pediatric otolaryngology disorders for primary care - bc.edu · disorders for primary care....
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ASHOK N. REDDY, MDC 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
Pediatric Otolaryngology Disorders for Primary Care
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Otolaryngology Pathology in Children
Head and Neck Masses
Sleep Disordered Breathing/OSA
Pharyngitis
Otitis Media/Cholesteatoma
Sinusitis
Airway
Dysphonia
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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
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Head and Neck Masses – Work Up
History
• Duration
• Size trend
• Pain
• Fever
• Constitutional Symptoms
• Dysphagia
• Difficulty breathing
Physical
• Size
• Erythema
• Tenderness
• Firmness
• Location
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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
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Inflammatory/Infectious Masses
Palpable LNs in children are common.
Differential Diagnosis
Reactive LN
Lymphadenitis (Strep, Mono)
Suppurative lymphadenitis
Lymphoreticulosis - “Cat scratch” disease
Retropharyngeal or parapharyngealspace abscess
Atypical Mycobacterium
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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.
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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
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Branchial Cleft Cyst Thyroglossal Duct 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.
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.
Congenital Neck Masses
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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
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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
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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
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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 15-20 yo
Firm, rubbery neck mass
Fever
Weight loss
Night sweats
Malaise
Lymphoma
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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
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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.*
*Owens JA. Neurocognitive and behavioral impact of sleep disordered breathing in children. Pediatr Pulmonol. 2009;44(5):417-422
Negative effects of SDB in children without OSA* Increased Anxiety
Increased Depression scores
Increased Social problems
*Holbrook CR, et al Neurobehavioral implications of habitual snoring in children. Pediatrics. 2004;114(1):44-49
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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
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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
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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
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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
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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.
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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
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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
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Peritonsillar Abscess
Symptoms
• Muffled (Hot Potato) voice
• Uvular deviation (Asymmetric oropharynx)
• Trismus
Treatment
• Drainage
• Oral antibiotics
• Steroids
Tonsillectomy after 2nd episode
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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
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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
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AOM Complications
Acute Mastoiditis
Coalescent Mastoiditis
Bezold’s Abscess
Intracranial Complications
• Sigmoid Sinus Thrombosis• Picket Fence Fevers
• Meningitis• Intracranial Abscess
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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.
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Chronic Otitis Media
OME usually resolves within 3 months.
• Hearing loss• Discomfort• Dizziness• Poor school performance
Symptoms
Minimal effectiveness found with using nasal
balloon inflation.
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.
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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 2nd set of tubes
Adenoidectomy with 2nd set of tubes if Age >4 yo.
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Tympanostomy Risks
Bleeding
Infection
Pain
Tympanic membrane perforation
Hearing loss
Cholesteatoma
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Post-Tympanostomy
Topical therapy 1st line - AOM
Oral antibiotics 2nd line - AOM
Consider debridement by Otolaryngologist
Tube Otorrhea
• Biofilm
• May need IM antibiotics
• May need replacement of PETs
See otolaryngologist every 6 Months.
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Tympanic Membrane Perforation
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Monomeric Tympanic Membrane Tympanic Membrane Retraction
Not Tympanic Membrane Perforation
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Tympanic Membrane Perforation
• Bloody otorrhea or blood in EAC- Not worrisome
• Perforation will heal easily• Treat AOM
AOM with spontaneous
rupture
• Hearing loss• Recurrent OM
TM perforation symptoms
• Tympanostomy, TraumaEtiology
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.
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Cholesteatoma
What is it?
• Expanding, keratinizing, squamous epithelial tumor
• Benign
Etiology
• Congenital
• TM perforation
• TM retraction
Congenital
• Asymptomatic “pearl” in intact TM
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Cholesteatoma
Symptoms
• Asymptomatic
• Hearing loss
• Recurrent OM
• Chronic otorrhea
• Aural Polyp
• Draining Ear
Treatment
• Surgery
Complications
• Hearing loss
• Intracranial extension
• Meningitis
• Intracranial abscess
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Sensorineural Hearing loss Conductive Hearing loss
Tuning Fork test is heard in normal hearing ear (opposite)
Humming with mouth closed – opposite ear
Not Reversible
Tuning Fork test is heard in hearing loss ear (same ear)
Humming with mouth closed – same ear as hearing loss
Largely Reversible
Hearing Loss
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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
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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
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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
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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
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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
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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
Sinusitis
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Acute Sinusitis Antibiotic Choice
• Amoxicillin double dose (80 mg/Kg)• Clarithromycin• Azithromycin
First Line
• Augmentin• 2nd or 3rd generation Cephalosporins (Cefuroxime)• Macrolides• Clindamycin
Second Line
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Acute Sinusitis Complications
Preseptal Cellulitis (Periorbital Cellulitis)
Orbital Involvement
• Orbital cellulitis• Orbital abscess
Cavernous Sinus Thrombosis
Intracranial Infection
• Meningitis• Intracranial Abscess
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Airway
Nasal
Laryngeal
Esophageal
• Respiratory distress• Stridor, Retractions
• Drooling/Dysphagia• Unilateral rhinorrhea• Infection that does not resolve with treatment
Symptoms
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Airway Obstruction
Foreign body
• URI – RSV, etc.• Croup• Epiglottitis
Infection
Trauma
Neoplasm
• Subglottic hemangioma
• Teratoma
• Dermoid cyst
Congenital
• Choanal atresia
• Laryngomalacia
• Laryngotracheal anomaly
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Toddlers – Foreign Body
Laryngeal, Nasal, Aural, Esophageal
• Sudden Stridor, Unilateral Rhinorrhea, Dysphagia, Drooling, Ear infection• Unresolving “Infection”
Symptoms
• Send to ER
Suspected laryngeal FB is an EMERGENCY.
• Send to ER
Suspected Battery FB is an EMERGENCY
• Can be handled in office.
Nasal/Ear FB
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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
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Neonatal period - Neoplasm
Subglottic hemangioma
• May resolve as they get older.
• Treated with B-blockers or surgery.
Lymphangioma
Teratoma
Dermoid cyst
Endoscopy or Imaging
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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
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Neonatal period - Laryngomalacia
• Hypoxemia• Cyanosis• OSA
Severe
May be associated with other congenital anomalies
Surgical intervention – 10%
Referral to Otolaryngologist for endoscopy
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Neonatal period – Choanal Atresia
• Life threatening
Bilateral
• Unilateral rhinorrhea
Unilateral
Unable to pass catheter through one or both nasal passages.
CT scan of sinuses
Referral to pediatric otolaryngologist
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Laryngotracheal Anomalies
• Dysphonia• Dysphagia• Aspiration• Recurrent pneumonia• Failure to thrive
Symptoms
Vocal Cord Paralysis
Laryngotracheal cleft
Tracheo-esophageal fistula
• Swallow study• Fiberoptic
laryngoscopy• Direct laryngoscopy
Workup
• Swallow therapy• Surgery
Treatment
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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)
Dysphonia
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Recurrent Respiratory Papillomatosis
RarePresents Age <5
yo.
Dysphonia
Fiberoptic laryngoscopy
shows papillomas of larynx
HPVPeripartum
transmission
Risk factors
• First Born• Mother Age <20 yo• Vaginal Delivery
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Recurrent Respiratory Papillomatosis
Suspect abuse – presents at age >5 yo
Malignant transformation – 3%
Treatment
• Repeat Surgery
• Cidofivir
May resolve or may persist
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Vocal Cord Nodules Vocal cord
Other Vocal Cord Lesions