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Toronto Notes 2019 Pediatric Otolaryngology
Contraindications
• uncontrollablecoagulopathy
• recentpharyngealinfection
• conditionsthatpredisposetovelopharyngealinsufficiency(cleftpalate,impairedpalatalfunction,or
enlarged pharynx)
Complications
• bleeding, infection
• velopharyngealinsufficiency(hypernasalvoiceornasalregurgitation) • scarringofEustachiantubeorifice
Sleep-Disordered Breathing in Children
Definition
• spectrumofsleep-relatedbreathingabnormalitiesrangingfromsnoringtoOSA
Epidemiology
• peakincidencebetween2-8yrwhentonsilsandadenoidsarethelargestrelativetothepharyngealairway
Etiology
• duetoacombinationofanatomicandneuromuscularfactors
■ adenotonsillar hypertrophy
■ craniofacial abnormalities
■ neuromuscular hypotonia (i.e. cerebral palsy, Down syndrome) ■ obesity
Clinical Features
• heavysnoring,mouthbreathing,pausesorapnea,enuresis,excessivedaytimesleepiness,behavioural/ learning problems, diagnosis of ADHD, morning headache, failure to thrive, sleeping with neck hyperextended, cyanosis
Investigations
• flexiblenasopharyngoscopyforassessmentofnasopharynxandadenoids • polysomnography(apnea-hypopneaindex>1/hconsideredabnormal)
■ children: Mild OSA ≥1 to <5/h; Moderate OSA ≥5 to <10/h; Severe OSA ≥10/h ■ adults: Mild OSA 5.1-15/h; Moderate OSA 15.1-30/h; Severe OSA >30.1/h
Treatment
• nonsurgical: CPAP, BiPAP, sleep hygiene, weight loss in overweight/obese child with OSA
• medication: topical nasal steroids and leukotriene-receptor antagonists for mild OSA or residual sleep-
disordered breathing post-adenotonsillectomy
• surgical:bilateraltonsillectomyandadenoidectomyisfirstsurgeryofchoice
■ if persistent obstructive sleep apnea following tonsillectomy and adenoidectomy, consider adenoid regrowth
■ if these fail and not tolerant of positive airway pressure (PAP) therapy, consider lingual tonsillectomy, midline glossectomy, or other surgeries targeting areas of resistance as required (STAR surgery); surgery may be guided by Drug-Induced Sleep Endoscopy (DISE) or cineradiography-MRI to localize site of resistance
Acute Tonsillitis
• seePediatrics,P53
Peritonsillar Abscess (Quinsy)
Definition
• cellulitisofspacebehindtonsillarcapsuleextendingontosoftpalate,leadingtoabscess
Etiology
• bacterial:GroupA.Streptococcus(GAS)(50%ofcases),S.pyogenes,S.aureus,H.influenzae,andanaerobes
Epidemiology
• candevelopfromacutetonsillitiswithinfectionspreadingintoplaneoftonsillarbed • unilateral
• mostcommonin15-30yragegroup
Clinical Features
• trismus(duetoirritationandreflexspasmofthemedialpterygoid)isthemostreliableindicatorof peritonsillar abscess
• feveranddehydration
• sorethroat,dysphagia,andodynophagia
• extensiveperitonsillarswellingbuttonsilmayappearnormal
Otolaryngology OT41
Quinsy Triad
• Trismus
• Uvular deviation
• Dysphonia (“hot potato voice”)