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OFFICE BASED ENT PRACTISE IN CHILDREN:DIFFICULT SITUATIONS & RECENT TRENDS DR SHEELU SRINIVAS CONSULTANT ENT SURGEON
We Can Only Refine Our Therapeutics When We Refine Our Diagnostic Abilities
 
 
 
 
Standard Equipment Assess nares / choanae Assess adenoid and lingual tonsil Assess TVC mobility Assess laryngeal structures
 
 
 
Nasoaryngoscopy video
Sleep disordered breathing in children <ul><li>4-8 yr olds with variable clinical symptoms at various ages </li></ul><ul><...
Pathogenesis  <ul><li>Not properly understood </li></ul><ul><li>Children with sleep-disordered breathing (SDB) can manifes...
Pathogenesis <ul><li>Adenotonsillar hypertrophy is the leading cause of OSA.  </li></ul><ul><li>Other risk factors include...
Symptoms   <ul><li>Symptoms of pediatric SDB vary and specialty referral is often done according to symptoms noted by pare...
Table 1.  Clinical Differences in Sleep-disordered Breathing between Children and Adults Variables  Children  Adults Sex d...
Diagnostic tool <ul><li>Polysomnography PSG gold standard </li></ul><ul><li>can be performed successfully in infants and c...
Apnea in children is defined as absence of airflow with continued chest wall and abdominal wall movement for a duration lo...
Physical examination
Treatments of Sleep-disordered Breathing in Children <ul><li>Non-surgical treatment   Surgical treatment </li></ul><ul><li...
NOISY BREATHERS <ul><li>STERTOR  </li></ul><ul><li>Snoring type of noise often made by   nasopharyngeal or oropharyngeal  ...
Venturi principle <ul><li>Pediatric airway more flexible  </li></ul><ul><li>Forces exerted by Venturi principle cause the ...
<ul><li>Infant larynx:   -More superior in neck    -Epiglottis shorter, angled more over glottis   -Vocal cords slanted: a...
Assessment <ul><li>Region  / LEVEL OF AIRWAY OBSTRUCTION </li></ul><ul><li>Voice   </li></ul><ul><li>Stridor   </li></ul><...
Above vocal cords <ul><li>Supraglottic laryngeal obstruction  </li></ul><ul><li>Muffled or throaty  </li></ul><ul><li>Snor...
Vocal cords & below <ul><li>Glottic –level of cords </li></ul><ul><li>Subglottic </li></ul><ul><li>tracheobronchial tree <...
Glottic obstruction   <ul><li>Hoarse or aphonic  </li></ul><ul><li>Inspiratory early; expiratory also as obstruction incre...
Subglottic obstruction   <ul><li>Hoarse, but can be husky or normal  </li></ul><ul><li>Inspiratory early; expiratory also ...
Tracheobronchial obstruction  <ul><li>Normal  </li></ul><ul><li>Expiratory and wheezing; becoming to and fro with increasi...
Evaluation -ABC <ul><li>every pediatric casualty should have flexible scopes </li></ul><ul><li>Choanal atresias </li></ul>...
Proper Equipment Assess nares/choanae Assess adenoid and lingual tonsil Assess true vocal cord  mobility Assess laryngeal ...
 
CHAOS (congenital high airway obstruction syndrome) <ul><li>Emergent airway management at the time of delivery is key for ...
EXIT Procedure (ex utero intrapartum treatment) <ul><li>Prenatal diagnosis is crucial </li></ul><ul><ul><li>Flattened diap...
Foreign Bodies <ul><li>2-4year olds </li></ul><ul><li>Acute episode of choking/gagging </li></ul><ul><li>Triad of acute wh...
Laryngopharyngeal reflux <ul><li>Up to two-thirds of infants exhibit signs of reflux  (Nelson 1997) </li></ul><ul><li>A ma...
WHAT IS THE DIFFERENCE BETWEEN GERD & LPR? <ul><li>Gastroesophageal reflux   (GER) </li></ul><ul><ul><li>Retrograde flow o...
 
diagnostic <ul><li>Double lumen pH monitering gold standard </li></ul><ul><ul><li>Laryngoscopy </li></ul></ul><ul><ul><li>...
Swallowing & feeding disorders <ul><li>40-70% kids with CNS disorders </li></ul><ul><li>Note: nasal obstruction, nasal mas...
Assessment of swallowing <ul><li>VSS : videofluoroscopy swallow study </li></ul><ul><li>FEES: functional endoscopic evalua...
Role of ENT in special children <ul><li>Airway </li></ul><ul><li>Swallowing & drooling </li></ul><ul><li>Hearing & speech ...
Drooling severity score (after Thomas-Stonell and Greenberg <ul><li>1. Dry </li></ul><ul><li>2. Mild – wet lips </li></ul>...
Management approaches <ul><li>Conservative methods  include behavioural approaches and techniques to improve sensory aware...
Head & neck tumors <ul><li>Congenital  </li></ul><ul><li>Inflammatory </li></ul><ul><li>Neoplastic  </li></ul><ul><li>Hema...
Hemangiomas   <ul><li>Look for associated cardiac, CNS  </li></ul><ul><li>Spontaneous resolution 90% </li></ul><ul><li>Res...
Have you recently seen a film? <ul><li>Biofilms: organised sessile communities of attached bacteria in an extracellular ma...
We Can Only Refine Our Therapeutics When We Refine Our Diagnostic Abilities THANK YOU SHEELU SRINIVAS [email_address] 9900...
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  1. 1. OFFICE BASED ENT PRACTISE IN CHILDREN:DIFFICULT SITUATIONS & RECENT TRENDS DR SHEELU SRINIVAS CONSULTANT ENT SURGEON
  2. 2. We Can Only Refine Our Therapeutics When We Refine Our Diagnostic Abilities
  3. 7. Standard Equipment Assess nares / choanae Assess adenoid and lingual tonsil Assess TVC mobility Assess laryngeal structures
  4. 11. Nasoaryngoscopy video
  5. 12. Sleep disordered breathing in children <ul><li>4-8 yr olds with variable clinical symptoms at various ages </li></ul><ul><li>Infants- noisy breathing,disturbed nocturnal sleep </li></ul><ul><li>Toddlers & preschoolers-snoring & mouth breathing </li></ul><ul><li>School goers-behavioral & dental problems </li></ul>
  6. 13. Pathogenesis <ul><li>Not properly understood </li></ul><ul><li>Children with sleep-disordered breathing (SDB) can manifest </li></ul><ul><li>a continuum from simple snoring and upper airway resistance syndrome to obstructive sleep apnea (OSA) </li></ul><ul><li>with secondary growth impairment, neurocognitive deficits, and less often cardiovascular sequelae. </li></ul>
  7. 14. Pathogenesis <ul><li>Adenotonsillar hypertrophy is the leading cause of OSA. </li></ul><ul><li>Other risk factors include allergic rhinitis, craniofacial anomalies, cleft palate following pharyngeal flap surgery, neuromuscular diseases, laryngomalacia, and obesity. </li></ul>
  8. 15. Symptoms <ul><li>Symptoms of pediatric SDB vary and specialty referral is often done according to symptoms noted by parents. </li></ul><ul><li>For example, </li></ul><ul><li>a child with snoring and tonsillar hypertrophy is most likely to be referred to an otolaryngologist, </li></ul><ul><li>a child with growth impairment to a pediatrician, and </li></ul><ul><li>a sleepy child to a neurologist. </li></ul>
  9. 16. Table 1. Clinical Differences in Sleep-disordered Breathing between Children and Adults Variables Children Adults Sex distribution Male: Female = 1:1 Male: Female = 8:1 Weight Underweight Commonly obese Snoring Continuous Intermittent with pause Mouth breathing Common Less common Chief complaint Snoring,difficult Daytime sleepiness breathing Enlarged tonsils/ Common Uncommon adenoids Obstructive pattern Mostly apneas Mostly hypopneas State with most REM REM or non-REM obstruction Clinical arousal Uncommon Common Sleep architecture Preserved Fragmented Sequelae Behavioral changes Daytime sleepiness Neurocognitive Cardiovascular deficits disease Primary treatment Adenotonsillectomy CPAP therapy Abbreviations: SDB: sleep-disordered breathing; REM: rapid eye movement; CPAP: continuous positive airway pressure.
  10. 17. Diagnostic tool <ul><li>Polysomnography PSG gold standard </li></ul><ul><li>can be performed successfully in infants and children of all ages. </li></ul><ul><li>An AHI > 1 event/h in children is considered abnormal </li></ul>
  11. 18. Apnea in children is defined as absence of airflow with continued chest wall and abdominal wall movement for a duration longer than 2 breaths,(9) whereas obstructive hypopnea is defined as a decrease in nasal flow between 30% and 80% from baseline with a corresponding decrease in oxygen saturation of 3% and /or arousal. <ul><li>differences in OSA between children and </li></ul><ul><li>adults. </li></ul><ul><li>1. Children with OSA frequently do not have </li></ul><ul><li>cortical arousal associated with obstructive apnea </li></ul><ul><li>and are less likely to have fragmented sleep than </li></ul><ul><li>adults. Consequently, sleep architecture is preserved </li></ul><ul><li>and daytime sleepiness is uncommon. </li></ul><ul><li>2. In children, the majority of obstructive apneas </li></ul><ul><li>occur during rapid eye movement (REM) sleep, particularly </li></ul><ul><li>in later REM sleep. As a result, OSA may </li></ul><ul><li>be missed if the REM stage is decreased or absent on </li></ul><ul><li>screening studies, e.g. nap studies. </li></ul><ul><li>3. Children may present with persistent obstructive </li></ul><ul><li>hypoventilation, rather than cyclic obstructive </li></ul><ul><li>apnea.Clinically, these children manifest constant </li></ul><ul><li>snoring and labored breathing instead of breathing </li></ul><ul><li>pauses or gasps. </li></ul>
  12. 19. Physical examination
  13. 20. Treatments of Sleep-disordered Breathing in Children <ul><li>Non-surgical treatment Surgical treatment </li></ul><ul><li>Rx of nasal allergy Adenotonsillectomy </li></ul><ul><li>Treat acute inflammation UPPP </li></ul><ul><li>Treatment of reflux Nasal surgery </li></ul><ul><li>CPAP Revision of posterior pharyngeal flap </li></ul><ul><li>Rapid maxillary expansion Distraction osteogenesis </li></ul><ul><li>Weight reduction Tracheotomy </li></ul>
  14. 21. NOISY BREATHERS <ul><li>STERTOR </li></ul><ul><li>Snoring type of noise often made by nasopharyngeal or oropharyngeal obstruction </li></ul><ul><li>May occassionally be created by supraglottic larynx </li></ul><ul><li>STRIDOR </li></ul><ul><li>Harsh sound produced by turbulent airflow through a partial obstruction </li></ul><ul><li>May be soft and tuneful/musical quality </li></ul><ul><li>Characteristic of certain pathology but never diagnostic </li></ul>
  15. 22. Venturi principle <ul><li>Pediatric airway more flexible </li></ul><ul><li>Forces exerted by Venturi principle cause the narrowed, flexible airway to be momentarily closed during either inspiration or expiration </li></ul><ul><li>Infant larynx-higher, close proximity to pharynx </li></ul>
  16. 23. <ul><li>Infant larynx: -More superior in neck -Epiglottis shorter, angled more over glottis -Vocal cords slanted: anterior commissure more inferior </li></ul><ul><ul><li>- Vocal process 50% of length -Larynx cone-shaped: narrowest at subglottic cricoid ring -Softer, more pliable: may be gently flexed or rotated anteriorly </li></ul></ul><ul><li>Infant tongue is larger </li></ul><ul><li>Head is naturally flexed </li></ul>
  17. 24. Assessment <ul><li>Region  / LEVEL OF AIRWAY OBSTRUCTION </li></ul><ul><li>Voice   </li></ul><ul><li>Stridor   </li></ul><ul><li>Retractions   </li></ul><ul><li>Feeding   </li></ul><ul><li>Mouth   </li></ul><ul><li>Cough   </li></ul>
  18. 25. Above vocal cords <ul><li>Supraglottic laryngeal obstruction  </li></ul><ul><li>Muffled or throaty  </li></ul><ul><li>Snoring; inspiratory; fluttering  </li></ul><ul><li>None, until very late  </li></ul><ul><li>Difficult to impossible  </li></ul><ul><li>Open; jaw held forward  </li></ul><ul><li>None  </li></ul><ul><li>Oropharyngeal obstruction  </li></ul><ul><li>Unaffected but can be throaty or full  </li></ul><ul><li>Inspiratory and coarse; increases during sleep  </li></ul><ul><li>Sternal and intercostal, increasing to total chest when severe  </li></ul><ul><li>Difficult to impossible, with drooling or saliva  </li></ul><ul><li>Open; jaw held forward  </li></ul><ul><li>None  </li></ul>
  19. 26. Vocal cords & below <ul><li>Glottic –level of cords </li></ul><ul><li>Subglottic </li></ul><ul><li>tracheobronchial tree </li></ul>
  20. 27. Glottic obstruction   <ul><li>Hoarse or aphonic  </li></ul><ul><li>Inspiratory early; expiratory also as obstruction increases  </li></ul><ul><li>Xiphoid early and intercostal later; suprasternal and supraclavicular  </li></ul><ul><li>Normal, except with severe obstruction  </li></ul><ul><li>May be closed; nares flared  </li></ul><ul><li>None  </li></ul>
  21. 28. Subglottic obstruction   <ul><li>Hoarse, but can be husky or normal  </li></ul><ul><li>Inspiratory early; expiratory also as obstruction increases  </li></ul><ul><li>Xiphoid early and intercostal later; suprasternal and supraclavicular  </li></ul><ul><li>Normal, except with severe obstruction  </li></ul><ul><li>May be closed; nares flared  </li></ul><ul><li>Barking  </li></ul>
  22. 29. Tracheobronchial obstruction  <ul><li>Normal  </li></ul><ul><li>Expiratory and wheezing; becoming to and fro with increasing obstruction  </li></ul><ul><li>None, except with severe obstruction; xiphoid and sternal  </li></ul><ul><li>Normal, except with severe airway obstruction or when extrinsic obstruction involves esophagus  </li></ul><ul><li>May be closed; nares flared  </li></ul><ul><li>Brassy  </li></ul>
  23. 30. Evaluation -ABC <ul><li>every pediatric casualty should have flexible scopes </li></ul><ul><li>Choanal atresias </li></ul><ul><li>Laryngomalacia </li></ul><ul><li>Vocal cord & glottic anamolies[?clefts] </li></ul><ul><li>RRP </li></ul><ul><li>Subglottic anamolies </li></ul>
  24. 31. Proper Equipment Assess nares/choanae Assess adenoid and lingual tonsil Assess true vocal cord mobility Assess laryngeal structures
  25. 33. CHAOS (congenital high airway obstruction syndrome) <ul><li>Emergent airway management at the time of delivery is key for survival </li></ul><ul><li>Prenatally </li></ul><ul><ul><li>Flattened diaphragms, polyhydramnios, cervical mass </li></ul></ul><ul><li>TEAM Members </li></ul><ul><ul><li>Maternal-fetal specialist </li></ul></ul><ul><ul><li>Neonatalogist </li></ul></ul><ul><ul><li>Anesthesiologist </li></ul></ul><ul><ul><li>Otolaryngologist </li></ul></ul><ul><ul><li>Patient </li></ul></ul>
  26. 34. EXIT Procedure (ex utero intrapartum treatment) <ul><li>Prenatal diagnosis is crucial </li></ul><ul><ul><li>Flattened diaphragms, polyhydramnios </li></ul></ul><ul><li>The head, neck, thorax, and one arm are delivered. </li></ul><ul><li>Uteroplacental circulation can be maintained for 45-60 minutes </li></ul>
  27. 35. Foreign Bodies <ul><li>2-4year olds </li></ul><ul><li>Acute episode of choking/gagging </li></ul><ul><li>Triad of acute wheeze, cough and unilateral diminished sounds only in 50% </li></ul><ul><li>5-40% of patients manifest no obvious signs </li></ul>
  28. 36. Laryngopharyngeal reflux <ul><li>Up to two-thirds of infants exhibit signs of reflux (Nelson 1997) </li></ul><ul><li>A majority of those children will outgrow their reflux by their second year of age </li></ul><ul><li>Laryngopharyngeal reflux (LPR) has gained increasing recognition as a common pediatric disorder over the past few years . </li></ul><ul><li>Its symptoms include </li></ul><ul><li>benign postprandial vomiting during the first year of life, </li></ul><ul><li>failure to thrive, </li></ul><ul><li>esophagitis, and airway disturbances. </li></ul><ul><li>In some conditions--such as tracheoesophageal fistula, neurologic impairment, or oral motor dysphagia--the incidence might be as high as 70%. </li></ul>
  29. 37. WHAT IS THE DIFFERENCE BETWEEN GERD & LPR? <ul><li>Gastroesophageal reflux (GER) </li></ul><ul><ul><li>Retrograde flow of gastric contents into the esophagus </li></ul></ul><ul><li>Laryngopharyngeal reflux (LPR) </li></ul><ul><ul><li>Extraesophageal reflux (EER) </li></ul></ul><ul><ul><li>denotes the gastric contents that reaches beyond the upper esophageal sphincter (UES) into oropharynx and/or nasopharynx </li></ul></ul>
  30. 39. diagnostic <ul><li>Double lumen pH monitering gold standard </li></ul><ul><ul><li>Laryngoscopy </li></ul></ul><ul><ul><li>Bronchoscopy </li></ul></ul><ul><ul><li>Esophagoscopy with biopsy </li></ul></ul><ul><ul><li>Barium Esophagram </li></ul></ul><ul><ul><li>Scintiscan </li></ul></ul><ul><ul><li>Esophageal intraluminal impedance </li></ul></ul>
  31. 40. Swallowing & feeding disorders <ul><li>40-70% kids with CNS disorders </li></ul><ul><li>Note: nasal obstruction, nasal masses, oral lesion, cleft lip/palate, upper aero digestive tract anomalies laryngomalacia, 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 </li></ul>
  32. 41. Assessment of swallowing <ul><li>VSS : videofluoroscopy swallow study </li></ul><ul><li>FEES: functional endoscopic evaluation of swallowing </li></ul><ul><li>FEESST Flexible Endoscopic Evaluation of Swallowing with Sensory Testing </li></ul><ul><li>Transnasal oesophagoscopy </li></ul>
  33. 42. Role of ENT in special children <ul><li>Airway </li></ul><ul><li>Swallowing & drooling </li></ul><ul><li>Hearing & speech </li></ul>
  34. 43. Drooling severity score (after Thomas-Stonell and Greenberg <ul><li>1. Dry </li></ul><ul><li>2. Mild – wet lips </li></ul><ul><li>3. Moderate – wet lips and chin </li></ul><ul><li>4. Severe – clothing damp </li></ul><ul><li>5. Profuse – clothing, hands and objects wet </li></ul>
  35. 44. Management approaches <ul><li>Conservative methods include behavioural approaches and techniques to improve sensory awareness </li></ul><ul><li>Appliances </li></ul><ul><li>Drug therapy </li></ul><ul><li>Surgery :salivary duct ligation/transposition </li></ul>
  36. 45. Head & neck tumors <ul><li>Congenital </li></ul><ul><li>Inflammatory </li></ul><ul><li>Neoplastic </li></ul><ul><li>Hemangiomas represent the most common of all congenital anomalies, with an incidence of 0.3-2% at birth and 10% at age 1 year. </li></ul>
  37. 46. Hemangiomas <ul><li>Look for associated cardiac, CNS </li></ul><ul><li>Spontaneous resolution 90% </li></ul><ul><li>Rest surgical: laser, coblation etc </li></ul><ul><li>PROPANOLOL </li></ul>
  38. 47. Have you recently seen a film? <ul><li>Biofilms: organised sessile communities of attached bacteria in an extracellular matrix </li></ul><ul><li>Role in ENT </li></ul>
  39. 48. We Can Only Refine Our Therapeutics When We Refine Our Diagnostic Abilities THANK YOU SHEELU SRINIVAS [email_address] 9900176770

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