paediatric ent

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esmond
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paediatric ent
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2015-06-25 10:30:02
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Paediatric ent
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Frcs paediatric ent
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  1. Haemangioma treatment
    50% sugglottic have cutaneous lesions
    1% cutaneous lesions have sugglottic lesion
    • Propanolol - hypoglycaemia,bradycardia/hypotension/non-responders
    • Vincristine=alkaloid,neurotoxicity,myelosuppression
    • Steroids - cushings
    • Interferon
    • Tracheostomy
    • Surgical removal
  2. Haemangioma treatment indications
    • Functional impairement - airway and sight
    • Cosmetic cartilage nose and ear
    • Failure to involute
  3. SIGN tonsillectomy guidelines
    • Disabling sore throats due to tonsillitis
    • 7+preceding year or
    • 5+ each of proceding 2 years
    • 3+ each of proceding 3 years
  4. SIGN guidelines AOM
    • Acute AOM should not routinely be prescribed antibiotics
    • If antibiotic prescribed 5 day course
    • Delayed antibiotic = alternative
    • Autoinflation may be beneficial
  5. Subglottic stenosis management
    • Conservative  
    • -adrenaline nebs
    • -steroids
    • -heliox
    • -anti reflux

    • Surgical
    • -Tracheostomy
    • -Mild Gd1 & 2 - Endoscopic dilatation,CO2 laser
    • - Grade 3 & 4 Open surgery

    • Open surgery
    • Anterior cricoid split 
    • Anterior laryngofissure with anterior graft
    • Posterior laryngofisuure with graft
    • Cricotracheal resection
  6. Paediatric equations
    Weight = 2(age+4)
  7. Choanal atresia
    McGovern nipple or Gudel

    • Surgery
    • through anterior nares under endoscopic guidance using a 120° endoscope through the mouth.
    • Palpate atresia using  small urethral dilator through the nose
    • Puncture membranous atresia on each side. The area that has been opened is serially dilated with urethral dilators.
    • If there is bony component of the atresia, this can be drilled open using a shielded diamond burr through the nose, always under thevision given by the 120 degree scope. 
    • back of the bony septum can also be removed using backbiters placed via the nose and again observed by the 120 degree scope via themouth.
    • Both nostrils may stented using custom made stents from endotracheal tubes and secured using prolene that runs through the middle of the stents. If stents are used one must make sure that they are not causing any pressure on the ala or columella. These stents are left in for 6 weeks
  8. Down syndrome
    • Narrow canals - wax, mould problems
    • OME - 90% age 1, 70% age 5 - HA incl soft band,BAHA ?grommets
    • 80% dehiscent facial nervec
    • SNHL - progressive, high freq, any age, 21%<20yrs,55%>20yrs
    • Immunocompromised - aom,tonillitis,pneumonias - t cell mediated pathway
    • Sleep disordered breathing 50=% - macroglossia, AT hypertrophy, upper airway hypotonia, midfacial hypoplasia, hypotonicity
    • Atlantoaxial instability
    • Hypothyroid 1% at birth, annual TFTs
    • Opthalmic pathology 40% e.g. squint hyermetropia, eiphoria(?pump problem)
    • Airway - subglottic stenosis,?laryngomalacia
  9. Drooling
    • History
    • Medication - cholinomimetics (such as anticonvulsants) may cause hypersalivation
    • Aspiration
    • Nasal obstruction
    • OSA
    • Drooling Severity and Frequency Scale
    • Drooling Impact Scale

    • Examination
    • Skin excoriation
    • Dental carries
    • Malocclusion

    • Management
    • SALT
    • Palatal training appliances
    • Medical hyoscine,glycopyrolate SE=urinary retention, dizziness, glaucoma and blurred vision - 20% not tolerate, contraindicated in children with glaucoma, myastheniagravis and a history of urinary retention
    • BOTOX - blocks ACh release atthe cholinergic neurosecretory junction

    • Surgery
    • Tympanic neurectomy
    • submandibular gland (SMG) excision
    • SMG duct rerouting
    • sublingual gland excision
    • SMG ligation
    • parotid duct rerouting
    • parotid duct ligation

    Bilateral submandibular gland excision and parotid duct rerouting appeared to have the highest subjective success rates at 87.8%, and 4-duct ligation was the lowest at 64.1%
  10. Paediatric parameters
    • Age           Heart Rate   Systolic BP    RespiratoryRate    
    • < 1year     120–140      70–90           30–40
    • 2–5 years  100–120      80–100         20–30
    • 5–12 years 80–100       90–110         15–20
  11. Paediatric airway history
    • Pregnancy
    • Birth
    • Perinatal history
    • Intubations
    • Age of onset
    • Feeding
    • Cry
    • Failure to thrive
    • Cough/aspiration
    • Immuniations
    • FB
  12. Indications for airway endoscopy
    • 1. Severe airway obstruction
    • 2. Worsening stridor or stertor
    • 3. Progressive airway obstruction
    • 4. Episodes of cyanosis
    • 5. Feeding difficulty and failure to thrive
    • 6. Diagnostic uncertainty
    • 7. Radiological abnormality
    • 8. Parental anxiety,
  13. Branchial anomalies
    • 1a branchial anomalies 
    • no mesoderm 

    Third branchial pouch sinuses are thought to result from persistence of the thymopharyngeal canal and open into the superior end of the piriform fossa.

    • 4th branchial pouch sinuses are thought to be derived from the pharyngobranchial canal connecting the pharynx to the ultimobranchial body and superior
    • parathyroid gland, and open into the apex of the piriform fossa.
    •  

    tract of a third pouch sinus runs through the thyrohyoid membrane above the superior laryngeal nerve

    4th pouch sinus through the cricothyroid membrane and below the nerve.

    Fourth pouch sinuses are rare and are located on the left side in 94% of cases

    • 4th pouch sinus leaves the apex of the piriform fossa, near the cricothyroid joint, and runs towards the deep surface of
    • the ipsilateral thryoid lobe.

    Endoscopic and open approaches have similar recurrence rates (15%).



  14. Perinatal infections
    TORCH

    • Toxoplasmosis
    • Other -  Coxsackievirus, Syphilis, Varicella-Zoster Virus, HIV, and Parvovirus B19.
    • Rubella
    • Cytlomeglovirus
    • Herpes simplex virus
  15. OSA
    • Differential - CSA & apparent life threatening events
    • AHI>1 abnormal
    •  PICU patients
    • Age<2
    • Wt <15kg
    • Severe OSA sleep study
    • cardiac complications OSA
    • Failure to thrive
    • Obesity
    • Prematurity
    • Recent respiratory infection
    • Craniofacial anomalies
    • Neuromuscular disorders
  16. Pouiseuille's law
    • Laminar flow proportional to the pressure difference between its ends and to the fourth power of its internal radius, and inversely proportional to its length and to the viscosity of the fluid
    • Resistance proportional to (viscosityXlength)/(radius to power of 4)
  17. Salivary masses
    • 90% salivary neoplasms in parotid
    • <10yrs old - lipomas & haemangiomas common
    • >10yrs - epithelial lesion likely
    • Malignancy rates - 50% parotid, 66% SMG, 15% sublingual

    • Parotid surgery increased complications , 9.5% permanent facial palsy, 2 total facial palsy
    • Recurrence rates pleomorphic adenoma higher
  18. Thyroid masses
    • 80% papillary, 20% benign
    • Increased neck mets - 80% central compartment
    • Prognosis even with mets very good
  19. Neonatal Hearing Screening
    Well babies - Transient evoked otoacoustic emission test, if failed repeated, if failed ABR(by 5/52)

    SCBU/ITU OAE & ABR - not before 34/40 but before 44/40

    • Assessment of Aetiology
    • Fam hx
    • Prenatal hx
    • Perinatal hx
    • Post natal hx
    • Clinical exam - syndromic fx
    • ECG
    • Urine dipstick
    • Genetic testing Connexin 26
    • Imaging CT/MRI
    • Opthalmology
    • Infection screen
  20. Laryngeal papillomatosis
    • Normally present <5yrs
    • 75% first born of teenage mother
    • HPV 6&11(more severe)
    • Risk of transmission from mother 1:400, no evidence reduced by C section
    • Maliganant transformation 5%
    • Treatment - resection, microdebrider 500 rpm
    • Avoid tracheostomy as incrased risk bronchial spread
    • Other treatment - cidofovir(nucleoside analogue), photodynamic therapy, interferon
    • Guardasil vaccine, not cervarix
    • Dietry supplements - Indole 3-carbinol (I3-C)
    • frequently experience remission after several years, which may be related to puberty
    • If tracheal papilloma baseline CT chest
  21. EXIT procedure
    • ex-utero intrapartum treatment
    • Caesariansection approach, but delivering only the head and uppertorso through the uterine incision, while maintaining the maternal foeto-placental circulation
    • allows timefor the otolaryngologist to secure the neonatal airway byintubation, tracheostomy, or other neck surgery
    • 37- 38 weeks
    • CHAOS = congenital high airway obstruction
  22. Paediatric tracheostomy decannulation
    • Laryngotrachoscopy
    • Down size
    • Cap Night & Day with o2 sats
    • Remove

    Neo tube up to 1 yr - check position with scope
  23. Sugglottic haemangioma resection
    • Small - laser
    • Intermediate - submucosal resection
    • Large - tracheostomy
  24. Bilateral vocal cord palsy
    • 50% require trachyostomy
    • 50% resolve 10% take >10years
  25. Pyriform aperutre stenosis
    • Dx CT <11m
    • Solitary median maxillary central incisor syndrome

    • Management
    • Condervative - steroid drops
    • Surgery - Sublabial approach with stenting
  26. Laryngeal web
    Need screen for velocardiofacial syndrome - FISH(fluorescent in situ hybridisation)
  27. Atypical mycobacteria
    Jerome et al 2007, ne'er lands
    Results. Intention-to-treat analysis revealed that surgical excision was more effective than antibiotic therapy (cure rates, 96% and 66%, respectively; 95% confidence interval for the difference, 16%–44%). Treatment failures were explained neither by noncompliance nor by baseline or acquired in vitro resistance to clarithromycin or rifabutin. Surgical complications were seen in 14 (28%) of 50 patients; staphylococcal wound infection occurred in 6 patients, and a permanent grade 2 facial marginal branch dysfunction occurred in 1 patient. The vast majority of patients who were allocated to antibiotic therapy reported adverse effects (39 [78%] of 50 patients), including 4 patients who had to discontinue treatment.






    Management of nontuberculous mycobacteria-induced cervical lymphadenitis with observation alone.





    Zeharia A, Eidlitz-Markus T, Haimi-Cohen Y, Samra Z, Kaufman L, Amir J.




    Source





    Day Hospitalization Unit, Schneider Children's Medical Center of Israel, Petah Tiqwa, Israel.





    Abstract








    BACKGROUND:





    RESULTS:


    Ninety-two children with lymph node positive cultures of nontuberculous mycobacterium were included in the study. Mycobacterium avium complex and Mycobacterium hemophilum were isolated in 90% of the cultures. In most cases, the affected lymph nodes underwent violaceous changes with discharge of purulent material for 3-8 weeks. Total resolution was achieved within 6 months in 71% of patients and within 9-12 months in the remainder. At the 2-year follow-up, a skin-colored, flat scar in the region of the drainage was noted. There were no complications.



    CONCLUSIONS:





    We suggest that the observational approach can be effective for managing NTM lymphadenitis in immunocompetent children.
  28. OSA indications for paediatric respiratory investigations
    • Diagnosis of OSA unclear or inconsistent
    • Age < 2 years
    • Weight < 15 kg
    • Down's syndrome
    • Cerebral palsyHypotonia or neuromuscular disorders
    • Craniofacial anomalies
    • Mucopolysaccharidosis
    • Obesity (body mass index > 2.5 standard deviation scores or > 99th centile for age and gender
    • Significant co-morbidity such as congenital heart disease, chronic lung disease
    • Residual symptoms after adenotonsillectomy
  29. OSA Children at risk from respiratory complications unsuitable for DGH adenotonsillectomy
    • Age < 2 years
    • Weight < 15 kg
    • Failure to thrive (weight < 5th centile for age)
    • Obesity (body mass index > 2.5 standard deviation scores or > 99th centile for age and gender
    • Severe cerebral palsy
    • Hypotonia or neuromuscular disorders (moderately severely or severely affected)
    • Significant craniofacial anomalies
    • Mucopolysaccharidosis and syndromes associated with difficult airway
    • Significant co-morbidity (e.g. congenital heart disease, chronic lung disease. ASA 3 or above)
    • ECG or echocardiographic abnormalities
    • Severe OSA (described by polysomnographic indices including Obstructive Index > 10, Respiratory Disturbance Index > 40, and Oxygen saturation nadir < 80%)
  30. Cervical lymphadenopathy
    should lead to urgent excision biopsy for histology:–Lymph nodes in the supraclavicular area. Lymph nodes which measure>3cm(possibly even 2cm) when measured properly with calipers.Lymph nodes in children with a history of malignancy.4–Children with hepatosplenomegaly, fever, weight loss or nightsweats although not every study supports the predictive value of these findings.

    they should be sent for a chest X-ray from clinic and blood should be taken for full blood count and serology for Bartonella, toxoplasma, cytomegalovirus and Epstein–Barr virus. The child should be reviewed in a fortnight with the test
  31. PHACE
    P-posterior fossa abnormalities,H-hemangioma,A-arterial lesions,C-cardic abnormalities/aortic coarctation and abnormalities of theE-eye.

    diagnosis of PHACE Syndrome can be made in patients presenting with a facial or neck hemangioma measuring > 5 cm in diameter plus 1 of the major criteria or 2 of the minor criteria.
  32. Airway reconstruction
    • LTR- 1 or 2 stage reconstruction - after 2yrs old
    • Laryngofissure - always divide cricoid and variable amount thyroid cartilage
    • 1 stage Intubate 1 week
    • 2 stage trachy + stent, remove stent at 6 weeks

    Need be term before extubate, if prmature prolonged intubation not indication for tracheostomy
  33. Tracheo-oesophageal fistula
    • Esophageal atresia with distal TEF
    • Isolated esophageal atresia without TEF
    • Isolated TEF
    • Esophageal atresia with proximal TEF
    • Esophageal atresia with proximal and distal TEF
  34. Lymph nodes to excise
    • >2cm short axsis on US
    • Supraclavicular
    • Hx of malignancy
  35. Lymph node US findings
    • Oval v round
    • Normal hilum
  36. Paeds lymph nodes

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