Paediatric ENT Update for General Practice PPG

Mr Daniel Tweedie MA FRCS(ORL-NHS) DCH

Consultant Paediatric ENT, Head and Neck Surgeon

Evelina London Children’s Hospital

Evelina London Children’s Hospital

• Dedicated tertiary paediatric hospital in central London

(St Thomas’ site)

• Completed in 2004

• Built around children’s requirements

• State of the art facilities

• Innovative management

Paediatric ENT Service

• Five consultants

• Among the largest specialist children’s ENT units in the UK

• All aspects of paediatric ENT

• Very large airway practice

• Excellent links with adult ENT and other specialities

My practice

• Trained in SW Thames, fellowship training at Great Ormond Street Hospital

• All aspects of paediatric ENT- including airway, otology and head and neck surgery

• Training programme director for South London

• Council member of BAPO and Children’s Surgical Forum at the Royal College of Surgeons

• Individualised patient care

• Latest evidence-based management and techniques

Today’s objectives

• Clinical scenarios in paediatric ENT

• Common problems

• Diagnosis and management

• Interactive

• Question and answer opportunities

Scenario 1

Obstructive sleep apnoea in children

• Very common

• 12-15% snore

• 2% have OSA

• ≡ 15000 cases/year in UK

• Major public health problem

• Greatly under-recognised

• Treatment delays common

Causes of OSA in children

• Large tonsils and adenoids

• Adenoids more so in infants

• Other factors: ethnicity, C-F geometry, obesity, syndromes, poor tone

• Also consider rarer cases of central apnoeas- in some syndromes, +/- neurological or developmental delay

Clinical effects of OSA in children

• Not necessarily as for adults: more variable

• Tiredness and lethargy or may be hyperactive • Neurocognitive impairment/ ↓ IQ • Poor concentration • Poor appetite, poor weight gain • Cardiopulmonary effects

• Many of these are reversible with prompt

treatment

Diagnosis (1)

• Not always easy

• May be obvious from history- but may not be • Snoring, apnoeas despite respiratory effort • Head-extended position, mouth open • Restlessness, frequent waking, bed wetting etc • Daytime effects

• But parental history not always reliable- anecdotally low

negative predictive value • Size of tonsils and adenoids not always predictive

Diagnosis (2)

• History and clinical examination- accepting limitations

• Sleep study- recorded domiciliary SaO2*

• Very fast turnaround at Evelina sleep centre

• One stop pick up; posted back; results in 5 days

• Polysomnography: gold standard, selected cases only

Treatment of childhood OSA

• Adenoidectomy

• Tonsillectomy

• Generally curative, some have residual or recurrent symptoms

• Other options including CPAP, and tracheostomy (rarely)

Scenario 2

Tonsillitis

• Very common

• Often viral

• Sometimes bacterial

• Glandular fever

• Management options

Tonsillitis: viral or bacterial? • Centor criteria- score out of 5 • Likelihood of group A Streptococcal pharyngitis

1. Fever 2. Tonsil exudates 3. Anterior cervical lymphadenopathy 4. Absence of cough 5. Age <16 add 1 point; age >44 subtract 1 point

All 4: PPV 40-60% for Group A Strep None: NPV 80% Original study in adults- ? applicability to children

Tonsillitis: management

• Management according to the SIGN guidelines 2010

• Severe attacks: emergency referral

• No routine throat swabs

• Simple analgesia

• Antibiotics according to clinical picture (Centor)

• Penicillin V QDS for 10 days

Recurrent tonsillitis

• SIGN recommendations

• Empirical treatment of each episode

• No great evidence for prophylactic antibiotics*

• Tonsillectomy if severe

• 7 attacks/ 1year; 5 attacks per year for 2 years; 3 attacks per year for 3 years

• Additional clinical judgement

Tonsillectomy

• Ancient procedure • Numerous methods • Traditionally extracapsular • Cauterisation → thermal injury • Muscle exposed → painful • Vessels exposed → risk of bleeding

• High rates of delayed discharge, readmission and

post-operative haemorrhage (3-5%) • Mortality risk

Coblation® intracapsular tonsillectomy

• An alternative approach

• Cold radiofrequency ablation 40-50°C

• Dissection within the tonsil capsule

• Underlying muscle and vessels not exposed

Coblation® intracapsular tonsillectomy

Experience at Evelina • Largest prospective series in the

UK • >430 cases since Spring 2013 • All children: OSA and/or tonsillitis

• Very rapid recovery: 5-6 days • Minimal analgesia • No phone calls from parents • No readmissions with pain • 2 cases of bleeding (0.47%) • Symptomatic improvement • Excellent feedback: > 99% of

parents would recommend

Scenario 3

Acute otitis media

• Commonest reason for under-5s to see their GP (70% affected by 2 years)

• Similar risk factors to glue ear- age, winter, male sex, family history, reflux

Plus: low birth weight, poor immunity (incl. PCV), dummy use, bottle feeding

AOM: pathophysiology

• Viral URTIs- 15-20/year in young children • Generalised mucosal inflammation • Impaired mucociliary clearance • Short, horizontal Eustachian tubes- may allow

bacterial ingress • Limited immunity

• Bacterial supra-infection is common following

initial viral infection • Pneumococcus, Haemophilus, Moraxella

AOM: diagnosis

• Not always easy

• Variable history, especially in younger children (may not be febrile or in pain, may or may not have discharge)

• “Softer” symptoms, eg reduced appetite and play, restlessness at night etc

• Difficult otoscopic view +/- crying-induced vasodilatation of tympanic vessels

AOM: management

• 2013 AAP guidelines • Single episodes • Recurrent AOM • Antibiotics • Grommets • Other measures

• Some differences vs equivalent Cochrane

recommendations • NICE CKS available (2009) but not formal guidelines-

similar to AAP

Single episodes of AOM

• Supportive measures: fluids, rest, regular analgesia (ibuprofen > paracetamol)

• Low threshold for admission of very young or toxic children

• Immediate or delayed antibiotic prescribing policy (see again at 24-48 hours)

• Consider early antibiotics for certain cases: 3 months or younger, symptoms >4 days, bilateral infection in under 2s, perforation and discharge, comorbidities

Benefits of antibiotics

• Reduced mean duration of symptoms by a small amount

• Reduced risk of complications eg mastoiditis, meningitis etc

Which antibiotic?

• Both AAP and NICE recommend amoxilicillin as first line (clarithromycin or erythromycin if allergic)

• No consensus regarding duration (?5-10 days)

• Consider co-amoxiclav or cefuroxime in resistant cases- expect improvement by 48-72 hours

What dose of amoxicillin?

• NICE: 40mg/kg/day in divided doses for 5 days (ie 13mg/kg TDS)

• But evidence from US CDC supports 80-90mg/kg/day, given high prevalence of resistant organisms

• Consider doubling the dose

Recurrent AOM

• AAP- 3 or more episodes in six months, or four in a year, with at least one in the past six months

• Particular risk factors:

First infection < 3 months of age

Persistent previous AOM > 10 days

Winter months

Male gender

Passive smoking

Recurrent AOM- management

• Manage each episode

• Wait for resolution with time

• Address reversible risk factors (incl.PCV)

• Prophylactic measures

Recurrent AOM- prophylaxis

• Antibiotics- limited evidence to support low dose prophylaxis. Cochrane review mildly supportive, AAP does not recommend

• Options include trimethoprim (1-2mg/kg nocte), amoxicillin or azithromycin (10mg/kg M,Tu,W then off for 11 days)

• Grommets- more evidence to support these, but risks of persistent discharge and permanent perforation

• No evidence to support adenoidectomy

Complications of AOM

• Outer ear- otitis externa • Middle ear- perforation, ossicular

erosion, tympanosclerosis, adhesions, facial palsy

• Inner ear- toxicity to cochlea and labyrinth

• Intratemporal- mastoiditis • Press on the cymba conchae • Intracranial- meningitis, abscess,

venous sinus thrombosis

Scenario 4

Glue ear

• Extremely common in pre-school children

• 40-60% affected at some point

• Inflammation of middle ear mucosa associated with non-purulent effusion and conductive hearing loss

• Variable clinical effects: poor listening skills, speech delay, frustration, withdrawn behaviour- or may have minimal effects

Glue ear- risk factors

• Individual

• Age- peaks at 2 and 5

• Male sex

• Family history

• Nasal allergy/ adenoiditis

• Reflux

• Environmental

• Winter months

• Passive smoking

• Daycare with >4 children

Glue ear- management framework

• Nice guidelines 2008

• Generally evidence based

• Some limitations

Glue ear-diagnosis

• Clinical suspicion

• Otoscopic examination

• Tympanometry

• Audiometry

Free field audiometry

Hearing tests for children

Visual reinforcement Toy test Conditioned play

Glue ear- general steps

• Maximise listening opportunities

• School or nursery should be aware

• Care with crossing road etc

• Parental advice and reassurance

• Benign condition

• Active monitoring in the first instance- 3 months

• Short/medium term sequelae, less likely to produce long term problems

Glue ear- autoinflation

• Either self-valsalva or using Otovent® balloon

• Not easy for younger children

• Some evidence to support use in parallel with active monitoring (Cochrane)

• Can be prescribed, or available online for about £6-8

Glue ear- after 3 months

• Options include further active monitoring • Particularly if parents are happy and child is doing

well

• Hearing aids- no complications, effective increase in volume with normal underlying sensorineural hearing (especially those with cleft palate or Down’s syndrome)

• Surgery- grommets +/- adenoidectomy • Other measures eg steroids, antibiotics,

osteopathy etc- not recommended by NICE

Grommets

• Reasonable option for hearing loss 25-30dB in the better hearing ear for 3 months

• Remain in situ for 6-18 months before extruding

• Consider adenoidectomy: prolongs benefits of grommets

Grommets- problems

• Limited duration of benefit ≈ 6-8 months on average

• Adenoidectomy at the same time is known to prolong the beneficial effects of grommets

• Difficult to demonstrate long-term benefits of surgical intervention for glue ear

• Risks of recurrence, discharge (5-10%) and persistent perforation (1-2%)

Grommets FAQs/ answers

• OK to swim after 6 weeks- no proven benefit of keeping the ears dry

• Avoid immersion in bath water + avoid diving deep under water

• Treat discharge with water precautions +/- topical medication

• OK to use antibiotic drops if the ear is infected- I tend to use ciprofloxacin eye drops: 3 drops BD for 10 days

Thank you

• ENT patient information and resources for doctors at danieltweedie.com