1. The document discusses office-based ENT practices for children, covering diagnostic tools, common conditions, and treatment approaches. Polysomnography is the gold standard for diagnosing sleep disorders, while adenotonsillectomy is often the primary treatment for sleep-disordered breathing. 2. Flexible laryngoscopy and other scoping procedures are important for evaluating the airway and detecting issues like laryngomalacia. Swallowing disorders are common in children with neurological conditions and may require videofluoroscopy. 3. Hemangiomas are a frequent congenital issue but often resolve spontaneously. Propranolol is now used to treat hemangiomas in addition to older surgical approaches.

1. OFFICE BASED ENT PRACTISE IN CHILDREN:DIFFICULT SITUATIONS & RECENT TRENDS DR SHEELU SRINIVAS CONSULTANT ENT SURGEON

2. We Can Only Refine Our Therapeutics When We Refine Our Diagnostic Abilities

7. Standard Equipment Assess nares / choanae Assess adenoid and lingual tonsil Assess TVC mobility Assess laryngeal structures

11. Nasoaryngoscopy video

12. 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

13. 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.

14. 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.

15. 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.

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.

17. 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

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. 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.

19. Physical examination

20. 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

21. NOISY BREATHERS STERTOR Snoring type of noise often made by nasopharyngeal or oropharyngeal obstruction May occassionally be created by supraglottic larynx STRIDOR Harsh sound produced by turbulent airflow through a partial obstruction May be soft and tuneful/musical quality Characteristic of certain pathology but never diagnostic

22. 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

23. 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

24. Assessment Region / LEVEL OF AIRWAY OBSTRUCTION Voice Stridor Retractions Feeding Mouth Cough

25. 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

26. Vocal cords & below Glottic –level of cords Subglottic tracheobronchial tree

27. 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

28. 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

29. 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

30. Evaluation -ABC every pediatric casualty should have flexible scopes Choanal atresias Laryngomalacia Vocal cord & glottic anamolies[?clefts] RRP Subglottic anamolies

31. Proper Equipment Assess nares/choanae Assess adenoid and lingual tonsil Assess true vocal cord mobility Assess laryngeal structures

33. 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

34. EXIT Procedure (ex utero intrapartum treatment) Prenatal diagnosis is crucial Flattened diaphragms, polyhydramnios The head, neck, thorax, and one arm are delivered. Uteroplacental circulation can be maintained for 45-60 minutes

35. 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

36. 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%.

37. 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

39. diagnostic Double lumen pH monitering gold standard Laryngoscopy Bronchoscopy Esophagoscopy with biopsy Barium Esophagram Scintiscan Esophageal intraluminal impedance

40. Swallowing & feeding disorders 40-70% kids with CNS disorders 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

41. Assessment of swallowing VSS : videofluoroscopy swallow study FEES: functional endoscopic evaluation of swallowing FEESST Flexible Endoscopic Evaluation of Swallowing with Sensory Testing Transnasal oesophagoscopy

42. Role of ENT in special children Airway Swallowing & drooling Hearing & speech

43. 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

44. Management approaches Conservative methods include behavioural approaches and techniques to improve sensory awareness Appliances Drug therapy Surgery :salivary duct ligation/transposition

45. 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.

46. Hemangiomas Look for associated cardiac, CNS Spontaneous resolution 90% Rest surgical: laser, coblation etc PROPANOLOL

47. Have you recently seen a film? Biofilms: organised sessile communities of attached bacteria in an extracellular matrix Role in ENT

48. We Can Only Refine Our Therapeutics When We Refine Our Diagnostic Abilities THANK YOU SHEELU SRINIVAS [email_address] 9900176770