8. Paediatric Otolaryngology Flashcards by Tiarnán Byrne

Floppy Larynx, collapsing supra-glottis on inspiration, inspiratory stridor, worse on crying and feeding?

Laryngomalacia

Aetiology unclear

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How is laryngomalacia classified?

Mild-Severe

Mild

Only whilst crying
No FTT (failure to thrive)

Mod/Severe

FTT/feeding difficulty
Cyanosis/Apnoeas

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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.

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Tx for laryngomalacia?

SURGICAL

Aryepiglottoplasty
Tracheostomy (rarely needed)

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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

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What are the clincial signs of subglottic stenosis?

Biphasic gives two tone stridor

Respiratory distress

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How is subglottic stenosis classified?

Mild-Severe
Cotton Myer classification
Grade 1-4
May not need intervention
Depends on symptoms

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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

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What is the Tx for subglottic haemangioma?

Treatment-Propanolol

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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

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What is the treatment for unilateral VC paralysis?

Medialisation of the affected cord

- Surgery or injection

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What is the treatment for bilateral VC paralysis?

Lateralise the cords
Adequate airway whilst preventing aspiration
Tracheostomy
Laser

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What is the primary cause of Laryngeal Papillomatosis?

HPV accquisation at birth

HPV 6 and 11

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What are the clinical signs of laryngeal papillomatosis?

Dysphonia-aphonia
Occasional respiratory distress
Microlaryngoscopy and debulking
Injection with cidofovir(antiviral)
Bevacizumab(anti VEGF)

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Condition caused by voice misuse?

Screamers Nodules

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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?

1. 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?

1. Distraction Testing 2. Visually Reinforced Audiometry 3. 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.