DOS CME Course 2011 1 October 2010 1 Confidential

ENT - Common Pediatric Issues

Tom I. Abelson M.D.

Medical Director Cleveland Clinic Beachwood Family Health and Surgery Center Department of Otolaryngology Head and Neck Institute Cleveland Clinic

© Cleveland Clinic 2015 DOS Course 2015 1

DOS CME Course 2011 2 October 2010 2 Confidential

Tubes (Infection, Effusion)

Adenoidectomy (Middle Ear Disease)

Tonsillectomy & Adenoidectomy

(Infection, Sleep Disordered Breathing) Tom I. Abelson M.D.

Medical Director Cleveland Clinic Beachwood Family Health and Surgery Center Department of Otolaryngology Head and Neck Institute Cleveland Clinic

© Cleveland Clinic 2014 DOS Course 2015 2

• Acute Otitis Media (AOM) – Rapid onset of signs and symptoms or inflammation of the middle ear

• Recurrent AOM – 3 episodes of AOM in 6 months or 4 in 12 months – Each episode well-documented

• Persistent AOM – Treatment failure or relapse of AOM within 1 month

• Middle ear effusion (MEE) – Fluid in the middle ear

• Conductive Hearing Loss – Hearing loss from abnormal transmission of sound to the inner ear

Definitions

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• Myringotomy (= tympanostomy) – Incision in the ear drum

• Myringotomy with tube – Incision in the ear drum with placement of a pressure equalizing tube

• Tympanogram – Measure of how well the tympanic membrane moves – often correlates

with effusion and with pneumatic otoscopy

• Throat infection – Sore throat caused by infection of a viral or bacterial (group A

streptococcus) etiology, involving the pharynx, palatine tonsils, or both

• Sleep Disordered Breathing – Abnormalities of respiratory pattern or the adequacy of ventilation during

sleep, including snoring, mouth breathing and pauses in breathing – Varies from primary snoring to obstructive sleep apnea (OSA) – Daytime symptoms may include excessive sleepiness, inattention, poor

concentration or hyperactivity

Definitions

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• Clinical Practice Guidelines: Polysomnography for Sleep-Disordered Breathing Prior to Tonsillectomy in Children

• Clinical Practice Guidelines: Tonsillectomy in Children

• Clinical Practice Guidelines: Cerumen Impaction

• Clinical Practice Guidelines: Tympanostomy Tubes in Children

• Clinical Practice Guidelines: Acute Otitis Externa

• HOW TO FIND THEM – Search for the above title (AAO-HNS – entnet.org) – Under “Physician Resources” click on “Published Guideline” – Choose “Full Text” or “Full Text (PDF)” (Both are free) – Note: The “Results” in “Abstract” have the key information

Clinical Practice Guidelines (CPG) American Academy of Otolaryngology – Head and Neck Surgery

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• 2 ½ year old daughter of a new State Department employee comes in for first well child check

• Her medical history includes 6 ear infections in the last year, some treated in the pediatrician’s office and some in urgent care centers. At previous well child checkups her ears have been clear. She is now asymptomatic and normal on exam.

• Risk Factors: • Family History: Father had tubes • Day Care: She has been in daycare since birth but will be staying

at home with mom now • Takes bottle lying on back: No • Exposure to cigarette smoke: None

• What do you do?

Case 1

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• Favorable for her prognosis – She is no longer in day care

• Are we confident that she has been correctly diagnosed?

• Her ear infections have not been well-documented. She is healthy by history and on exam at this moment.

• Plan – See her with subsequent infections

• Decide on tubes based on CPG going forward • If the subsequent sick visits turn out to be acute otitis media, refer

to ENT

• If you have the option to refer to ENTs who do not operate on every patient you send to them – use them

Case 1 (continued)

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Tubes are indicated • If middle ear effusion (MEE) has been present for 3

months, with documented hearing loss – If hearing is normal reassess every 3 months – Follow until the effusions clear or tubes are placed

• If chronic MEE exists with symptoms such as imbalance, poor school performance, behavioral problems, ear discomfort or reduced quality of life

• If she has recurrent AOM with effusion – CPG definition: Recurrent AOM – 3 episodes of AOM in 6

months or 4 in 12 months. Each episode well-documented. – I question this recommendation in some circumstances – Effusions after AOM persist at 2 weeks 70% of the time and at 3

months 10% of the time

CPG: Tympanostomy Tubes in Children

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• At risk children

• Clinicians should determine if a child with recurrent AOM or with OME of any duration is at increased risk for speech, language, or learning problems from otitis media because of baseline sensory, physical, cognitive, or behavioral factors.”

• These patients should be more liberally considered for placement of tubes.

CPG: Tympanostomy Tubes in Children

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Rosenfeld R M et al. Otolaryngology -- Head and Neck Surgery 2013;149:S1-S35 Copyright © by American Academy of Otolaryngology- Head and Neck Surgery

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• 3 ½ year old boy with no episodes of infection but with 4 months of effusion, borderline hearing, mild autism, and previous tubes placed at 2 years of age

• What do you do?

Case 2

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• Based on the CPG he has two indications for tubes – Effusion and hearing loss for over 3 months – Increased risk with hearing loss in the face of autism

• Is there anything else to consider?

Case 2 (continued)

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• Based on having had previous tubes and being over three years of age, adenoidectomy should be done as well as tubes.

• Do steroid sprays shrink adenoids? – While my impression is that a month of steroid nasal spray (one

spray once a day for a month) can improve nasal airway by decreasing adenoid size, published studies do not support my impression.

– Watch for more study results. – In the meantime, I try it if tonsils are small and nasal obstruction is

the main symptom, with our without snoring.

Case 2 (continued)

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• The parents of a child with tubes calls because there is thick drainage coming out of one ear, tinged with blood

• What do you do?

Case 3

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• Acute Tympanostomy Tube Otorrhea – “Prescribe antibiotic eardrops only, without oral antibiotics, for

children with uncomplicated acute tympanostomy tube otorrhea.” This child does not need to be seen in the office

– Only topical drops approved for use with tympanostomy tubes should be prescribed (e.g., ofloxacin or ciprofloxacin-dexamethasone)

– Treat with drops for a week. – Advise a call back if still draining.

• Caring for ear tubes – “Ear plugs are not necessary for most children” – Except: Swimming deep under water, in lakes or non-chlorinated

pools, dunking head in bath water – Except: Recurrent otorrhea

CPG: Tympanostomy Tubes in Children

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Validated Questions For Assessing Hearing

Rosenfeld R M et al. Otolaryngology -- Head and Neck Surgery 2013;149:S1-S35

Hearing difficulty is likely when 2 or more failed responses are recorded

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• An 8 year old girl comes in with sore throat and fever

• On exam she has diffuse erythema of the tonsils, tonsil pillars, posterior and lateral pharyngeal walls without cervical adenopathy

• What do you do?

Case 4

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• Take a throat culture –If negative

–Supportive therapy for symptoms –No antibiotics

–If positive –Treat with appropriate antibiotics

• Document in the chart that the patient has acute pharyngitis, not tonsillitis

Case 4

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• An 8 year old girl comes in with sore throat and fever

• On exam she has erythema and hypertrophy of the tonsils with patchy white exudates and bilateral cervical adenopathy

• She has had similar episodes 4 times in the last 12 months and never previously

• What do you do?

Case 5

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• Take a throat culture. –If negative

–Supportive therapy for symptoms –No antibiotics

–If positive –Treat with appropriate antibiotics

• Note in the chart that the patient has acute tonsillitis.

• When is tonsillectomy indicated?

Case 5 (continued)

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• Indications for tonsillectomy – 7 episodes of tonsillitis in one year – 5 episodes of tonsillitis each year for two years – 3 episodes of tonsillitis each year for three years

• Modifying factors – Antibiotic intolerance – PFAPA (Periodic fever, aphthous stomatitis, pharyngitis and adenitis) – Recurrent peritonsillar abscess

• What about tonsillitis twice a year for 6 years? – Clinical decision – Shared decision making

Case 5 (continued)

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• 8 year old boy with loud disruptive snoring, with occasional observation of brief apnea episodes, with large tonsils, with intermittent enuresis and behavioral problems in school

• He is otherwise healthy.

• Does he need to have a polysomnogram before tonsillectomy and adenoidectomy (T&A)?

Case 6

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• If he does not exhibit failure to thrive, obesity or other airway co-morbidities this otherwise healthy boy does not need a polysomnogram and can have outpatient T&A

• Parents should be counseled that all symptoms may not resolve and if that is the case further work up should be accomplished

• Partial vs. complete tonsillectomy?

Case 6 (continued)

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• 2 ½ year old boy with loud disruptive snoring, occasional observation of brief apnea episodes and large tonsils

• He is otherwise healthy

• Does he need to have a polysomnogram before tonsillectomy and adenoidectomy (T&A)?

Case 7

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• Yes

• Children under 3 have – Greater potential for morbidity and mortality in the post T&A period – The worse the apnea, the worse the risk.

• This patient should have a polysomnogram and the procedure should be done as an inpatient – If the apnea is severe and any symptoms persist, a post op

polysomnogram should be obtained as well

• Any patient with severe apnea should be admitted for T&A

Case 7 (continued)

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• Polysomnogram should be done in patients with complex medical conditions including – Obesity – Down Syndrome – Craniofacial abnormalities – Neuromuscular disorders – Sickle cell disease – Mucopolysaccharidosis

• Polysomnogram should be considered when the need for surgery is uncertain or physical findings do not correlate with symptoms

CPG: Polysomnography for Sleep-Disordered Breathing Prior to Tonsillectomy in Children

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• CONCLUSION

• “In the majority of cases, symptoms of chronic sinusitis in children are relieved by adenoidectomy.”

• Prior to considering surgery – Evaluate and treat appropriately for allergies – Treat sinusitis with antibiotics and steroid nasal sprays

Adenoidectomy for Rhinosinusitis

Arch Otolaryngology Head Neck Surg. 1997 Jul 123(7): 675-8 Efficacy of adenoidectomy in relieving symptoms of chronic sinusitis in children. Vandenberg SJ, Heatley DG.

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