Diagnosis of ENT Disorders:

You Make the Call

A127 Audience Response Case Discussion

Ellen S. Deutsch, MD, FACS, FAAP

AI duPont Hospital for Children, Wilmington, DE

Bruce R. Maddern, MD, FACS, FAAP

Jacksonville, FL
 Faculty Disclosure Information
• In the past 12 months, we have not had significant
financial interests or other relationships with the
manufacturers of products that will be discussed in
our presentation.

• This presentation will include discussion of

pharmaceuticals which are not approved by the FDA
or “off-label” uses
– Medications to inhibit or treat
• Scar formation
• Recurrent respiratory papillomas
• Otorrhea
• Lymphangioma
EARS
Family reports acute otitis media a couple of
weeks ago, which seemed to have resolved.
Otherwise she was well until this morning.
On examination, there is no tragal tenderness,
canal edema or otorrhea.
Acute Coalescent Mastoiditis

Notice:
Pinna is “down and out”
Effacement of post-auricular sulcus
Epicenter is over the mastoid antrum
Acute
Coalescent
Mastoiditis
 Acute Coalescent Mastoiditis
Diagnosis: exam, CT scan
Treatment:
– intravenous antibiotics
– myringotomy +/- tube
• or laser fenestration +/- tube
– +/- I&D of subperiosteal abscess
– +/- mastoidectomy
– ? steroids if facial nerve paralysis
– MRI if suspicious of intracranial complication
Otitis Media with Effusion
Can be symptomatic
(pain or hearing loss)
or can be a
“Silent Effusion”

May cause hearing

loss and, if severe,
destruction of
ossicles, without
other symptoms.
 What condition is this?
1. Acute otitis media
2. Cholesteatoma
3. Chronic eustachian
tube dysfunction
4. Tympanic membrane
perforation
Otitis Media with Effusion:
“Glue Ear”

Despite tympanic membrane retraction,

a thick middle ear effusion may be present.
 Eustachian tube dysfunction
• Treatment considerations for this patient may
include all of the following EXCEPT:

1. Treat nasal or
nasopharyngeal obstruction
2. Remove adenoids
3. Place tympanostomy tube
4. Tympanoplasty
5. Watchful waiting
 What is the best diagnosis?
1. Tympanosclerosis
2. Tympanic membrane
perforation
3. Cholesteatoma
4. Otitis media
with effusion
5. Other

Image courtesy of Glenn Isaacson, MD

What causes
tympanosclerosis?
(aka myringosclerosis)
1. Tympanostomy tube
2. Chronic ear disease
3. Tympanic membrane perforation
4. Other
A 5 yo boy accidentally injured his right ear with
a wooden matchstick. He had bloody otorrhea,
otalgia, vertigo, nausea and an unsteady gait.

The best management is:

1. Ear drops, refer to ENT

2. Oral antibiotics, refer to
ENT
3. Ear drops, oral antibiotics
and refer to ENT
4. Urgent referral to ENT
 Posterosuperior
Tympanic Membrane Perforation
• Emergency if
– Posterosuperior
quadrant
– Vertigo
– Emesis
– Ataxia
• Risk of
– Inner ear damage
– Sensorineural
hearing loss
 Pre-operative
audiogram

Post-operative
audiogram
 Otorrhea
The family of a 2 year old calls because
he has thick white drainage in his ear
canal.
He underwent placement of middle ear
ventilation tubes about 6 months ago.
He is otherwise well, has not been
swimming, and his family denies
trauma.
Does otorrhea mean that the
middle ear ventilation tube
is working?

1. YES
2. NO
 Otorrhea
For uncomplicated tube otorrhea,
I recommend EAR DROPS:
1. Never
2. Rarely
3. Occasionally
4. Usually
5. Always
 Treatment of Tube Otorrhea

• EAR DROPS!
– Antibiotic with steroid
• Aural toilet, remove
granulation tissue;
consider placing a wick
• Consider culture
• Consider oral antibiotic if other URI
symptoms or treatment failure
 Acute
Perichondritis
• Often Pseudomonas,
can be Staph., etc.
• Treatment:
– IV Antibiotics
• Cefepime (4th gen) active against Staph. and
Pseudomonas
• Ceftazidime, Imipenim (3rd gen) active against
Pseudomonas, poor against Staph
– Debridement
Acute Perichondritis
Before
treatment

After
treatment
Relapsing
Polychondritis

• Differential Diagnosis:
– acute perichondritis
• Diagnosis: > 3 of McAdam’s criteria
 Relapsing Polychondritis
McAdam’s criteria*: >3 of the following:
– recurrent bilateral auricular chondritis
– non-erosive inflammatory polyarthritis
– nasal cartilage chondritis
– ocular inflammation
– laryngotracheal chondritis
– vestibulocochlear inflammation
Tx: corticosteroids, cyclosporin
(dapsone in adults)

*McAdam LP, O’Hanlan MA, Bluestone R, Pearson CM.

Medicine 1976;55:193-215
 Hearing Assessment
Given a skilled audiologist and a cooperative
child, the best hearing test is

1. ABR / BEAR / AEBR

(auditory evoked brainstem response)
2. OAE (otoacoustic emissions)
3. Behavioral audiogram
 Behavioral Hearing Assessment:
Behavioral Observation Audiometry

Ages • Birth - 4 months

Response • eye widening, wakening,
startle, quieting, head-turn

Photos courtesy of Aly Lent

Behavioral Hearing Assessment:
Visual Reinforcement Audiometry
Ages • 6 months - 2 years
Response • head-turn

Photo courtesy of Aly Lent

 Behavioral Hearing Assessment:
Conditioned Play Audiometry
Ages • 2 to 5 years

Response • perform task

Yield • full audiogram

Photos courtesy of Aly Lent

 ABR
(ABER, BEAR, etc.)
Auditory evoked brainstem response
Test for:
Threshold
Site of lesion

Photo courtesy of Aly Lent

 Otoacoustic Emissions
“OAEs”
• sounds generated in the cochlea, recorded by
microphones in EAC
• “present” is normal

Schering handout
1st Branchial
Cleft Cyst

Notice:
• location: inferior
post-auricular
sulcus
• evidence of
recurrence
1st Branchial
Cleft Cyst

Diagnosis:
– clinical
– CT
– ?U/S, ?MRI
 1st Branchial
Cleft Cyst

• Type I cyst is medial to

the concha, often in
post-auricular crease

• Type II may be found below the

angle of the mandible, along the
anterior border of SCM, superior
to hyoid bone
• can cause otorrhea
Diagnosis & Management of Congenital
Head &Neck Masses SIPAC 1981 AAO-HNS
1st Branchial Cleft Cyst
 1st Branchial Cleft Cyst
Treatment:
Acute:
– antibiotics
– avoid I&D
Definitive
– excision after
inflammation subsides
but before involution
occurs
 Temporal Bone Fracture
Notice: ecchymosis
over mastoid tip
• Evaluate
– Ear canal and
tympanic membrane
– Facial Nerve
– Hearing
• Consider CT Scan
NOSE
 Choanal Atresia

View of unilateral choanal

atresia from nasopharynx

CT scan of bilateral
choanal atresia
Choanal Atresia
I assess for nasal patency by:
1. Passing a catheter
through the nose
2. Listening for airflow at the
nares
3. Using a cotton wisp to
visualize airflow
4. Other
 Choanal Atresia
• If bilateral, in a neonate:
medical emergency
• Open the mouth
• Intubate
 Intranasal Foreign Body
Notice:
unilateral
excoriation
odor
 Most likely
diagnosis?
1. Glioma
2. Dermoid
3. Encephalocele
4. Insect bite
5. Foreign body
6. Other
 Nasal Dermoid
CT and/or MRI to
evaluate
possibility of
Notice: intracranial
midline
extension for
nasal pit
often with midline or near
hair, midline nasal
sometimes lesions
has
drainage
 EXAMINATION

• anterior rhinoscopy
• nasal endoscopy
Nasal polyps
ORAL CAVITY
 Epulis
Treatment:
excision
The family of a 7
year old girl
complains of
“swollen tonsils.”
They report that
she snores “a
very little bit;” they
deny apnea or
increased work of
breathing.
 “Swollen tonsils”
Sleep study demonstrated
an obstructive apnea
index of 2.6
(>1 is abnormal)
and mild hypoventilation
 In a child with OSA
(obstructive sleep apnea)
I am concerned about adverse
neuro-cognitive or behavioral effects:
1. Always
2. Frequently
3. Occasionally
4. Rarely
5. Never
 Which of the following is NOT
true?
In selected patients,
adenotonsillectomy may alleviate / improve:
1. Enuresis
2. ADHD
3. Polyarteritis nodosa
4. PFAPA
5. Psoriasis (Palmoplantar pustolosis)
6. Reactive Airway disesae
Which of the following IS true?
Adenotonsillectomy can contribute to?

1. Immune Deficiency
2. Asthma
3. Weight gain
4. Increased number of infections
 She complains of a sore throat;
won’t swallow; and has trismus
Most likely diagnosis?

1. Acute tonsillitis
2. Peritonsillar
abscess
3. Retropharyngeal
abscess
 Peri-Tonsillar Abscess
Treatment:
– antibiotics
– +/- I&D
– +/- tonsillectomy
(“hot” or interval)
 New onset of neck pain and torticollis;
poorly defined fullness in right neck;
recent URI
Most likely diagnosis?

1. Acute tonsillitis
2. Peritonsillar
abscess
3. Retropharyngeal
abscess
 Retropharyngeal Abscess/
Parapharyngeal Abscess
Evaluation:
– Lateral neck radiograph
– Neck CT with contrast
Group A strep, Staph
Treatment:
– intravenous antibiotics
– ?steroids
– +/- transoral I & D
Risks:
– Airway obstruction
– Mediastinal extension
FACE
Non-tuberculous Mycobacteria
(atypical mycobacteria)
Diagnosis:
– Clinical, generally indolent
– PPD weakly (+)
– Microbiology can be
difficult to confirm with
stains or cultures
– Histology may be
supportive
Non-tuberculous mycobacteria
(Atypical Mycobacteria)

Notice:
– location: angle or body of
mandible
– age: toddlers
– color: purple
– number: sometimes multiple
DDx:
– other adenopathy, including
cat scratch
Non-TB
Mycobacteria
Treatment:
• Medical: usually at least 2:
– Macrolides
– Flouroquinolones
– Rifamycins
– Ethambutol
• Surgical
– I&D contraindicated
– Excision
– Serial curettage
• Combined Medical/Surgical
 Endobronchial
Non-TB Mycobacteria

• 10 month old
presented with
new onset
unilateral
wheezing
SINUSES
 Is it sinusitis?
• A 7 year old boy has had purulent
rhinorrhea for 10 days, not improving; with
day and nighttime coughing. He has not
taken an antibiotic.

Is it sinusitis?
1. Yes
2. Not sure
3. No
 In the clinical context of URI,
the best indicator of sinusitis is?
1. Character of the rhinorrhea
2. Low-grade fever
3. Duration of symptoms
4. Headache
5. Purulent rhinorrhea in the middle meatus
 SINUSITIS DEFINITIONS
• Sinusitis remains a difficult [clinical] diagnosis
to confirm, even for experienced specialists.
Annals ORL Oct. 1995

• The diagnosis of acute bacterial sinusitis is

based on clinical criteria in children who
present with upper respiratory symptoms that
are either persistent or severe (strong
recommendation based on limited scientific
evidence and strong consensus of the panel)
AAP Clinical Practice Guideline:
Management of Sinusitis 2001
 At this point, the best
radiologic study is?

1. Plain Xrays (“sinus series”)

2. CT scan
3. MRI
4. UltraSound
5. Other
 RADIOGRAPHS
NOT USUALLY
USEFUL:
• plain sinus radiography
• tomography
• ultrasonography
• MRI
RADIOGRAPHS
USEFUL: CT scans

(known allergic rhinitis)

Nasal polyps without sinusitis

Unilateral sinusitis with

nasal septal deviation
Nasal congestion without sinusitis

Nasal polyps with cystic fibrosis

Chronic sinusitis
Orbital Complications
of Acute Sinusitis
Consult ENT, Ophtho
CT Scan
– axial AND coronal
– WITH contrast
– ?format for image
guided sinus surgery
Treatment
– IV antibiotics
– close observation
– +/- open or
endoscopic drainage
 Intracranial Complications of
Acute Sinusitis
• Location:
– forehead a/o orbit,
adjacent to frontal sinus
• age: adolescent
• sex: male
• possible mental status
changes, seizures,
neurologic deficits
Intracranial
Complications of
Acute Sinusitis
Intracranial Complications of
Acute Sinusitis
Orbital subperiosteal abscess

Epidural abscess
NECK
Hemangioma
Natural progression
 Hemangioma
• Present within few weeks of birth
• Most common parotid neoplasm in children
• Superficial (red), deep (blue) or compound
 Hemangioma
• Rapid growth for weeks to months
• Transition from proliferation to involution by
age 1, complete by 5-6 years old
• Evaluation:
– MRI, high flow lesion,
bright T2,
flow voids T1 and T2
– CT scan with contrast
 Hemangioma
• Complications: Ulceration, airway obstruction,
high-output cardiac failure, ophthalmic, Kasabach-
Merritt
• Treatment options: Steroids, interferon, laser
• Corrective surgery for residual disease ,
vital structures
 Thyroglossal duct cyst

Notice:
• Midline upper neck
• Moves with tongue
protrusion or
swallowing
Evaluation:
• Ultrasound of neck to confirm
normal thyroid anatomy
• +/- thyroid function tests or scan
Treatment:
• Excision
 Congenital Torticollis
• aka
– Sternocleidomastoid tumor of Infancy
– Fibromatosis Colli
• Notice:
– Within SCM
– present at birth or within weeks
• Fibrosis of SCM muscle
• Evaluation: ultrasound
• Treatment:
– Physical Therapy
– Uncommonly, muscle release to avoid
hemifacial asymmetry
 Branchial Vestige
Notice:
• +/- skin tag
• Involving or anterior to
SCM
May extend into SCM
 Neck Masses
1. Midline Cervical Defect
2. Branchial Cleft Cyst
3. Lymphangioma
4. Retropharyngeal Abscess
5. Infectious Mono
 Midline Cervical Defect

Notice:
– Midline
– 3 components:
• skin tag
• sinus with mucosal lining
• Vertical, non-epithelialized strip
– Rarely, linear bands extend
from mandible to sternum
Etiology unknown, F > M
Treatment:
– Excision
Neck Masses
1. Branchial Cleft Cyst
2. Lymphangioma
3. Retropharyngeal Abscess
4. Infectious Mono
 Infectious Mononucleosis
• Notice:
– Mouth breathing, massive cervical adenopathy
– Exudative tonsillitis, adenotonsillar hypertrophy
• Testing:
– Mono spot, EBV titers, CBC: atypical lymphocytes
• Differential Diagnosis:
– lymphoma, other viral illnesses
• Treatment:
– supportive, steroids, maintain airway,
antibiotics for superinfection
Lymphangioma
• aka Cystic hygroma
• Variable location
• Notice:
– large, soft, non-discolored mass
– “frogs eggs” on
dorsal tongue
• Treatment
– Excision
– Sclerosis
– None
 Lymphangioma
Sclerosis with OK-432 (Picibanil)
(not FDA approved)
Retropharyngeal Abscess
Branchial Cleft Cyst
• Anterior to SCM
• 2nd BCC most common;
4th rarest
• Differential diagnosis:
– Other congenital mass
– Infectious
– Malignant
– other
 LARYNX,
TRACHEA, BRONCHI;
ESOPHAGUS
 Diagram of
airway anatomy
THYROID LARYNX
CARTILAGE
subglottis CRICOID Vocal folds
CARTILAGE = glottis

TRACHEA

BRONCHI
 Stridor Qualities
high pitched
(can be low pitched)
inspiratory
(extrathoracic)
low pitched

high pitched expiratory

(intrathoracic)
 Stridor Qualities
hoarseness
high pitched
(can be low pitched)
inspiratory
(extrathoracic)
low pitched

high pitched expiratory

(intrathoracic)
 Otolaryngology
Airway Evaluation
HISTORY
PHYSICAL EXAMINATION
PLAIN RADIOGRAPHS
ENDOSCOPY (FOL a/o DL,B)
SPECIALIZED RADIOGRAPHS
 Organizing the
Airway Evaluation:
3 Layers
Basic algorithm
How much is enough?
How urgently to proceed?
 Most likely diagnosis is?
1. Croup
2. Vascular ring
3. Laryngomalacia
4. Subglottic stenosis
5. Aspirated foreign body
6. Other
Laryngomalacia
Laryngomalacia
Notice
• inspiratory stridor
– high pitched in infants
– “vibratory”
Most common congenital laryngeal anomaly
Management
• Usually expectant, treat GERD
• If severe: epiglottoplasty
 Most likely diagnosis is?
• Croup
• Vascular ring
• Laryngomalacia
• Subglottic stenosis
• Aspirated foreign body
• Other
Laryngomalacia
(acquired)
Selected causes of hoarseness

Exudative Laryngitis/Tracheitis

Vocal fold nodules

Post-intubation granulation Recurrent respiratory papillomas

tissue, synechiae
How quickly should this child’s
airway be visualized?
1. Today
2. Within 2 weeks
3. No rush
 Proceed urgently if:
• Significant respiratory distress
– increased supplemental oxygen requirement
– child uncomfortable or becoming fatigued
– not explained by other organ system problem

• Stridor of acute onset - risk of progression

– foreign body
– infection
– Trauma

• Significant dysphonia - risk of complete obstruction

– papillomas
– exudative infections
– foreign body
Recurrent respiratory
papilloma
Recurrent respiratory
papilloma
• Predilection for vocal folds
• If untreated, may progress
to stridor and airway
obstruction
• Excise with microdebrider, CO2 laser or
forceps
• Relentless recurrence
• ?cidofovir, cimetidine, interferon, other?
• ?tracheotomy
7 month old male, stridorous since 1 month of
age, recently worse with upper respiratory
tract infection; Full Term, never intubated,
eats without difficulty, stridor worsens with
agitation.
Subglottic Stenosis
Acquired Subglottic Stenosis
 SUBGLOTTIC STENOSIS
• stridor, cough, persistent or recurrent
“croup”
• Congenital or Acquired
– Acquired is usually a result of intubation
• Diagnosis: endoscopy
 The subglottis is at risk
because:
• It is the narrowest portion
of the airway in infants
• The cricoid ring is the
only complete ring and is
non-distensible
5 month old male, stridorous for 2
days, Mom thought because of URI,
but no other symptoms; FT, never
intubated, stridor worsens with
agitation.
 EXTRINSIC LARYNGEAL
COMPRESSION
• post-cricoid foreign body
• deep neck infection
2 1/2 month old female, stridorous
since birth, worsening.
 VASCULAR RING
DOUBLE AORTIC ARCH
• recurrent “croup,” dysphagia
• reflex apnea
• stridor, staccato cough
• diagnosis: endoscopy and/or barium
swallow
• diagnosis: ?CT ?MRI/MRA
• treatment: surgical
New onset stridor
ASPIRATED FOREIGN
BODY
• Sometimes the foreign
body can be seen in
an XRay; but at other
times only the
consequences of the
foreign body are seen
Chevalier Jackson. Bronchoscopy and Esophagoscopy. A Manual
of Peroral Endoscopy and Laryngeal Surgery 2nd ed. 1927.
Atelectasis: stop valve effect
Hyperinflation:
check valve effect
Decubitus XRay
Sunflower seed,
right main bronchus
2 1/2 year old female with
chronic cough, fever, and
persistent right lower lobe
atelectasis despite oral and
intravenous antibiotics. XRay
from February and March.
 ENDOBRONCHIAL
FOREIGN BODY
• gagging, coughing, choking
• symptoms may become quiescent
• endoscopy if
– suggestive history
– suggestive XRay
– pulmonary disease with atypical course
 Resources
• www.guideline.gov
• www.aap.org
– http://aappolicy.aappublications.org
• www.entnet.org
• www.kidshealth.org
Tonsillectomy Myths, Facts and
Special Considerations
• D Howel, et al, Family Practice, 2002
• Bicknell PG, Pediatr Infect Dis J, 1994
• Paradise JL, Ann Otol Rhinol Laryngol 1992
• Peter, G. Ped Infect Dis J 1994
• Griffin JL et al, Arch Otolaryngol Head Neck Surg, 1994
• Rosenfeld RM et al, Ann Otol Rhinol Laryngol, 1990
• L Brodsky, Ped Clinics North America 1989
• Kerns DB et al, ENT Journal Vol 70
• Prim MP et al, Int J Ped Otorhino, 2002
• Dahn KA et al, Arch Otolaryngol Head NeckSurg, 2000
• Galanakis E et al, Arch Dis Child 2002
• Misago N et al, J Dermatology, 2001
• Bicknell PG, Pediatr Infect Dis J, 1994
• McMillin BD et al, ENT Journal, 1999
• Nouwen J et al, Ann Otol Rhinol Laryngol 2002
• Yellin SA, et al, Otolaryngol Head Neck Surg 1995
• Myer and Cotton, ed. A Practical Approach to Pediatric Otolaryngology
 Selected References
Relapsing Polychondritis:
1. McAdam LP, O’Hanlan MA, Bluestone R, Pearson CM. Medicine
1976; 55:193-215

Congenital Head and Neck Masses:

1. Diagnosis and Management of Congenital Head & Neck Masses
SIPAC 1981 Amer. Acad. Oto.-Head & Neck Surgery

Sinusitis:
1. Annals Otorhinolaryngology Oct. 1995
2. AAP Clinical Practice Guideline: Management of Sinusitis 2001
3. Oto Head & Neck Surgery vol 117 no. 3 part 2 Sept. 1997
4. Pediatric Sinusitis SIPAC, 2000 Amer. Acad. Oto.-Head & Neck
Surgery