1、Ear Nose and Throat Concerns in Children with Down Syndrome,Fuad M. Baroody, M.D., FACS Professor of Otolaryngology-Head and Neck Surgery and Pediatrics, Director of Pediatric Otolaryngology,Outline,Ear issues: Hearing testing Hearing screen Hearing loss Ear infections Nose issues: Frequent episodes
2、 of nasal/sinus drainage Throat issues: Obstructive sleep apnea,Otoacoustic Emissions (OAEs),Advantages: Ear specific information No need for sedation Disadvantages: Yes/no answer about hearing loss Can be affected by anatomic factors such as size of canal or middle ear fluid leading to falsely abno
3、rmal result,ABR,Advantages: Golden standard Ear specific information Quantitates the extent of hearing loss Disadvantages: Difficult to distinguish conductive from nerve problems Does not test all frequency ranges Requires sedation if 6mos,Soundfield Audiogram/Play,Advantages: More like a real life
4、situation No need for sedation Can evaluate response to both speech and pure tones Disadvantages: No ear specific information,Pure Tone Audiometry,Patients presented pure tones and speech at different intensities and frequencies with headphones. Golden standard for older children and adults. Provide
5、s ear specific information. Distinguishes conductive from sensorineural losses.,Management of Children with Hearing Impairment,Medical Management Hearing Aids Cochlear Implants Genetic Counseling Speech/Language therapy,EAR INFECTIONS,Otitis Media with Effusion-Prevalence,OME may occur spontaneously
6、 or following AOM. Approximately 90% of children have OME at some time before school age, most often between 6 mos and 4 years. Children experiencing OME: 50% of children in first year of life 60% by age 2 years Many resolve spontaneously within 3 mos, but 30-40% of children have recurrent OME and 5
7、-10% of episodes last 1 yr or longer.,Child at Risk,Distinguish the child with OME who is at risk for speech, language, or learning problems. Risk factors for developmental difficulties include: Permanent hearing loss independent of OME Suspected or diagnosed speech and language delay or disorder Au
8、tism-spectrum disorder and PDD Syndromes (eg, Downs) or craniofacial disorders that include cognitive, speech and language delays Blindness or uncorrectable visual impairment Cleft palate with/without associated syndrome Developmental delay,AAP Practice Guidelines. Pediatrics 2004;113:1412-29.,Child
9、 at Risk,Management of the hi-risk child should include: Hearing testing Speech and language evaluation Possible speech and language therapy Hearing aids or assistive listening devices Management of OME Repeat hearing testing after resolution of OME to determine residual deficit and attend to it,AAP
10、 Practice Guidelines. Pediatrics 2004;113:1412-29.,Myringotomy and Tubes,If effusion lasts 3 months If a child has recurring acute ear infections: 3/6months or 4/yr,NOSE ISSUES,Factors Associated With The Diagnosis Of Rhinosinusitis (1996 Task Force),Major Factors Facial pain/pressure Facial congest
11、ion/fullness Nasal obstruction/blockage Nasal discharge/purulence/ discolored postnasal drainage Hyposmia/anosmia Purulence in nasal cavity on examination Fever (acute rhinosinusitis only),Lanza et al. Otolaryngol Head Neck Surg 1997;117:S1-S7.,Minor Factors Headache Fever (all nonacute) Halitosis F
12、atigue Dental pain Cough Ear pain/pressure/fullness,Viral URIs and Acute Bacterial Rhinosinusitis,In the U.S., the average child has 3-8 acute viral respiratory illnesses/year. Almost 90% of these patients will have a self limiting viral rhinosinusitis. Bacterial infections complicate roughly 0.5-2%
13、 of viral rhinosinusitis. Avoid treating uncomplicated viral URI with antibiotics.,OHNS 2000;123:S4-S32.,Duration of Symptoms in Rhinovirus URIs,Persistence of cough and runny nose in a significant proportion of patients is entirely consistent with an uncomplicated viral cold,OHNS 2000;123:S4-S32.,V
14、iral URIs and Acute Bacterial Rhinosinusitis,In general, the diagnosis of acute bacterial rhinosinusitis may be made in adults or children with a viral URI if: Illness no better after 10 ds Illness worsens after 5-7 ds & is accompanied by some or all of: Nasal drainage Nasal congestion Facial pressu
15、re/pain (unilateral & in the region of a particular sinus) Postnasal drainage Hyposmia/anosmia Fever, cough,fatigue, maxillary dental pain Ear pressure/fullness,OHNS 2000;123:S4-S32.,Medical Treatment,Antibiotics are mainstay Antihistamines and intranasal steroids are useful especially if the child
16、has allergies Avoid treating every cold with an antibiotic Reasonable to treat if cold symptoms persist for more than 10-14 days,Surgery,Adenoidectomy Adenoidectomy with sinus irrigation Functional endoscopic sinus surgery (FESS),Obstructive Sleep Apnea,Sleep Disordered Breathing,Primary Snoring: Sn
17、oring without interruptions in breathing and drops in oxygen levels Obstructive sleep apnea/hypopnea syndrome (OSAHS): Snoring with breathing pauses (apnea) Intermittent drops in oxygen level (hypoxia) Fragmented restless sleep Repeated arousals,OSAS,OSAS is estimated to occur in 2-3% of children. I
18、t leads to a variety of sequalae including: Cardiovascular complications Failure to thrive Behavioral disturbances Excessive daytime sleepiness ADHD Poor learning,Upper Airway Obstruction/OSA Clinical Presentation,Snoring, mouth breathing Sleep pauses, apneas (10 secs) Frequent awakenings Hypersomno
19、lence Behavioral problems Bed wetting (Enuresis) Growth retardation,Upper Airway Obstruction Assessment,Careful parental observation with documentation of presence and length of apneic episodes. Audiotape or videotape of sleep. Sleep Study (Polysomnography). CXR, EKG, Echocardiogram if necessary.,Po
20、lysomnography,Golden standard in evaluating OSA Monitors: Duration and efficiency of sleep EKG and EEG Number of obstructive apneas and hypopneas Changes in pulse oximetry (oxygen saturation in blood) Number of arousals RDI, REM RDI, arousals, and lowest desaturations help determine severity of OSA.
21、,Treatment of OSAS,Most common treatment in children is removal of the tonsils and adenoids. Continuous positive airway pressure (CPAP). Nasal sprays, Montelukast.,OSAS and DS,Predisposing factors for OSAS: Smaller midface and mandible Large tongue Obesity Generalized hypotonia (floppiness),OSAS and
22、 DS,Children with DS frequently have OSAS. OSAS Is seen frequently in children even when it is not suspected by the physician or the parents. Removal of the tonsils and adenoids helps but might not completely eliminate the problem.,Special Considerations in Children with DS Preparing for Surgery,SBE prophylaxis Subacute bacterial endocarditis prophylaxis Neck stability obtain flexion and extension films before surgery especially for tonsils and adenoids,
