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.

There is also some evidence suggesting that the greater the amount of time between implants, the less benefit. Also the people who seem to benefit are those who don’t have a lot of a lot of motor issues, Dr. Kenna said.

Another factor to take into account with bilateral implants is that the cost-effectiveness of the second implant is reduced if a second surgery is required, said Dr. Papsin.

How to Manage Benign Laryngeal Tumors

Panelists were challenged with a sample case of a recurrent respiratory papillomatosis of the larynx that presented in childhood and caused some airway obstruction. Many cases are resolved but we’re now managing cases graduating to adulthood and developing to significant secondary disease as a result of papilloma of the larynx, said Dr. Papsin. The question presented was: What is the best way to treat recurring papillomatosis in a 4-year-old child?

Different centers tend to treat the problem differently, according to Christopher Hartnick, MD, Assistant Professor of Otology and Laryngology at the Massachusetts Eye and Ear Infirmary in Boston. A committee with the American Society of Pediatric Otolaryngology is working on developing a protocol for this sort of problem.

He described his experience in using pulsed dye laser in a series of children whose lesions were difficult to treat with a microdebrider. The laser treatment was very effective in dealing with this particular lesion, he said. The pulsed dye laser has an advantage over CO₂ lasers in that it doesn’t promote epithelial scarring, can be used in the office, and can be used for tracheal lesions.

On the other hand, Joseph Haddad, Jr., MD, Associate Professor of Otolaryngology at Columbia University in New York City, reported that in his experience, the CO₂ laser was effective in most cases he’s worked on.

However, there are significant voice issues, especially in the children who get regular treatments. I’ve also had good results with the microdebrider, he said. However, there are children who have recurrences and need procedures close to every month. For these kids, he suggested the use of cidofovir to try to reduce the need for surgery-though there are significant side effects parents should be made aware of.

Dr. Myer added that he has had good experience with microdebriders. He also suggested that when treating papillomas, doing a biopsy should be considered. Over a 21 year period, he has had four young patients have malignancies develop. It’s a benign disease until it’s not, he reminded the audience.

Team Approach to Complex Cases

The next topic addressed was how to manage infants with a large lymphatic malformation below the mylohyoid muscle. The overall message from panelists was that this is a complex problem that requires a team approach, and that it is important to develop a team that can work together well.

We have a team with anesthesia, pediatric surgery, and otolaryngology-one of the things I’d say is that close collaboration and respect is essential, said Dr. Haddad. It’s important to not let egos get in the way of good patient care.

Teamwork is even more critical when it comes to managing something such as CHAOS (congenital high airway obstructive syndrome) when treatment has to begin right in the delivery room.

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. – Blake Papsin, MD

They’re not easy cases to do. It’s not the place for a resident or fellow to take a lead role. What’s difficult is when the child’s head and neck is delivered, but it’s not continuously breathing. You’re dealing with distorted anatomy, but you’re also not dealing with a dynamic airway, said Dr. Haddad. The trachea is small and hard to find.

Dr. Papsin added that at his center, the babies are delivered through planned Caesarian section with two teams of medical personnel present-one for each the mother and the baby.

Using Technology

Imaging is key to knowing how to manage these cases, said Dr. Haddad. We’ve had good success on at least three cases under CT guidance-in the really challenging cases where it doesn’t look easily resectable, if you have the availability of interventional radiology, that’s the way to go, he said.

Putting the newborn on ECMO (extracorporeal membrane oxygenation) is useful in cases where there is trouble establishing the airway, said Dr. Kenna. She has seen a couple of babies placed on ECMO in the delivery room which allowed time for airway assessment and resection of the mass.

Having a CHAOS cart with all the needed equipment constantly at the ready is a big help too, said Dr. Haddad.

Still, there is the question of whether these procedures even provide much help to these patients. Research should be done to look at this prospectively and decide whether there is actually an improvement in the length of life and the quality of life… In my short experience, that has not been the case. We have not caused a significant improvement in quality in the life. It’s usually aggressive tumors, said Dr. Papsin.

The fact that many of these babies don’t survive is an important aspect to discuss with parents before the baby is born.

Treating Macrocystic Lesions

Dr. Kenna reported she had some experience using the sclerosing agent OK-432 for macrocystic lesions, but said it’s important to pick the right lesion and the right patient. It’s not the benign thing some of the literature suggests. There’s a big inflammatory component that has quite a bit of discomfort, she said. Also, there is little experience in pediatric otolaryngology with the use of the compound, and it is not widely available.

There was some debate regarding the timing of removing lesions. Some surgeons have the philosophy of waiting a short while so parents have a better understanding of the severity of the abnormality that needs repair-so they aren’t as shocked by any deformities that may be left after surgery, said Dr. Haddad.

However, Dr. Papsin added that the philosophy at his center is to get them as soon as the kid is stable. Earlier removal can lead to less scarring, he said.

Endoscopic Sinus Surgery

The final topic of discussion was endoscopic sinus surgery and whether there is still much of a role for it. The approach was advocated in the mid 1990s, then interest waned in later years as follow-up showed results that weren’t as good as anticipated. But, there are still problems for which it is a useful procedure.

One example discussed was the case of a 6-year-old boy with a visible polyp in his nostril. An endoscopic approach is good for this, but a CT scan should be performed ahead of time to verify details of the polyp and whether there is obstruction, said Dr. Haddad.

However, the effectiveness of endoscopic surgery verses other approaches still has some uncertainty because the evidence is weak, said Dr. Myer. We don’t have data- its more what you feel, he said. At this point, it’s better for doctors to use the approach they are most comfortable with.

Sometimes an endoscopic approach doesn’t solve the problem and there can be recurrence. A second procedure may require an open approach, and families should be made aware ahead of time that recurrence is a possibility, said Dr. Hartnick.

Panelists agreed that in a case where a child has a periorbital abscess, endoscopy would be the best first approach. If it didn’t solve the problem, then they would switch to an open incision.

©2006 The Triological Society