Lasting Consequences
Blake Papsin, MD, MSc, otolaryngologist-in-chief at the Hospital for Sick Children in Toronto, said the crucial ways in which pediatric otolaryngology differs from adult otolaryngology are causes and effects. He encouraged the audience to remember that their care can have far-reaching consequences.
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April 2020Dr. Papsin pointed to the way screening in newborns has transformed care and dramatically improved outcomes. Early detection and early intervention, a 2010 study showed, can result in near-normal hearing for children with severe to profound sensorineural hearing loss (JAMA. 2010;303:1498-1506).
If everything else checks out, tell the family, ‘This looks like a developmental issue.’ I personally do not bring up the word ‘autism’ unless the family does first. —Anna Messner, MD
Advances in our understanding of the genetic causes of diseases can be an asset in surgery, giving an early alert that a procedure is likely to be more difficult than might otherwise be expected, Dr. Papsin said. He pointed to surgery for branchio-oto-renal (BOR) syndrome and CHARGE, a complex genetic disorder involving an array of physical anomalies, sensory deficits, and behavior traits.
Pediatric otolaryngologists also have to remember the long-term effects that imaging can have, Dr. Papsin said. The field has advanced in being able to get enough information from MRI, he noted, so less CT imaging, which involves radiation exposure, is needed.
“We irradiate a child and their developing brain—they have a lifetime risk of cancer associated with that radiation,” he said. “It’s not big—but it’s not zero.”
Dr. Papsin pointed to “spatial intelligence,” the way in which children gain knowledge through a range of processes, from hearing to vision to proprioception to vestibular function.
“We are the pediatric otologists that have to preserve the capacity of the organ to get language,” he said.
Laryngeal Cleft
Reza Rahbar, DMD, MD, director of the Center for Airway Disorders at Boston Children’s Hospital, said that his outlook and approach in the management of laryngeal cleft, a space between the esophagus and windpipe that allows food and liquid into the airway, has changed over the years.
Often, even after the defect is closed, swallowing problems persist—about half the time in the most severe cases. Dr. Rahbar said he used to explain away these difficulties by pointing to the array of problems seen in patients with laryngeal cleft: pneumonia, G tubes, and cardiac issues, among others.
“I kept telling myself that they fail because these are complex patients,” he said.
Now, he knows that there is more to the story, Dr. Rahbar said. The children aspirate not only because of the anatomic defect, but also because their neuromuscular function is not properly coordinated.
His approach is now more nuanced, he said, with a treatment timeline that depends on function, an appropriate length of time to allow medical management to work, and factoring in parent expectations and choosing an endoscopic or open surgical approach depending on the severity of the case.
“This really changed the whole management of these patients from my perspective.”
Sometimes, he said, “despite our best surgical approach to correct the hole,” swallowing problems persist.
“I have no ability to change this except providing feeding therapy—and time.”