Rise of Subspecialties in Pediatric Otolaryngology Has Changed Practice

TORONTO-Pediatric otolaryngology has advanced by leaps and bounds over the past couple of decades, but it’s the rise in subspecialties within the field that has lead to the most changes in practice.

A panel of pediatric otolaryngology experts here at the meeting of the Eastern Section of the Triological Society described some of the changes in practice seen in areas such as testing, surgery, and the quality of evidence for commonly done procedures.

Twenty years ago, pediatric otolaryngologists were members of the senior society. It became a subspecialty, truly, and we went out and developed our own society, said Blake Papsin, MD, Associate Professor of Otolaryngology at the University of Toronto in Ontario. He was moderator of the panel, Tiny Humans/Massively Complex Problems: A Glimpse into Tertiary-Quartnary Pediatric Otolaryngology.

Screening for Hearing Loss in Newborns

The first issue addressed by the panel was screening the hearing of newborns and young children with hearing loss. Panelists agreed that all newborns should be screened, but when it comes to sensorineural hearing loss, the number and approaches to testing have changed in recent years.

It used to be that numerous tests were ordered with a shotgun approach that included all sorts of cost ineffective methods of looking at them. We did blood, we did ECGs, we did ophthalmology, said Dr. Papsin. But now tests are better targeted.

However, despite test selection tailored to a child’s risks, low yield tests such as ECGs shouldn’t be discounted, according to Margaret Kenna, MD, Associate Professor of Otolaryngology and Laryngology at Harvard Medical School in Boston, Mass. Vision should also be assessed, she said.

The approach to testing and screening has changed with the introduction of pediatric subspecialists, said Charles M. Myer III, MD, Professor of Otolaryngology at the University of Cincinnati College of Medicine (Ohio). He said that he used to order tests himself, but now he sends cases of sensorineural hearing loss to an otologist on staff.

I think this is very a good way of doing it because a) it’s cost effective, and b) there’s consistency because you’ve got one person deciding what tests are appropriate for the child. The otologists are clearly more at the forefront than I am as to when new tests will become available, Dr. Myer said.

At the same time, there is the issue that test results won’t necessarily change treatment. For instance, genetic testing can help with family planning, but not in doing anything with the patient at hand. A CT could show whether there is a structural problem causing the hearing loss, and while knowing this may not lead to a treatment change, it provides parents with more information about the child’s condition. Dr. Myer advised that CT scans be done at a very early age to reduce the need for the child to be sedated.

Bilateral Implants: Yes or No?

When it comes to the issue of bilateral cochlear implants, the panelists have mixed experiences. Dr. Kenna reported that 15 bilateral implantations have been performed at her institution, but added that not all patients are good candidates. Sometimes a patient who already has one implant won’t necessarily benefit from a second.