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