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OFFICE BASED ENT PRACTISE IN CHILDREN:DIFFICULT SITUATIONS & RECENT TRENDS
DR SHEELU SRINIVASCONSULTANT ENT SURGEON
We Can Only Refine Our Therapeutics When We Refine Our Diagnostic Abilities
Standard EquipmentStandard EquipmentAssess nares / choanaeAssess nares / choanaeAssess adenoid and lingual tonsilAssess adenoid and lingual tonsilAssess TVC mobilityAssess TVC mobilityAssess laryngeal structuresAssess laryngeal structures
Nasoaryngoscopy video
Sleep disordered breathing in children 4-8 yr olds with variable clinical
symptoms at various ages Infants- noisy breathing,disturbed
nocturnal sleep Toddlers & preschoolers-snoring &
mouth breathing School goers-behavioral & dental
problems
Pathogenesis
Not properly understood Children with sleep-disordered breathing
(SDB) can manifest a continuum from simple snoring and
upper airway resistance syndrome to obstructive sleep apnea (OSA)
with secondary growth impairment, neurocognitive deficits, and less often cardiovascular sequelae.
Pathogenesis
Adenotonsillar hypertrophy is the leading cause of OSA.
Other risk factors include allergic rhinitis, craniofacial anomalies, cleft palate following pharyngeal flap surgery, neuromuscular diseases, laryngomalacia, and obesity.
Symptoms
Symptoms of pediatric SDB vary and specialty referral is often done according to symptoms noted by parents.
For example, a child with snoring and tonsillar
hypertrophy is most likely to be referred to an otolaryngologist,
a child with growth impairment to a pediatrician, and
a sleepy child to a neurologist.
Table 1. Clinical Differences in Sleep-disordered Breathingbetween Children and AdultsVariables Children AdultsSex distribution Male: Female = 1:1 Male: Female = 8:1Weight Underweight Commonly obeseSnoring Continuous Intermittent with pauseMouth breathing Common Less commonChief complaint Snoring,difficult Daytime sleepiness breathingEnlarged tonsils/ Common UncommonadenoidsObstructive pattern Mostly apneas Mostly hypopneasState with most REM REM or non-REMobstructionClinical arousal Uncommon CommonSleep architecture Preserved FragmentedSequelae Behavioral changes Daytime sleepiness Neurocognitive Cardiovascular deficits diseasePrimary treatment Adenotonsillectomy CPAP therapyAbbreviations: SDB: sleep-disordered breathing; REM: rapideye movement; CPAP: continuous positive airway pressure.
Diagnostic tool
Polysomnography PSG gold standard
can be performed successfully in infants and children of all ages.
An AHI > 1 event/h in children is considered abnormal
Apnea in childrenis defined as absence of airflow with continued chestwall and abdominal wall movement for a durationlonger than 2 breaths,(9) whereas obstructive hypopneais defined as a decrease in nasal flow between30% and 80% from baseline with a correspondingdecrease in oxygen saturation of 3% and /orarousal.
differences in OSA between children and adults. 1. Children with OSA frequently do not have cortical arousal associated with obstructive apnea and are less likely to have fragmented sleep than adults. Consequently, sleep architecture is preserved and daytime sleepiness is uncommon. 2. In children, the majority of obstructive apneas occur during rapid eye movement (REM) sleep, particularly in later REM sleep. As a result, OSA may be missed if the REM stage is decreased or absent on screening studies, e.g. nap studies. 3. Children may present with persistent obstructive hypoventilation, rather than cyclic obstructive apnea.Clinically, these children manifest constant snoring and labored breathing instead of breathing pauses or gasps.
Physical examination
Treatments of Sleep-disordered Breathing in Children
Non-surgical treatment Surgical treatment Rx of nasal allergy Adenotonsillectomy Treat acute inflammation UPPP Treatment of reflux Nasal surgery CPAP Revision of posterior
pharyngeal flap Rapid maxillary expansion Distraction
osteogenesis Weight reduction Tracheotomy
NOISY BREATHERS STERTOR Snoring type of noise often made by
nasopharyngeal or oropharyngeal obstruction
May occassionally be created by supraglottic larynx
STRIDORHarsh sound produced by turbulent airflow
through a partial obstruction May be soft and tuneful/musical quality Characteristic of certain pathology but
never diagnostic
Venturi principle
Pediatric airway more flexible Forces exerted by Venturi principle
cause the narrowed, flexible airway to be momentarily closed during either inspiration or expiration
Infant larynx-higher, close proximity to pharynx
Infant larynx: -More superior in neck -Epiglottis shorter, angled more over glottis -Vocal cords slanted: anterior commissure more inferior- Vocal process 50% of length
-Larynx cone-shaped: narrowest at subglottic cricoid ring -Softer, more pliable: may be gently flexed or rotated anteriorly
Infant tongue is larger Head is naturally flexed
Assessment
Region / LEVEL OF AIRWAY OBSTRUCTION
Voice
Stridor
Retractions
Feeding
Mouth
Cough
Above vocal cords Supraglottic laryngeal
obstruction
Muffled or throaty
Snoring; inspiratory; fluttering
None, until very late
Difficult to impossible
Open; jaw held forward
None
Oropharyngeal obstruction
Unaffected but can be throaty or full
Inspiratory and coarse; increases during sleep
Sternal and intercostal, increasing to total chest when severe
Difficult to impossible, with drooling or saliva
Open; jaw held forward
None
Vocal cords & below
Glottic –level of cords Subglottic tracheobronchial tree
Glottic obstruction
Hoarse or aphonic
Inspiratory early; expiratory also as obstruction increases
Xiphoid early and intercostal later; suprasternal and supraclavicular
Normal, except with severe obstruction
May be closed; nares flared
None
Subglottic obstruction
Hoarse, but can be husky or normal
Inspiratory early; expiratory also as obstruction increases
Xiphoid early and intercostal later; suprasternal and supraclavicular
Normal, except with severe obstruction
May be closed; nares flared
Barking
Tracheobronchial obstruction
Normal
Expiratory and wheezing; becoming to and fro with increasing obstruction
None, except with severe obstruction; xiphoid and sternal
Normal, except with severe airway obstruction or when extrinsic obstruction involves esophagus
May be closed; nares flared
Brassy
Evaluation -ABC
every pediatric casualty should have flexible scopes
Choanal atresias Laryngomalacia Vocal cord & glottic anamolies[?
clefts] RRP Subglottic anamolies
Proper EquipmentProper EquipmentAssess nares/choanaeAssess nares/choanaeAssess adenoid and lingual tonsilAssess adenoid and lingual tonsilAssess true vocal cord mobilityAssess true vocal cord mobilityAssess laryngeal structuresAssess laryngeal structures
CHAOS(congenital high airway obstruction syndrome) Emergent airway management at the
time of delivery is key for survival Prenatally
Flattened diaphragms, polyhydramnios, cervical mass
TEAM Members Maternal-fetal specialist Neonatalogist Anesthesiologist Otolaryngologist Patient
EXIT Procedure(ex utero intrapartum treatment)
Prenatal diagnosis is crucialPrenatal diagnosis is crucialFlattened diaphragms, Flattened diaphragms, polyhydramniospolyhydramnios
The head, neck, thorax, and one The head, neck, thorax, and one arm are delivered.arm are delivered.Uteroplacental circulation can be Uteroplacental circulation can be maintained for 45-60 minutesmaintained for 45-60 minutes
Foreign Bodies
2-4year olds Acute episode of choking/gagging Triad of acute wheeze, cough and
unilateral diminished sounds only in 50%
5-40% of patients manifest no obvious signs
Laryngopharyngeal reflux Up to two-thirds of infants exhibit signs of reflux (Nelson
1997) A majority of those children will outgrow their reflux by
their second year of age Laryngopharyngeal reflux (LPR) has gained increasing
recognition as a common pediatric disorder over the past few years .
Its symptoms include benign postprandial vomiting during the first year of
life, failure to thrive, esophagitis, and airway disturbances. In some conditions--such as tracheoesophageal fistula,
neurologic impairment, or oral motor dysphagia--the incidence might be as high as 70%.
WHAT IS THE DIFFERENCE BETWEEN GERD & LPR?
Gastroesophageal reflux (GER)
Retrograde flow of gastric contents into the esophagus
Laryngopharyngeal reflux (LPR)
Extraesophageal reflux (EER)
denotes the gastric contents that reaches beyond the upper esophageal sphincter (UES) into oropharynx and/or nasopharynx
diagnostic
Double lumen pH monitering gold standard
LaryngoscopyBronchoscopyEsophagoscopy with biopsyBarium EsophagramScintiscan Esophageal intraluminal impedance
Swallowing & feeding disorders 40-70% kids with CNS disorders Note: nasal obstruction, nasal masses,
oral lesion, cleft lip/palate, upper aero digestive tract anomalieslaryngomalacia, vocal cord paralysis, laryngeal clefts, tracheo-esophageal fistula, foregut malformations, or vascular rings of the aorta or pulmonary arteries that compress the esophagus or trachea may all contribute to feeding problems and dysphagia
Assessment of swallowing VSS : videofluoroscopy swallow
study FEES: functional endoscopic
evaluation of swallowing FEESST Flexible Endoscopic
Evaluation of Swallowing with Sensory Testing
Transnasal oesophagoscopy
Role of ENT in special children Airway Swallowing & drooling Hearing & speech
Drooling severity score (after Thomas-Stonell and Greenberg 1. Dry 2. Mild – wet lips 3. Moderate – wet lips and chin 4. Severe – clothing damp 5. Profuse – clothing, hands and
objects wet
Management approaches Conservative methods include
behavioural approaches and techniques to improve sensory awareness
Appliances Drug therapy Surgery :salivary duct
ligation/transposition
Head & neck tumors
Congenital Inflammatory Neoplastic
Hemangiomas represent the most common of all congenital anomalies, with an incidence of 0.3-2% at birth and 10% at age 1 year.
Hemangiomas
Look for associated cardiac, CNS Spontaneous resolution 90% Rest surgical: laser, coblation etc PROPANOLOL
Have you recently seen a film? Biofilms: organised sessile
communities of attached bacteria in an extracellular matrix
Role in ENT
We Can Only Refine Our Therapeutics When We Refine Our Diagnostic Abilities
THANK YOU
SHEELU SRINIVASdrsheelusrinivas@gmail.com9900176770
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