Otolaryngology for the Pediatrician

The anatomy of the head and neck is rich in depth and detail. This chapter explores the fundamentals of otolaryngologic anatomy and discusses common pathologies associated with each section. The chapter is separated in sections discussing the ears, nasal cavity, oral cavity and oropharynx, the neck and the larynx.

Pediatric neck masses can be divided into two broad categories: congenital and acquired. The most common congenital neck masses in children are branchial cleft cysts and thyroglossal duct cysts. The majority of pediatric neck masses are acquired and can be sub-classified as either infectious or inflammatory. Commonly encountered benign tumors include hemangiomas and lipomas. Unlike adult neck masses, malignant neoplasms are rare, accounting for only 15% of persistent neck masses. Cervical malignancies in children include rhabdomyosarcoma, lymphoma, and neuroblastoma. A careful history and physical examination is paramount in the diagnostic approach to the pediatric patient with a neck mass. Radiologic and laboratory tests can assist in the diagnosis, and occasionally surgical biopsy is necessary.

Otitis media (OM) is the most common diagnosis for medical visits in preschool-age children and is the most frequent indication for outpatient antibiotic use in the United States. For any provider who works with pediatric patients, diagnosis and appropriate management of OM is an essential skill, as an estimated 80% of children will suffer from at least one episode in their lifetime. Timely and accurate diagnosis and appropriate management of AOM may have significant consequences for ambulatory health care utilization and expenditures. This chapter addresses the epidemiology, risk factors, pathogenesis, microbiology, diagnosis, treatment and complications of otitis media.

With the widespread utilization of universal newborn hearing screening during the past two decades, early detection of hearing impairment in children has improved markedly. This chapter provides an overview of early identification of childhood hearing impairment, methods used for early detection, common causes, and the various rehabilitative interventions both medical, surgical, and technological. A primary care physician who is knowledgeable about pediatric hearing impairment can play a key role in achieving the best possible outcome.

Pediatric sinusitis and adenoiditis are common conditions that are difficult to distinguish. Disruption of normal sinus physiology can lead to sinusitis and conditions such as asthma, GERD, cystic fibrosis, and ciliary dysmotility may contribute to the condition of chronic sinusitis. Diagnosis of adenoiditis and sinusitis may be difficult and necessitate more work-up than physical exam. The firstline treatment of both conditions requires antibiotics but may require adjuvant treatment such as nasal steroids nasal saline and targeted therapy towards any contributing conditions such as allergies or GERD. Evaluation involves physical exam, nasal endoscopy, and in patients recalcitrant to treatment, CT scans. Failure of medical therapy may necessitate surgical intervention.

Sleep disordered breathing (SDB) is a commonly encountered medical problem in the pediatric patient population with varying ranges of severity including primary snoring, upper airway resistance syndrome and obstructive sleep apnea/hypopnea syndrome. While many clinicians are aware of certain risk factors that predispose children to obstructive sleep apnea syndrome, the prompt identification of all patients at risk for each of these syndromes is imperative. Clinicians currently use a combination of clinical indicators and polysomnographic data to diagnose children who may fall into the SDB spectrum. Without prompt diagnosis, a child be subject to multiple neurocognitive deficits, which may have been ameliorated by treatment. The appropriate treatment for obstructive sleep apnea hypopnea syndrome has traditionally been thought to be surgical, however, the ability to properly categorize children into the above spectrum of disorders will help a practitioner evaluate each patient individually and determine if surgery or other treatments are appropriate for a particular patient.

Clinicians must be familiar with the evaluation and treatment of common pediatric otolaryngology emergencies such as airway obstruction, head and neck trauma, caustic ingestion, airway and esophageal foreign bodies, and epistaxis. Pediatric otolaryngology emergencies frequently involve the airway. Etiologies for airway obstruction in children are diverse and include disease processes like croup, bacterial tracheitis, and angioedema. The majority of children with foreign body aspiration do not present with acute airway compromise. These patients often have non-specific symptoms such as chronic cough. Thus, the provider must have a high index of suspicion to make the diagnosis of an airway foreign body. While laryngeal trauma in children is rare, findings such as neck crepitus and stridor warrant further evaluation to rule out pathology such as laryngeal fracture. The majority of cases of pediatric epistaxis can be managed conservatively with topical decongestants and chemical cautery of the anterior septum.

Deep neck space infections (DNSI) are common in the pediatric population but frequently present diagnostic and management challenges for the practitioner. If undiagnosed or inappropriately managed, infections of the deep neck can progress rapidly and cause significant morbidity and mortality. In this chapter, relevant anatomy, etiology, pathophysiology, clinical presentation, diagnosis, medical and surgical management, and potential complications are discussed.

Stridor is noisy breathing due to airway obstruction, and may be caused by a vast array of pathologies. Children present with stridor along a continuum of acuity and severity. Causes of acute stridor include infections and foreign bodies. Chronic stridor may be due to a wide array of functional and anatomic anomalies, with common causes including laryngomalacia, recurrent respiratory papillomatosis, subglottic stenosis, vocal fold paralysis, and airway hemangioma. Laryngomalacia is far and away the most common cause for chronic stridor in the infant.

In order to correctly diagnose and manage the stridulous child, a detailed history regarding the onset, progression, and nature of the stridor, and a thorough physical examination, potentially including laryngoscopy must be performed. Management must start with ensuring a safe and secure airway, followed by correction of the underlying cause.

The inability to communicate effectively can result in significant socialdevelopmental compromise in children. Children who suffer from velopharyngeal insufficiency (VPI) will suffer from loss of volume and intelligibility of their speech, which is resultantly hypernasal.

Most causes of VPI in children are anatomic or neuromuscular. A history of cleft palate either before or after repair is the most common cause of VPI. The importance of syndrome recognition in patients with VPI is critical, as this population may be at particular risk for postoperative airway obstruction, respond less reliably to surgical correction, and require more aggressive adjunctive speech therapy.

The evaluation of VPI consists of a thorough history, physical examination, velopharyngeal assessment, and most importantly, a speech resonance analysis. A multidisciplinary approach consisting of an initial assessment conducted by an otolaryngologist and a speech pathologist is most effective for the diagnosis and management of VPI. Also, directed speech therapy remains a central component in the primary or adjunctive treatment of children with VPI.

In general, surgical procedures employed to treat VPI can be classified as palatal, palatopharyngeal, or pharyngeal. Outcomes after VPI surgery are probably dependent on a multitude of factors, including severity of preoperative VPI, gap size, presence or absence of comorbidities or syndromes and surgeon comfort.

Recurrent respiratory papilloma is a disease process that has significant implications for the patient as well as socioeconomic implications as the disease is costly both in individual and societal terms. The pediatrician plays an essential role in both the diagnosis and management of children with RRP. Only through thorough knowledge and astute observation can delay in diagnosis be avoided, appropriate referral initiated, and suffering of this disease alleviated.

Congenital vascular anomalies are a heterogeneous group of lesions that may occur as isolated findings or as part of a constellation of symptoms or syndrome. These anomalies are divided into vascular tumors or vascular malformations depending on the growth rate of their constituent cells. Infantile hemangiomas are vascular tumors and are the most common of the vascular anomalies followed by capillary malformations, lymphatic malformations, venous malformations and arteriovenous malformations. Proper diagnosis is critical for appropriate management of these enigmatic lesions. Diagnosis is usually readily secured by history and physical findings although imaging studies are sometimes necessary. Management varies considerably depending on the nature of the lesion, its propensity for growth and its physical impact. Observation is appropriate for some vascular anomalies, while others require pharmacologic treatment, sclerotherapy, embolization, laser treatment or surgical excision. Nearly all patients with vascular anomalies should be seen by a physician or team of physicians who specializes in the care of these unique disorders.