8. Paediatric Otolaryngology Flashcards
Floppy Larynx, collapsing supra-glottis on inspiration, inspiratory stridor, worse on crying and feeding?
Laryngomalacia
Aetiology unclear
How is laryngomalacia classified?
Mild-Severe
Mild
- Only whilst crying
- No FTT (failure to thrive)
Mod/Severe
- FTT/feeding difficulty
- Cyanosis/Apnoeas
How is laryngomalacia diagnosed?
Flexible nasoendoscopy
Endoscopy under GA
SHOWS
Shortened aryepiglottic folds
Omega shaped epiglottis
Redundent arytenoid tissue
Arytenoid tissue and epiglottis prolapse into airway with inspiration + expel with expiration.
Tx for laryngomalacia?
SURGICAL
- Aryepiglottoplasty
- Tracheostomy (rarely needed)
What is subglottic stenosis?
- Narrowing of the subglottis
- Usually due to prior intubation (e.g. pre-term babies)
- Narrowing is non-expandable
- Infection can be a cause but is rare
What are the clincial signs of subglottic stenosis?
Biphasic gives two tone stridor
Respiratory distress
How is subglottic stenosis classified?
Mild-Severe Cotton Myer classification Grade 1-4 May not need intervention Depends on symptoms
What is a subglottic haemangioma?
Benign vascular lesions
Undergo rapid growth in the first few weeks-months of life
Biphasic stridor
Involution in 50% by 5 yrs
Beard (cervicofacial or mandibular) distribution
What is the Tx for subglottic haemangioma?
Treatment-Propanolol
What is a sign of VC paralysis?
Abscence of weal cry = Unilateral vc
Bilateral will have voice, cry and stridor
If symptomatic
= Recurrent aspirations
= Severe phonatory difficulty
What is the treatment for unilateral VC paralysis?
Medialisation of the affected cord
- Surgery or injection
What is the treatment for bilateral VC paralysis?
Lateralise the cords
Adequate airway whilst preventing aspiration
Tracheostomy
Laser
What is the primary cause of Laryngeal Papillomatosis?
HPV accquisation at birth
HPV 6 and 11
What are the clinical signs of laryngeal papillomatosis?
Dysphonia-aphonia Occasional respiratory distress Microlaryngoscopy and debulking Injection with cidofovir(antiviral) Bevacizumab(anti VEGF)
Condition caused by voice misuse?
Screamers Nodules
What is the clinical presentation of screamers nodules? MOA? Tx?
Voice misuse Anterior 1/3 of the vocal cord Point of maximum vibration Repeated trauma with fibrotic healing Speech therapy
What is an important Ddx for epistaxis in adolescent males?
Juvenile angiofibroma
Refer to ENT
What is Choanal Atresia?
Obliteration of the posterior nasal aperture
Due to the persistence of the oronasal membrane
Can be Unilateral or bilateral
What are the signs and symptoms of Choanal Atresia?
Unilateral may not be detected for some time since baby manages
Bilateral is life threatening since neonates are obligate nasal breathers.
How is choanal atresia managed?
Confirm with CT scan
Temporary alleviation can be achieved by inserting an oral airway into the mouth. However, the only definitive treatment is surgery to correct the defect by perforating the atresia to create a nasopharyngeal airway. If the blockage is caused by bone, this is drilled through and stent inserted.
What abnormalities are associated with choanal atresia?
CHARGE syndrome
- Coloboma of the iris (break in border)
- Heart defects
- Atresia
- Retarded growth
- Genitourinary abnormalities
- Ear abnormalities
What is congenital microtia?
Absence or the malformation of the auricle
With what is congential microtia associated?
Often associated with other craniofacial anolamies
- Treacher collins
- Pierre Robin sequence
What are the common causes of sensorineural hearing loss?
Congenital
Infection/Hereditary/Congenital Malformation
Acquired
Prematurity/Infection/Ototoxins/
What infections might cause SNHL?
Intrauterine Infection
- Cytomegalovirus
- Toxoplasmosis
- Rubella
Bacterial Meningitis Most common
Early hearing assessment and followup essential
How might prematurity cause SNHL?
Multifactorial
- Medications
- Loud environment
- Perinatal hypoxia
- Hyperbiliruinaemia
What are the objective hearing tests in children?
- Otoacousic emissions (OAE)
2. Auditory Brainstem Response (ABR)
Describe the Otoacoustic Emissions Test
Sound is presented into the ear canal via a probe.
This stimulates the hair cells in the cochlear causing the outer hair cells to twitch
The twitch is detected by a microphone situated in the probe.
The outer hair cells are able to increase the sensitivity of the cochlea when functioning normally by up to a factor of 1000 times.
An absence of or damage to these cells will significantly reduce hearing thresholds.
Describe the Auditory Brainstem Response Test
Tones are presented via probes placed in the ear canal.
Electrodes are attached to the mastoids behind each ear and one to the upper forehead. The sound in the ear canal passes to the cochlea which converts the sound waves into a nerve action potential which passes along the auditory nerve.
The signal then travels to the brainstem and on to the cortex where it is processed by the brain.
This wave of activity is collected by the electrodes, amplified, and passed to a machine for processing.
What are the subjective hearing tests for children?
- Distraction Testing
- Visually Reinforced Audiometry
- Pure Tone Audiometry
Describe distraction testing?
Babies, six to eight months old
Assesses the ability of the baby to hear a sound then turn to locate it.
The loudness of the sounds produced are varied to try and establish the minimum level that the baby is able to hear
Not ear specific however(i.e could have a unilateral hearing loss and pass distraction testing).
Describe Visual Reinforced Audiometry?
Six months to two years old.
Determine frequency and ear specific hearing thresholds.
The child is seated between two visual reinforcing reward boxes with a loud speaker on top of each one. To condition the child a sound is played from one of the boxes on the left or right, as the child turns to the sound they are presented with a visual reward in the form of an illuminated puppet in the box.
To obtain ear specific hearing thresholds the child may wear headphones or have small insert phones placed in the ear canals to generate the stimulating sounds
Describe Pure Tone Audiometry?
Standard hearing assessment from schoolage to adult
From 4 yrs(girls) and 4 ½(boys)
Tones of varying frequency and intensity
The child must press a hand held button for as long as they can hear a sound.
The loudness of the sounds are reduced until the child stops responding, this is the threshold of hearing.
What must be performed before deciding to implant a choclear hearing aid in a child?
- Battery of test prior
- Mundini malformations
- Genetic studies
- Extensive counseling
- Pre lingually (≤1.5yrs) versus post-lingually deaf
- Before 4 years of age important as maximum neuroplasticity.
