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ENT Updates for the General Pediatric Office R. Christopher Miyamoto, M.D., FACS, FAAP Pediatric Otolaryngology Peyton Manning Children’s Hospital at St. Vincent’s. Intro. Provide update on interesting ENT developments for primary care Pediatric offices Excellent New Text/Resource: - PowerPoint PPT PresentationTRANSCRIPT
ENT Updates for the General ENT Updates for the General Pediatric OfficePediatric Office
R. Christopher Miyamoto, M.D., FACS, FAAPR. Christopher Miyamoto, M.D., FACS, FAAP
Pediatric OtolaryngologyPediatric OtolaryngologyPeyton Manning Children’s Hospital Peyton Manning Children’s Hospital
at St. Vincent’sat St. Vincent’s
IntroIntro
Provide update on interesting ENT Provide update on interesting ENT developments for primary care Pediatric developments for primary care Pediatric officesoffices
Excellent New Text/Resource: Excellent New Text/Resource: Pediatric OtolaryngologyPediatric Otolaryngology, Schoem SR, , Schoem SR,
Darrow DH ed. AAP 2012Darrow DH ed. AAP 2012
Disclosure: I have no financial Disclosure: I have no financial interest/relationships with any interest/relationships with any biomedical companies, etc.biomedical companies, etc.
Congenital Hearing LossCongenital Hearing Losssignificancesignificance::
Hearing impairment one of the most common sensory Hearing impairment one of the most common sensory deficits in children & significant healthcare problemdeficits in children & significant healthcare problem
1 - 2 infants per 1000 births have significant hearing 1 - 2 infants per 1000 births have significant hearing loss [HL] loss [HL] Bilateral severe-profoundBilateral severe-profound
Up to 4/1000 births if mild-moderate or unilateral HL Up to 4/1000 births if mild-moderate or unilateral HL included included [compare to signif congenital heart disease [compare to signif congenital heart disease 4/1000, cleft lip 1/1000, cleft palate 1/2500]4/1000, cleft lip 1/1000, cleft palate 1/2500] Steel KP Steel KP Science 1998;279:1870-71Science 1998;279:1870-71
= = 40,000 infants born/year w/ significant HL;40,000 infants born/year w/ significant HL; = 4000 profoundly deaf= 4000 profoundly deaf
DevelopmentsDevelopments 1) Universal Newborn Hearing Screening1) Universal Newborn Hearing Screening
Healthcare providers must now screen & manage HL in infants— Healthcare providers must now screen & manage HL in infants— substantial pt population— substantial pt population— Goal 1 mosGoal 1 mos
Joint Committee on Infant Hearing Joint Committee on Infant Hearing and AAP:endorsed UNHS and AAP:endorsed UNHS revised guidelines 2000, revised guidelines 2000, Position update 2007Position update 2007 Confirm HL by 3 mos Confirm HL by 3 mos
Logistical issues:Logistical issues: Otolaryngology referral – timeOtolaryngology referral – time Ability of otolaryngologist to confirm:Ability of otolaryngologist to confirm:
Middle ear fluid, audiological capabilities [OAE, ABR]Middle ear fluid, audiological capabilities [OAE, ABR] Intraoperative vs office sedation ABR capabilities Intraoperative vs office sedation ABR capabilities
Intervention by 6 mosIntervention by 6 mos Increased receptive/expressive language quotientsIncreased receptive/expressive language quotients
EHDI / ISDH Physician tool kitEHDI / ISDH Physician tool kit
DevelopmentsDevelopments
2) 2) Molecular/geneticMolecular/genetic understanding of understanding of hereditary hearing loss vastly enhanced hereditary hearing loss vastly enhanced over last 10 yearsover last 10 years Genetic testing now integral for evaluation of Genetic testing now integral for evaluation of
hearing impairment in childrenhearing impairment in children Expertise of Medical Genetic specialists Expertise of Medical Genetic specialists
invaluableinvaluable 3) 3) Early intervention Early intervention [medical vs surgical] [medical vs surgical]
now standard of carenow standard of care
Importance?Importance? Significance: Significance: COST EFFECTIVE, POSITIVE QUALITY OUTCOME COST EFFECTIVE, POSITIVE QUALITY OUTCOME Early hearing diagnosis= early intervention at 6mos or Early hearing diagnosis= early intervention at 6mos or
earlierearlier = better speech/language development, school performance, = better speech/language development, school performance,
economic outcomeeconomic outcome = early identification of profound hearing loss requiring = early identification of profound hearing loss requiring
cochlear implantationcochlear implantation
NEJM 2008---Cochlear implantation one of few truly NEJM 2008---Cochlear implantation one of few truly cost effective interventions cost effective interventions
22
Hearing ScreeningHearing Screening
Per UNHS, must occur prior to d/cPer UNHS, must occur prior to d/c Automated auditory brainstem response Automated auditory brainstem response
[ABR] preferred[ABR] preferred +/- otoacoustic emissions [OAE]+/- otoacoustic emissions [OAE]
OAE alone can miss auditory neuropathyOAE alone can miss auditory neuropathy Failure [PC = “refer”] requires diagnostic Failure [PC = “refer”] requires diagnostic
audiology eval as outptaudiology eval as outpt = ABR, tympanograms, OAE= ABR, tympanograms, OAE
Hearing Loss BreakdownHearing Loss Breakdown Historically, infectious disorders [TORCH, meningitis], Historically, infectious disorders [TORCH, meningitis],
teratogens, ototoxic meds were primary causes of congenital & teratogens, ototoxic meds were primary causes of congenital & acquired HLacquired HL
Vaccines, abx, awareness of teratogens changed ddxVaccines, abx, awareness of teratogens changed ddx Hereditary causes account for 50% Hereditary causes account for 50% childhood deafnesschildhood deafness
Morton NE Morton NE Ann NY Acad Sci 1991;630:16-31Ann NY Acad Sci 1991;630:16-31 Over 150 loci [areas on genes] identifiedOver 150 loci [areas on genes] identified
70% hereditary hearing loss nonsyndromic70% hereditary hearing loss nonsyndromic 75% of this autosomal recessive75% of this autosomal recessive Important for evaluation processImportant for evaluation process Autosomal recessive hearing loss locus DFNB1 found on Autosomal recessive hearing loss locus DFNB1 found on
Chromosome 13q—contains GJB2 geneChromosome 13q—contains GJB2 gene Mutations in GJB2 responsible for up to 50% severe-Mutations in GJB2 responsible for up to 50% severe-
profound SNHL in autosomal recessive nonsyndromic HL in profound SNHL in autosomal recessive nonsyndromic HL in US & EuropeUS & Europe
Hearing Loss BreakdownHearing Loss Breakdown
The Rest: The Rest: 50% hearing loss NOT inherited50% hearing loss NOT inherited
Acquired—ototoxics, risk factors, othersAcquired—ototoxics, risk factors, others May have Genetic comp making susceptibleMay have Genetic comp making susceptible
30% Syndromic30% Syndromic 823 syndromes linked to hearing loss823 syndromes linked to hearing loss 150 gene loci linked to hearing loss150 gene loci linked to hearing loss
Importance of Medical Genetics EvaluationImportance of Medical Genetics Evaluation JCIH 2007 statement guidelinesJCIH 2007 statement guidelines
GJB2GJB2 Gene in DFNB1 locus on chromosome 13Gene in DFNB1 locus on chromosome 13 GJB2 gene codes for connexin 26 proteinGJB2 gene codes for connexin 26 protein
Membrane proteins that form gap junctionsMembrane proteins that form gap junctions Seem important in electrolyte, second messenger and metabolite Seem important in electrolyte, second messenger and metabolite
exchange in cochleaexchange in cochlea
Multiple mutations [60+ and counting] describedMultiple mutations [60+ and counting] described 35delG mutation especially common [15-40%] 35delG mutation especially common [15-40%]
[white/European descent, some Hispanic, Asian, african-[white/European descent, some Hispanic, Asian, african-american]—Connexin 26american]—Connexin 26
Many other genes involved with congenital hearing loss– Many other genes involved with congenital hearing loss– can screen with Chip technologycan screen with Chip technology 17-19 gene mutations 17-19 gene mutations screened screened
Hereditary Syndromic Hearing LossHereditary Syndromic Hearing Loss
Most are congenital and some acquiredMost are congenital and some acquired 400 - 800+ syndromes associated w/HL400 - 800+ syndromes associated w/HL Cause of HL: sensorineural, conductive, Cause of HL: sensorineural, conductive,
mixedmixed Craniofacial & other features associatedCraniofacial & other features associated Findings may be subtleFindings may be subtle Medical genetics evaluation helpful with Medical genetics evaluation helpful with
subtle phenotypessubtle phenotypes
Nonhereditary Congenital Hearing LossNonhereditary Congenital Hearing Loss TORCH:TORCH:
Toxoplasmosis, Rubella, CMV, HerpesToxoplasmosis, Rubella, CMV, Herpes SyphilisSyphilis CMV: most frequent cause nonhereditary HL in neonatesCMV: most frequent cause nonhereditary HL in neonates
40,000 CMV infected infants/yr; 4000 HL40,000 CMV infected infants/yr; 4000 HL 8-10% CMV-infected infants asx at birth can develop HL---need 8-10% CMV-infected infants asx at birth can develop HL---need
long-term f/ulong-term f/u
Cytomegalovirus [CMV]: 0.5 -2% live birthsCytomegalovirus [CMV]: 0.5 -2% live births Congenital CMV infection: Congenital CMV infection:
10% Symptomatic: 44% have HL by age 3yrs10% Symptomatic: 44% have HL by age 3yrs 21%are delayed onset21%are delayed onset
90% Asymptomatic: 7.4% have HL by 3yrs90% Asymptomatic: 7.4% have HL by 3yrs 33% delayed onset33% delayed onset
50% of both groups w/progressive loss50% of both groups w/progressive loss
Evaluation of Hearing Loss in Evaluation of Hearing Loss in Infants & Young ChildrenInfants & Young Children
Thorough History/physical examThorough History/physical exam Directed toward issues discussed earlierDirected toward issues discussed earlier Syndromic features—refer to Med GeneticsSyndromic features—refer to Med Genetics
Prenatal, perinatal,postnatal eventsPrenatal, perinatal,postnatal events AAP JCIH 2007 Risk Indicators AAP JCIH 2007 Risk Indicators
(congenital, delayed onset or progressive hearing loss(congenital, delayed onset or progressive hearing loss
PrematurityPrematurity TeratogensTeratogens Perinatal maternal infections: TORCHPerinatal maternal infections: TORCH Low birth wgt <1500 gLow birth wgt <1500 g Prolonged mechanical ventilation, hyperbilirubinemia, Prolonged mechanical ventilation, hyperbilirubinemia,
hypoxiahypoxia
Evaluation of Hearing Loss in Evaluation of Hearing Loss in Infants & Young Children Infants & Young Children
Prenatal, perinatal,postnatal eventsPrenatal, perinatal,postnatal events NICU graduatesNICU graduates
Persistent pulmonary hypertension of the Persistent pulmonary hypertension of the newbornnewborn
Extracorporeal membrane oxygenation Extracorporeal membrane oxygenation [ECMO]: [diaphragmatic hernia, heart [ECMO]: [diaphragmatic hernia, heart disease, etc]disease, etc]
20-25% with late-onset or progressive HL20-25% with late-onset or progressive HL = ABR at 6mos, audiogram 1 yr and annual = ABR at 6mos, audiogram 1 yr and annual
x3yrsx3yrs
Evaluation of Hearing Loss in Evaluation of Hearing Loss in Infants & Young ChildrenInfants & Young Children
Infections—neonatal meningitisInfections—neonatal meningitis Syncope [fainting]—Jervell & Lange-NielsenSyncope [fainting]—Jervell & Lange-Nielsen
Family members with syncopal or sudden Family members with syncopal or sudden cardiac death in teens, early adult yearscardiac death in teens, early adult years
Delayed walking/visual issues—UsherDelayed walking/visual issues—Usher Family historyFamily history
Evaluation of Hearing Loss in Evaluation of Hearing Loss in Infants & Young ChildrenInfants & Young Children
Physical Exam:Physical Exam: Check for craniofacial issues, subtle ear Check for craniofacial issues, subtle ear
deformitiesdeformities Check for ocular abnormalities: coloboma, Check for ocular abnormalities: coloboma,
hypertelorism, other abnormalitieshypertelorism, other abnormalities Up to 50% severe-profound hearing impaired kids Up to 50% severe-profound hearing impaired kids
have eye issueshave eye issues Armitage IM et al. Arch of Dis Childhood 1995;73(1);53Armitage IM et al. Arch of Dis Childhood 1995;73(1);53
Pediatric Ophthalmology evaluation for all hearing Pediatric Ophthalmology evaluation for all hearing impaired children recommendedimpaired children recommended
JCIH 2007 statementJCIH 2007 statement
Evaluation of Hearing Loss in Evaluation of Hearing Loss in Infants & Young ChildrenInfants & Young Children
Confirm Confirm with OAE with OAE / ABR/ ABR OAE alone can miss auditory neuropathyOAE alone can miss auditory neuropathy
If bilateral SNHL and diagnosis not If bilateral SNHL and diagnosis not apparent [identifiable syndrome, apparent [identifiable syndrome, meningitis, autosomal dominant meningitis, autosomal dominant SNHL,trauma]SNHL,trauma] genetic testing for genetic testing for hearing loss/genetic evaluationhearing loss/genetic evaluation
Auditory NeuropathyAuditory Neuropathy
PathophysiologyPathophysiology Hair cell death? Hair cell death?
HypoxiaHypoxia Temporal bone studiesTemporal bone studies
Genetics: Otoferlin geneGenetics: Otoferlin gene
Cochlear ImplantationCochlear Implantation
Currently the standard surgical treatment for Currently the standard surgical treatment for patients with hearing impairment & well-fit patients with hearing impairment & well-fit hearing aids that fail to permit effective oral hearing aids that fail to permit effective oral communicationcommunication
Designed to help the severe-profoundly deaf Designed to help the severe-profoundly deaf patientpatient Perceive environmental soundsPerceive environmental sounds Understand speech Understand speech Maximal benefit depends on patient and rehabMaximal benefit depends on patient and rehab
How it works: neural stimulationHow it works: neural stimulation
Implant with electrode Implant with electrode array placed array placed surgically in the surgically in the lumen of the cochlealumen of the cochlea Scala tympaniScala tympani near spiral ganglion near spiral ganglion
cell bodies/auditory cell bodies/auditory nervenerve
How it works: neural stimulationHow it works: neural stimulation External microphone picks up External microphone picks up
speech signalsspeech signals Signal processor transforms Signal processor transforms
into digital impulsesinto digital impulses Radio-frequency carrier Radio-frequency carrier
transmits percutaneously to transmits percutaneously to internal receiver-stimulator and internal receiver-stimulator and electrode arrayelectrode array
auditory nerve/cortex auditory nerve/cortex stimulated; perception of stimulated; perception of digitally processed info as digitally processed info as speechspeech
Current statusCurrent status
Technology reliable, sophisticated, tested over 20 years Technology reliable, sophisticated, tested over 20 years clinical useclinical use
200,000 + implants worked wide, ½ adult, ½ pediatric200,000 + implants worked wide, ½ adult, ½ pediatric 1 million potential U.S. candidates1 million potential U.S. candidates 3 companies manufacture: Cochlear, Med-EL, Advanced 3 companies manufacture: Cochlear, Med-EL, Advanced
BionicsBionics Outcomes similar among modelsOutcomes similar among models No single method for predicting better results among No single method for predicting better results among
devices—differ in processing strategies, slight technical/ devices—differ in processing strategies, slight technical/ surgical variationssurgical variations
Current statusCurrent status
Chief predictor of success = a short duration of Chief predictor of success = a short duration of hearing losshearing loss
Children: earlier implantation bestChildren: earlier implantation best Narrow window of opportunity for speech/language Narrow window of opportunity for speech/language
first 2 years life; best 18mos & underfirst 2 years life; best 18mos & under Adults: chronologic age itself not a factorAdults: chronologic age itself not a factor Requires detailed fitting, rehabilitation, practiceRequires detailed fitting, rehabilitation, practice
Special education in children without languageSpecial education in children without language Auditory/speech rehab the key element of Auditory/speech rehab the key element of
successsuccess
Selection criteria: pediatricsSelection criteria: pediatrics FDA minimum age recommendation = 12 mosFDA minimum age recommendation = 12 mos
CI at younger age may be advantageousCI at younger age may be advantageous Audiometric Pure Tone Averages [PTA]:Audiometric Pure Tone Averages [PTA]:
12- 18 mos: Profound loss >/=90 dbHL12- 18 mos: Profound loss >/=90 dbHL 18 mos and up: severe-profound loss 70-90 dbHL18 mos and up: severe-profound loss 70-90 dbHL
Speech Perception testing for infants [<24 mos]Speech Perception testing for infants [<24 mos] Lack of auditory progress measured on IT-MAIS [best aided condition]Lack of auditory progress measured on IT-MAIS [best aided condition]
No benefit/lack of progress with conventional No benefit/lack of progress with conventional amplificationamplification
Psychologically appropriate: no significant mental/neuro Psychologically appropriate: no significant mental/neuro disability*disability*
Enrollment in educational program emphasizing auditory Enrollment in educational program emphasizing auditory developmentdevelopment
Motivation to complete rehabMotivation to complete rehab
Selection criteria: pediatricsSelection criteria: pediatrics Older children--2 years-18 years:Older children--2 years-18 years:
Severe-profound loss both earsSevere-profound loss both ears Lack of progress with HA=Lack of progress with HA=
25 mos-4yrs,11 mos: Multisyllabic Lexical Neighborhood Test 25 mos-4yrs,11 mos: Multisyllabic Lexical Neighborhood Test [MLNT] <30% in better-aided ear[MLNT] <30% in better-aided ear
5 yrs – 17 yrs,11 mos: Lexical Neighborhood Test [LNT] <30%5 yrs – 17 yrs,11 mos: Lexical Neighborhood Test [LNT] <30% Other tests to evaluate: MAIS, HINT, WIPIOther tests to evaluate: MAIS, HINT, WIPI
High motivation, no medical contraindicationsHigh motivation, no medical contraindications Enrollment in educational program emphasizing auditory Enrollment in educational program emphasizing auditory
developmentdevelopment Careful selection of pts ESSENTIALCareful selection of pts ESSENTIAL
Do not want to implant pt who will do better with Hearing aidDo not want to implant pt who will do better with Hearing aid
Contraindications for implantationContraindications for implantation
Completely atretic VIII nerveCompletely atretic VIII nerve Small internal auditory canal syndromeSmall internal auditory canal syndrome
Agenesis of cochlea: Michel deformityAgenesis of cochlea: Michel deformity Active middle ear/mastoid infectionActive middle ear/mastoid infection Tympanic membrane perforationTympanic membrane perforation Severe organic brain dysfunctionSevere organic brain dysfunction Severe mental retardationSevere mental retardation Psychosis, unrealistic expectationsPsychosis, unrealistic expectations
Minimum expected benefitsMinimum expected benefits
Awareness of environment [warnings, others talking]Awareness of environment [warnings, others talking] Detection [not understanding] of sound in speech range Detection [not understanding] of sound in speech range Awareness of musicAwareness of music Improved speech reading ability with practiceImproved speech reading ability with practice Awareness of own voice (ability to monitor intensity and Awareness of own voice (ability to monitor intensity and
speech production)speech production) Potential for improvement in speech intelligibility (based Potential for improvement in speech intelligibility (based
on pt and therapy)on pt and therapy) Potential for telephone use (dependent on speech Potential for telephone use (dependent on speech
intelligibility)intelligibility)
Team approach for implantationTeam approach for implantation
Physician/Surgeon:Physician/Surgeon: Medical evaluation of candidatesMedical evaluation of candidates Responsible for all surgical care & complicationsResponsible for all surgical care & complications
Audiologists, speech-language pathologists, Audiologists, speech-language pathologists, psychologistspsychologists Vital/Key role in evaluation of candidacyVital/Key role in evaluation of candidacy Key for rehabilitation, learning use of deviceKey for rehabilitation, learning use of device Education, implant maintenanceEducation, implant maintenance
Cochlear Implants in InfantsCochlear Implants in Infants Universal Newborn Hearing ScreeningUniversal Newborn Hearing Screening Technological advances in CI systemsTechnological advances in CI systems Language delayLanguage delay Surgical feasibility:Surgical feasibility:
Pediatric Otolaryngology and Neurotologists: Pediatric Otolaryngology and Neurotologists: experienced with infants 1 to 12 mos of age in children’s experienced with infants 1 to 12 mos of age in children’s hospitals [pediatric anesthesiologists]hospitals [pediatric anesthesiologists]
routine airway interventions for premature routine airway interventions for premature and term infantsand term infants
Sublgottic /tracheal stenosis surgerySublgottic /tracheal stenosis surgery Choanal atresia surgeryChoanal atresia surgery Congenital masses of neck, vascular tumorsCongenital masses of neck, vascular tumors
SurgeonSurgeon: PMD referral, family preference : PMD referral, family preference
ComplicationsComplications Skin Flap breakdownSkin Flap breakdown Facial nerve stimulationFacial nerve stimulation Facial nerve injury/paralysisFacial nerve injury/paralysis CSF leak/gusherCSF leak/gusher Device failure : 3-6%, Device failure : 3-6%, Infection: otitis media, mastoiditis, implant pocketInfection: otitis media, mastoiditis, implant pocket Meningitis:Meningitis:
26 out of 4264 U.S. pediatric implants = 26 out of 4264 U.S. pediatric implants = 0.6 % 0.6 % Reefhuis J et al. NEJM 2003;349:435-45.Reefhuis J et al. NEJM 2003;349:435-45. 2 deaths2 deaths
Many cases occurred in pts with cochlear malformationMany cases occurred in pts with cochlear malformation Most cases involved device with spacerMost cases involved device with spacer Current protocol = Current protocol = pneumococcal & H. influenza vaccinationpneumococcal & H. influenza vaccination
Hib, Prevnar, PneumovaxHib, Prevnar, Pneumovax
ComplicationsComplications AnesthesiaAnesthesia: pertinent for all ENT operations: pertinent for all ENT operations Current anesthesia fatality rate 1:250,000 Current anesthesia fatality rate 1:250,000
for healthy individuals >1yrfor healthy individuals >1yr For perspective: activities with same risk of For perspective: activities with same risk of
death as anesthesia:death as anesthesia: 40 hours automobile driving [2,000 miles]40 hours automobile driving [2,000 miles] 40 hrs bicycle riding40 hrs bicycle riding 24 hrs commercial airline flying24 hrs commercial airline flying 7 hrs downhill skiing; 30 minutes rock climbing7 hrs downhill skiing; 30 minutes rock climbing 340 trips in passenger elevator340 trips in passenger elevator
Emerging IssuesEmerging Issues
Earlier implantation: prior to 1yearEarlier implantation: prior to 1year Bilateral implantationBilateral implantation
Why?Why? Psychoacoustic literaturePsychoacoustic literature Diminished function with only unilateral aiding of bilateral HLDiminished function with only unilateral aiding of bilateral HL
Improvement in speech intelligibilityImprovement in speech intelligibility 3 binaural mechanisms3 binaural mechanisms
Head shadow effect, Head shadow effect, Binaural squelch, SummationBinaural squelch, Summation Sound localization, listening in noisy environmentSound localization, listening in noisy environment Adult studies support, growing peds literatureAdult studies support, growing peds literature Sequential vs simultaneous implantationSequential vs simultaneous implantation
Risk/benefit ratio; insurance approvalRisk/benefit ratio; insurance approval Possible future alternative TX in future: stem cell,new implants---Possible future alternative TX in future: stem cell,new implants---
save one cochlea?save one cochlea?
CI Outcomes in Children: CI Outcomes in Children: Key FindingsKey Findings
Large individual differences; each child uniqueLarge individual differences; each child unique No preimplant predictors of outcomeNo preimplant predictors of outcome Abilities emerge after implantation Abilities emerge after implantation
Nature of early experience—Nature of early experience— Earlier implantation= better CI performance, better Earlier implantation= better CI performance, better
auditory/verbal communicationauditory/verbal communication
Implant must be worn every day, all day Implant must be worn every day, all day Environment with robust auditory input Environment with robust auditory input
necessary for maximal CI resultsnecessary for maximal CI results
CI Outcomes in Children: CI Outcomes in Children: Language Language
Children with CIs Outperform their Profoundly Deaf Peers Who Use Hearing Aids Faster rates of language learning and higher overall language achievement levels in
CI pts vs unimplanted Deaf children
Literacy: Tomblin & GeersTomblin & Geers reading levels CI pts approaches hearing peers reading levels CI pts approaches hearing peers 15 yr Deaf ASL students: reading comprehension = 315 yr Deaf ASL students: reading comprehension = 3rdrd grade; grade; Some CI pts do not do as well [IQ, Oral commun, language skills]Some CI pts do not do as well [IQ, Oral commun, language skills]
Children Using both Oral and Total Communication Improve in their Language Skills After CI; but as a group Oral Communication Users Outperform Those TC
Many variables to further examineMany variables to further examine
Ref: Ref: Oto Clin N America: Feb 2012 Robbins A, Niparko JOto Clin N America: Feb 2012 Robbins A, Niparko J
Otitis MediaOtitis Media AAP 2004 AOM guidelinesAAP 2004 AOM guidelines AAO 2004 OME guidelinesAAO 2004 OME guidelines Cochrane reviews: OME, BMT, adenoidectomyCochrane reviews: OME, BMT, adenoidectomy Evidence-based medicine vs evidence based Evidence-based medicine vs evidence based
common sensecommon sense Smith and Pell BMJ 2003: Parachute use to Smith and Pell BMJ 2003: Parachute use to
prevent death and major trauma related to prevent death and major trauma related to gravitational challengegravitational challenge
AHRQ 2012: comparative effectiveness reviews AHRQ 2012: comparative effectiveness reviews for OME--pendingfor OME--pending
Nose and SinusNose and Sinus
Chronic sinusitis:Chronic sinusitis: Role of adenoidectomy, +/- maxillary Role of adenoidectomy, +/- maxillary
irrigationsirrigations Role of Role of balloon sinuplastyballoon sinuplasty: evidence based : evidence based
medicine support pending medicine support pending Useful tool for frontal sinus disease in our practiceUseful tool for frontal sinus disease in our practice Useful for maxillaryUseful for maxillary New hammer—many looking for usesNew hammer—many looking for uses Time will tellTime will tell
Nose and SinusNose and Sinus
Image Gently Image Gently campaigncampaign
selected imaging of selected imaging of sinus diseasesinus disease
In era of easy In era of easy antibiotic antibiotic availability, still availability, still mindful of sinusitis mindful of sinusitis complicationscomplications
::
Adenotonsillar Disease/OSAAdenotonsillar Disease/OSA
2011 American Academy of Otolaryngology-2011 American Academy of Otolaryngology-HNS adenotonsillectomy clinical guidelineHNS adenotonsillectomy clinical guideline Chronic tonsillitis: 7 per 1 yr, 5x2 yr, 3x3 yrsChronic tonsillitis: 7 per 1 yr, 5x2 yr, 3x3 yrs OSA sx, +/- PSGOSA sx, +/- PSG Admission >3yrsAdmission >3yrs PFAPAPFAPA
Recall prior data: recurrent tonsillitis in children: Recall prior data: recurrent tonsillitis in children: 80% resolution in 1 year80% resolution in 1 year
Adenotonsillar Disease/OSAAdenotonsillar Disease/OSA
2011 American Academy of 2011 American Academy of Otolaryngology-HNS CPG: PSG for sleep-Otolaryngology-HNS CPG: PSG for sleep-disordered breathing prior to tonsillectomy disordered breathing prior to tonsillectomy in childrenin children for complex medical conditions preopfor complex medical conditions preop Discordance between tonsil size & SDB sxDiscordance between tonsil size & SDB sx Admit postop if <3yrs or severe OSA Admit postop if <3yrs or severe OSA
AHI>10, sats< 80%AHI>10, sats< 80%
Laboratory based PSG rather than home PSGLaboratory based PSG rather than home PSG
Adenotonsillar Disease/OSAAdenotonsillar Disease/OSA
AAP 2012 : CPG Diagnosis/management of AAP 2012 : CPG Diagnosis/management of Obstructive sleep apnea syndromeObstructive sleep apnea syndrome [OSAS] [OSAS] 1) all children screened for snoring1) all children screened for snoring 2) PSG for snoring, OSAS2) PSG for snoring, OSAS 3) T&A primary treatment3) T&A primary treatment 4) high risk pts monitored inpt postop4) high risk pts monitored inpt postop
AHI>24, sat>80%, PCO2>60AHI>24, sat>80%, PCO2>60
5) intranasal steroids: indications5) intranasal steroids: indications 6) CPAP postop or if T&A not performed6) CPAP postop or if T&A not performed
Adenotonsillar Disease/OSAAdenotonsillar Disease/OSA
Multiple publications on neurocognitive effectsMultiple publications on neurocognitive effects School aged children—even with negative PSGSchool aged children—even with negative PSG
ADHD behaviorADHD behavior Decreased cognitionDecreased cognition IQ testing changesIQ testing changes
Beebe DW: Persistent snoring in preschool children, Pediatrics sept Beebe DW: Persistent snoring in preschool children, Pediatrics sept 2012: --2012: --ages 2-3 yrs Cincinnatiages 2-3 yrs Cincinnati large prospective birth cohort study n=249 2 to 3 yrs oldlarge prospective birth cohort study n=249 2 to 3 yrs old Persistent loud snoring occurs 9% childrenPersistent loud snoring occurs 9% children = significantly higher behavior problems= significantly higher behavior problems
Hyperactivity, depression, inattentions, Hyperactivity, depression, inattentions, Worse cognitive developmentWorse cognitive development
Adenotonsillar Disease/OSAAdenotonsillar Disease/OSA
Childhood Adenotonsillectomy Study Childhood Adenotonsillectomy Study [CHAT] 2012: [CHAT] 2012: First prospective, randomized controlled study, First prospective, randomized controlled study,
multicenter evaluated effectiveness of T&A or multicenter evaluated effectiveness of T&A or watchful waiting for OSAwatchful waiting for OSA
464 children, 5-9yrs with PSG proven mild-464 children, 5-9yrs with PSG proven mild-moderate OSA randomizedmoderate OSA randomized
Publication forthcomingPublication forthcoming PSG results, neurocognitive testing improvesPSG results, neurocognitive testing improves
Observation arm: may also show improvementObservation arm: may also show improvement
Hemangiomas/Vascular Hemangiomas/Vascular malformationsmalformations
Propranolol: Propranolol: Significant improvement in our care for Significant improvement in our care for
hemangiomas of airway, head/neckhemangiomas of airway, head/neck
Sclerotherapy vascular malformationsSclerotherapy vascular malformations
Neck Mass vs Lymph node vs Neck Mass vs Lymph node vs Cancer?Cancer?
Midline vs Lateral Neck MassMidline vs Lateral Neck Mass EvaluationEvaluation
HistoryHistory Growth 4-6 wks,+sx Growth 4-6 wks,+sx Abx no effectAbx no effect Cat, TB exposureCat, TB exposure Constitutional / Lymphoma symptomsConstitutional / Lymphoma symptoms
Ultrasound helpfulUltrasound helpful
Neck Mass vs Lymph node vs Neck Mass vs Lymph node vs Cancer?Cancer?
Midline DDXMidline DDX Thyroglossal duct cystThyroglossal duct cyst Dermoid cystDermoid cyst Thyroid and Parathyroid massesThyroid and Parathyroid masses Vascular lesions/hemangiomaVascular lesions/hemangioma LaryngocelesLaryngoceles
Neck Mass vs Lymph node vs Neck Mass vs Lymph node vs Cancer?Cancer?
Lateral Neck Masses:Lateral Neck Masses: Acute adenitisAcute adenitis Chronic adenitisChronic adenitis
Atypical mycobacterialAtypical mycobacterial Cat-ScratchCat-Scratch ToxoplasmosisToxoplasmosis HIVHIV
CongenitalCongenital Branchial CleftBranchial Cleft Pseudotumor infancy,Pseudotumor infancy, Thymus,Thymus, Vascular/Lymphatic Vascular/Lymphatic
Malignant Lateral Malignant Lateral Neck Masses;Neck Masses; LymphomaLymphoma SarcomaSarcoma NeuroblastomaNeuroblastoma Salivary glandSalivary gland
Neck Mass vs Lymph node vs Neck Mass vs Lymph node vs Cancer?Cancer?
Inflammatory syndromesInflammatory syndromes Persistent, enlarging chronic adenopathyPersistent, enlarging chronic adenopathy Odd/usually rareOdd/usually rare
-history, exam give clues-history, exam give clues
SarcoidosisSarcoidosis
KawasakiKawasaki
Castleman’s disease, Castleman’s disease,
JRA, SLE, Rosai-Dorfman disease/histiocytosisJRA, SLE, Rosai-Dorfman disease/histiocytosis
AnkyloglossiaAnkyloglossia
To release or not to release?To release or not to release? Feeding/latching to breast/bottleFeeding/latching to breast/bottle
Can release in office or nursery 1Can release in office or nursery 1stst weeks life weeks life Studies support Studies support
Speech /articulation difficulties laterSpeech /articulation difficulties later Weigh vs anesthetic risksWeigh vs anesthetic risks