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

Otolaryngology Pathology in Children

Head and Neck Masses

Sleep Disordered Breathing/OSA

Pharyngitis

Otitis Media/Cholesteatoma

Sinusitis

Airway

Dysphonia

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

Head and Neck Masses – Work Up

History

• Duration

• Size trend

• Pain

• Fever

• Constitutional Symptoms

• Dysphagia

• Difficulty breathing

Physical

• Size

• Erythema

• Tenderness

• Firmness

• Location

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

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

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.

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

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

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

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

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

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

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

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

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

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

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

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

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.

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

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

Peritonsillar Abscess

Symptoms

• Muffled (Hot Potato) voice

• Uvular deviation (Asymmetric oropharynx)

• Trismus

Treatment

• Drainage

• Oral antibiotics

• Steroids

Tonsillectomy after 2nd episode

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

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

AOM Complications

Acute Mastoiditis

Coalescent Mastoiditis

Bezold’s Abscess

Intracranial Complications

• Sigmoid Sinus Thrombosis• Picket Fence Fevers

• Meningitis• Intracranial Abscess

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.

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.

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.

Tympanostomy Risks

Bleeding

Infection

Pain

Tympanic membrane perforation

Hearing loss

Cholesteatoma

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.

Tympanic Membrane Perforation

Monomeric Tympanic Membrane Tympanic Membrane Retraction

Not Tympanic Membrane Perforation

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.

Cholesteatoma

What is it?

• Expanding, keratinizing, squamous epithelial tumor

• Benign

Etiology

• Congenital

• TM perforation

• TM retraction

Congenital

• Asymptomatic “pearl” in intact TM

Cholesteatoma

Symptoms

• Asymptomatic

• Hearing loss

• Recurrent OM

• Chronic otorrhea

• Aural Polyp

• Draining Ear

Treatment

• Surgery

Complications

• Hearing loss

• Intracranial extension

• Meningitis

• Intracranial abscess

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

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

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

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

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

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

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

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

Acute Sinusitis Complications

Preseptal Cellulitis (Periorbital Cellulitis)

Orbital Involvement

• Orbital cellulitis• Orbital abscess

Cavernous Sinus Thrombosis

Intracranial Infection

• Meningitis• Intracranial Abscess

Airway

Nasal

Laryngeal

Esophageal

• Respiratory distress• Stridor, Retractions

• Drooling/Dysphagia• Unilateral rhinorrhea• Infection that does not resolve with treatment

Symptoms

Airway Obstruction

Foreign body

• URI – RSV, etc.• Croup• Epiglottitis

Infection

Trauma

Neoplasm

• Subglottic hemangioma

• Teratoma

• Dermoid cyst

Congenital

• Choanal atresia

• Laryngomalacia

• Laryngotracheal anomaly

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

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

Neonatal period - Neoplasm

Subglottic hemangioma

• May resolve as they get older.

• Treated with B-blockers or surgery.

Lymphangioma

Teratoma

Dermoid cyst

Endoscopy or Imaging

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

Neonatal period - Laryngomalacia

• Hypoxemia• Cyanosis• OSA

Severe

May be associated with other congenital anomalies

Surgical intervention – 10%

Referral to Otolaryngologist for endoscopy

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

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

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

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

Recurrent Respiratory Papillomatosis

Suspect abuse – presents at age >5 yo

Malignant transformation – 3%

Treatment

• Repeat Surgery

• Cidofivir

May resolve or may persist

Vocal Cord Nodules Vocal cord

Other Vocal Cord Lesions