pediatric otolaryngology 101: the e’s n’s & t’s

Pediatric Otolaryngology 101:The E’s N’s & T’s

Heena Narsi Prasla, MSN, RN, CPNPDepartment of Surgery

Disclosures

• No financial disclosures

Objectives

• The provider will be able to describe common otolaryngologic problems and determine the treatment plan

• The provider will be able to determine when to refer patients to otolaryngology

• The provider will be able to utilize current guidelines to diagnose and manage common otolaryngology disease processes

Ears

Photo Credit: Rosenfeld, 2013

Acute Otitis Media (AOM)

• Most common reason for antibiotic prescription

• 50% are less than 5 yrs of age

• Common pathogens: H. influenzae, S. pneumoniae, M. catarrhalis

• S/S: recent or current URI, fever, ear pain, bulging of TM or otorrhea r/t perforated tympanic membrane, yellowish/white effusion

Acute Otitis Media

One sign or symptom from each category

Bullous Myringitis

Acute Otitis Media

Intratemporal Complications• Hearing Loss• Balance/Motor Problems• Tympanic Membrane Rupture• Mastoiditis• Facial Paralysis

Intracranial Complications• Meningitis• Epidural Abscess• Lateral/Cavernous Sinus

Thrombosis• Subdural Empyema• Carotid Artery Thrombosis

Mastoiditis

• Complication of AOM• Can be accompanied by a

subperiosteal abscess• Most commonly seen in 0-3yrs• S/S: postauricular tenderness,

erythema, swelling (with loss of the postauricular crease), fluctuance, pinna protrusion, changes to TM, otorrhea if AOM with perforation

• Diagnosis/Management: CT of Temporal bone with contrast, surgical intervention, antibiotics

Photo credit: http://www.medicoaid.com/qod-451-acute-mastoiditis/

Otitis Media with Effusion (OME)

• Commonly referred to as ear fluid, serous, non-suppurative otitis media

• Ages 6 months- 4 years• Persist for ≥3 months (COME)• Can lead to conductive hearing loss• S/S: recent URI, decreased hearing, behavioral

changes, fluid/air bubbles behind the TM

Rosenfeld, 2013

OME Management

• Pneumatic Otoscopy (especially in those patients with otalgia and/or hearing loss)

• Tympanometry • Watchful waiting for 3 months • Steroids are not recommended • Antibiotics are not recommended• Antihistamines/Decongestants/Nasal steroids are not

recommend • Refer to ENT if effusion persists for >3months with

symptoms• Complications: Speech delay & Hearing loss

Cholesteatoma

• Abnormal growth of squamous epithelium in the middle ear and mastoid

• Predisposing Factors: – Tympanic membrane retraction pocket– Tympanic membrane perforation– Prior ear surgery– Older age at first placement of tympanostomy tubes, and

increasing number of, and longer interval between insertions– Craniofacial anomalies– Down Syndrome; Turner Syndrome

Cholesteatoma: S/S

• A white mass behind an intact TM• A deep retraction pocket with or without granulation

and skin debris • Focal granulation or aural polyps on the surface of

the TM, especially at pars flaccida• New onset hearing loss in an ear that has undergone

surgery• Chronic ear drainage not responding to treatment is

the most common presentation for acquired cholesteatomas – refer to ENT

Photo Credit: http://www.dubuqueent.com/tag/cholesteatoma/

Cholesteatoma

Photo Credit: Dr. Giannoni

Cholesteatoma: Diagnosis & Plan

• Visual Exam• CT of temporal bones (noncontrast)• Surgical excision (Tympanoplasty +/-

Mastoidectomy, ossicular chain reconstruction)• Multiple surgeries• High reoccurrence rate• Risk of residual CHL

http://www.entusa.com/JS-Slide-Shows-ENTUSA/Cholesteatoma-1/Cholesteatoma-1.htm

Otitis Externa

• Inflammation of the external auditory canal• Commonly due to water exposure (maceration of skin

of ear canal) or QTip trauma• S. aureas and P. aeruginosa• S/S: pain to tragus, otorrhea, edema to canal• Treatment plan includes cortisporin (if no PE tube)

otic drops, ofloxacin if PE tube in place, ear cultures, and dry ear precautions; oral antibiotics are only recommended if there are signs invasive infection

http://www.ghorayeb.com/seborrheicotitisexterna.html

http://www.medrx-education.com/usmle-review/otitis-externa

http://www.medrx-education.com/usmle-review/otitis-externa

Temporal Bone Fracture

• Associated with 18-40% of head fractures

• Classified as longitudinal, transverse, or oblique

• S/S: hearing loss, vertigo, hemotympanum, otorrhea (CSF leak), ruptured TM, facial paralysis

• Diagnosis: CT temporal bone• Management: case by case

basis; audiogram recommended for all

Tympanostomy Tubes

• Most common ambulatory surgical procedure in the United States

• Refer to ENT for:- RAOM (3 or more episodes

of AOM in 6 months or 4 episodes in 1 year)

- COME (OME for 3 mo or longer)

• Tubes placed on the discretion of the surgeon

• Duration is 6mo-12moPhoto credit: Rosenfeld, 2013

Nose

Photo Credit: physiology-of-olfaction-6-638.jpg

Rhinosinusitis

• Sinusitis is inflammation of the mucosal lining of one or more of the paranasal sinuses

• Acute vs Chronic• Can occur at any age but less common under the age

of 2yrs• 6-9% viral URI complicated by bacterial sinusitis• Predisposing factors: URI, allergic rhinitis, anatomic

obstruction, mucosal irritants

http://www.aboutcancer.com/Sinuses_and_OMC_external.jpg

Rhinosinusitis

• S/S: purulent nasal discharge, cough, halitosis, fever, headache, facial pain

• Diagnosis: – Nasal congestion or daytime cough >10 days without

improvementOR

– Worsening course after initial improvement OR

– Severe onset which would be concurrent fever and purulent nasal discharge for at least 3 consecutive days

Rhinosinusitis

Photo Credit: IDSA

Epistaxis

• Most common during 3-15 yrs of age

• 90% of bleeds occur at Kiesselbach plexus

• Etiology:– Inflammation– Dry air– Trauma– Topical nasal sprays– Other (juvenile angiofibroma,

rhabdomyosarcoma, hypertension, coagulopathies

http://accessemergencymedicine.mhmedical.com/Content.aspx?bookid=683&Sectionid=45343820http://wellpath.uniovi.es/es/contenidos/cursos/otorrino/Rinologia/tema6_exploracion_basica/links/Area_k.htm

Epistaxis

• Initial treatment:– Hold local pressure by pinching the nasal ala against the septum for a

minimum of 10 minutes– Afrin + Pressure– Chemical or Electrocautery– Anterior packing – Labs for severe epistaxis cases– Reverse coagulation abnormalities

• Continued treatment:– Nasal saline sprays BID– Nasal ointment BID – Patient education https://www.childrensmn.org/educationmaterials/childrensmn/article/15507/nosebleeds-

epistaxis/

Throat/Airway

Tonsillitis/Pharyngitis

Strep (GAS)• Can affect all ages• RST and Throat Culture• Fever, pharyngitis, diffuse

cervical lymphadenopathy, petechiae to soft palate

• GAS carrier

Mononucleosis • Affects more adolescents• Fever, severe pharyngitis,

anterior and posterior cervical or diffuse lymphadenopathy, lymphocytosis, fatigue, anorexia, weight loss, hepatomegaly, and splenomegaly

• EBV or CMV

Peritonsillar Abscess

• Can be a complication of GAS Pharyngitis (usually polymicrobial)

• S/S: drooling, trismus, muffled “hot potato” voice, possible uvular deviation to contralateral side, soft palate bulge, odynophagia

• Treatment: PO antibiotics with or without surgical drainage; imaging not usually necessary

Photo Credit: UptoDate

Retropharyngeal Abscess

• More commonly in 2-4 yr olds• Can compromise the airway• S/S: dysphagia, pain with swallowing, drooling,

neck stiffness, ie unwillingness to move the neck secondary to pain (torticollis), muffled or "hot potato" voice, respiratory distress (stridor, tachypnea), neck swelling or lymphadenopathy, chest pain (in patients with mediastinal extension)

• Diagnosis/Treatment: CT soft tissues neck w/ contrast; Incision and Drainage; Antibiotics

Phlegmon

Photo Credit: University of Chicago

Tonsillectomy for Sore Throat

• Paradise Criteria for Tonsillectomy– 7 episodes of sore throat in last year– 5 episodes in each of the last two years– OR 3 episodes in each of the last three years

AND– One of the following:

• Fever (>100.9F)• Cervical adenopathy • Tonsillar exudate• Positive culture for GAS

Tonsillectomy for Sleep

• Sleep disordered breathing (SDB)• Obstructive Sleep Apnea (OSA)

– Mild (AHI: 1-4)– Moderate (AHI: 5-10)– Severe (AHI: >10)

Photo Credit: https://www.rchsd.org/health-articles/obstructive-sleep-apnea/

Stridorhttps://pedclerk.bsd.uchicago.edu/page/stridor

Stridor

• High-pitched sound signifying narrowed upper airway

• Types:– Inspiratory– Expiratory – Biphasic

• Congenital– Laryngomalacia– Tracheomalacia– Vocal Fold Paralysis– Vascular Ring– Laryngeal Web

• Acquired– Infectious (croup, retro/parapharyngeal abscess)– Subglottic stenosis– VF immobility (cardiac surgery, intubation)– Recurrent Respiratory Papillomatosis (HSV)– Foreign Body

Stridor

• History– Time of Onset– Character of Stridor– Aggravating/Alleviating Factors– Intubation or Surgeries

• Evaluation– Imaging:

• AP and Lateral Neck Xray• CT angio (tracheal compression)

• Procedures– Bedside Flexible Laryngoscopy– Direct Laryngoscopy and

Bronchoscopy in OR

• Treatment https://voicedoctor.net/sites/default/files/styles/original/public/flexible-endoscope-model-20121130-005.jpg?itok=pQeankEt

Laryngomalacia

• Laryngomalacia refers to collapse of the supraglottic structures during inspiration

• S/S: Inspiratory stridor, snoring, GERD, poor weight gain, apnea or cyanosis

• Diagnosis: Flexible Laryngoscopy or DLB

• Treatment: Reflux management, “Wait and See”, Surgical intervention in severe cases (10%)

Laryngomalacia

Acknowledgements

• Dr. Carla Giannoni• Dr. Tiffany Raynor

References

• Bluestone, C.D., Simons, J.P., Healy, G.B. (2014). Bluestone and stool’s pediatric otolaryngology, 5th. People’s Medical Publishing House: USA

• Chow, A.W., Benninger, M.S., Brook, I., Brozek,J.L., Goldstein,E., Hicks, A., Pankey, G. A., Seleznick, M., Volturo, G., Wald, E. R. File, T. M. (2012). IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clinical Infectious Diseases 2012;54(8):e72–112

• Isaacson, G. C., Messner, A. H., Armsby, C. (2017). Cholesteatoma in children. Retrieved from https://www.uptodate.com/contents/congenital-anomalies-of-the-larynx?search=laryngomalacia&sectionRank=1&usage_type= default&anchor=H3&source=machineLearning&selectedTitle=1~22&display_rank=1#H3

• Lieberthal, A.S., Carroll, A.E., Chonmaitree, T., Ganiats, T. G., Hoberman, A., Jackson, M. A., Joffe, M. D., Miller, D.T., Rosenfeld, R.M., Sevilla, X.D., Schwartz, R. H., Thomas, P.A., Tunkel, D. E. (2013). Clinical practice guideline: The diagnosis and management of acute otitis media. Pediatrics, 131:e964–e999

• Marcus, C.L., Brooks, L.J., Draper, K.A., Gozal, D., Halbower, A.C., Jones, J., Schechter, M.S., Sheldon, S.H., Spruyt, K., Ward, S.D., Lehmann, C. , Shiffman, R. N. (2012). Clinical practice guideline: Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics,130 (3)

• Parikh, S. R. (2014). Pediatric Otolaryngology head and neck surgery: Clinical reference guide. San Diego, CA: Plural Publishing• Randel, A. (2011). AAO-HNS guidelines for tonsillectomy in children and adolescents. American Family Physician. 84 (5)• Rosenfeld, R. M., Shin, J.J., Schwartz, S. R., Coggins, R., Gagnon, L., Hackell, J. M., Hoelting, D., Hunter, L.L., Kummer, A. W., Payne, S.,

C., Poe, D. S., Veling, M., Vila, P. M., Walsh, S. A., Corrigan, M. D. (2016). Clinical practice guideline: Otitis media with effusion (Update). Otolaryngology–Head and Neck Surgery, 154(1S) S1–S41

• Rosenfeld, R.M., Schwartz, S.R., Pynnonen, M. A., Tunkel, D. E., Hussey, H. M., Fichera, J. S., Grimes, A. M., Hackell, J. M., Harrison, M.F., Haskell, H., Haynes, D.S., Kim, T. W., Lafreniere, D. C., LeBlanc, K., Mackey, W. L., Netterville, J. L., Pipan, M. E., Raol, N. P., Schellhase, K. G. (2013). Clinical practice guideline: Tympanostomy tubes in children. Otolaryngology–Head and Neck Surgery 149(1S)S1–S35

References

• Shulman, S. T., Bisno, A.L, Clegg, W. H., Gerber, M. A., Kaplan, E. L., Lee, G., Martin, J.M., Van Beneden, C. (2012). Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the infectious diseases society of America. Clinical Infectious Diseases, 55, 86-102

• Wald, E.R., Applegate, K. E., Bordley, C., Darrow, D. H., Glode, M. P., Marcy, M., Nelson, C.E., Rosenfeld, R. M., Shaikh, N., Smith, M.J., Williams, P.V., Weinberg, S.T. (2013). Clinical Practice Guideline for the diagnosis and management of acute bacterial sinusitis in childrenaged 1 to 18 years. Pediatrics, 132, (1)

• Wald, E. (2018). Retropharyngeal infections in children. Retrieved from https://www.uptodate.com/contents/group-a-streptococcal-tonsillopharyngitis-in-children-and-adolescents-clinical-features-and-diagnosis?search=mono%20and%20strep&source=search_ result&selectedTitle=3~150&usage_type=default&display_rank=3

• Wald, E. (2017) https://www.uptodate.com/contents/retropharyngeal-infections-in-children?search=retropharyngeal%20abscess%20children& source=search_result&selectedTitle=1~44&usage_type=default&display_rank=1