreign bodies of the nose or ear are not an emergency Exception would be a caustic substance which should be removed immediately When the foreign body is a battery drops are contraindicated because the electrical charge will produce electrolysis of any electrolyte-rich fluid This produces hydroxides which will cause a severe alkaline burn
Foreign Bodies of the Nose
Foreign bodies of the nose
Auricular Perichondritis i i
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