Oxford Handbook of ENT and Head and Neck Surgery (2 edn)
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Assessing the paediatric patient
Children present several difficulties
They are small and so is their anatomy
They are usually unable to give an accurate history
They have parents who may be very anxious
Their condition can deteriorate very quickly
Be able to assess a child in its entirety.
Gain knowledge of how a child feeds and its daily requirements, especially the total time it takes to feed.
Become familiar with height and weight charts and the centile ranges which chart a child’s physical development.
Become familiar with the developmental milestones showing a child’s speech development (
see Table 17.1).
| Age | Normal language development | Normal speech development | Intelligibility |
|---|---|---|---|
Infant | Cooing Babbling | Non-cry vocalic sounds Consonant—vowel syllables with intonation patterns | |
1 year | Appearance of first 2–3 words Imitates sounds of animals | Omits most final and some initial consonants Substitutes consonants m, w, p, b, k, g, n, t, d, and h for more difficult sounds | Usually no more than 25% intelligible to familiar listener |
2 years | Uses 2–3-word phrases | Uses above consonants with vowels but inconsistently and with substitution | 50–65% of spoken language can be understood |
Has a vocabulary of 250–300 words Can put together simple 2–3-word phrases | Word usage and comprehension develops but comprehension lags behind expressive ability | ||
Uses I, me, and you | Can understand much adult communication directed to them | ||
3 years | Says 4–5-word sentences, with a vocabulary of about 900 words. Uses who, what, and where. Uses plurals, pronouns, and prepositions | Says b, t, d, k, and g, but r and l may be unclear. W is either omitted or substituted. Often repeats self. | 75% of communications are intelligible |
4–5 years | Vocabulary has increased to about 1500–2100 words. Sentences are complete and most grammar correct | Says f and v. May still have some distortion of r, l, s, z, sh, ch, y, and th | All speech can be understood, although some words may not be perfectly enunciated |
5–6 years | Vocabulary of 3000 words | May still distort s, z, ch, sh, and j |
| Age | Normal language development | Normal speech development | Intelligibility |
|---|---|---|---|
Infant | Cooing Babbling | Non-cry vocalic sounds Consonant—vowel syllables with intonation patterns | |
1 year | Appearance of first 2–3 words Imitates sounds of animals | Omits most final and some initial consonants Substitutes consonants m, w, p, b, k, g, n, t, d, and h for more difficult sounds | Usually no more than 25% intelligible to familiar listener |
2 years | Uses 2–3-word phrases | Uses above consonants with vowels but inconsistently and with substitution | 50–65% of spoken language can be understood |
Has a vocabulary of 250–300 words Can put together simple 2–3-word phrases | Word usage and comprehension develops but comprehension lags behind expressive ability | ||
Uses I, me, and you | Can understand much adult communication directed to them | ||
3 years | Says 4–5-word sentences, with a vocabulary of about 900 words. Uses who, what, and where. Uses plurals, pronouns, and prepositions | Says b, t, d, k, and g, but r and l may be unclear. W is either omitted or substituted. Often repeats self. | 75% of communications are intelligible |
4–5 years | Vocabulary has increased to about 1500–2100 words. Sentences are complete and most grammar correct | Says f and v. May still have some distortion of r, l, s, z, sh, ch, y, and th | All speech can be understood, although some words may not be perfectly enunciated |
5–6 years | Vocabulary of 3000 words | May still distort s, z, ch, sh, and j |
Reproduced with permission from Glasper, McEwing, and Richardson, Oxford Handbook of Children’s and Young Person’s Nursing, page 13, 2007 © Oxford University Press.
Shared care
No group of patients demonstrates the principles of shared care better than the paediatric population
Help from paediatricians, midwives, neonatal intensivists, and anaesthetists with special paediatric training is invaluable.
Neonatal problems
In utero
Occasionally pre-delivery ultrasound scanning can detect congenital problems leading to a planned Caesarean section and possible ENT intervention, for example, cystic hygroma ( see ‘Congenital neck remnants’, p. 266).
The ENT team should be in the theatre, scrubbed and on standby for intubation or tracheostomy if the baby’s airway is compromised. Secondary treatment of cystic hygroma is given after further investigation.
Delivery problems
Airway difficulties
Newborn infants are obligate nasal breathers.
Failure to breathe and the development of hypoxia may be related to choanal atresia. The attending paediatrician/anaesthetist may be able to restore breathing with an oral airway.
Bilateral choanal atresia is the likely diagnosis. Failure to pass the nasal suction tube is not always a good sign of atresia.
Placing a metal tongue depressor and watching whether it mists is a good method of measuring nasal airway patency.
Congenital abnormalities
Microtia
Branchial cysts or fistulas
Smaller cystic hygromas
Haemangiomas
These lesions may all be noticed at birth or during the neonatal examination.
Hearing assessment
Soon all newborn children will be tested for hearing problems in universal newborn hearing programmes. It is important that children who are too sick to be screened are not missed.
Airway problems
Noisy breathing
Many children have periods of noisy breathing. It is not normal.
Stertor and stridor are caused by turbulent airflow in the partially compressed airway:
Stertor
—is the noise associated with snoring and is due to a supraglottic narrowing of the airway, e.g. enlarged tonsils.
Stridor
—is due to narrowing of the airway in and around the glottis and upper airway.
Assessment and examination aim to establish a likely diagnosis and to set parameters for further intervention.
History
When did it start?
Related to feeding?
Position-dependent? Worse on back or front?
Growth and development
Neonatal history
Examination
General examination for birthmarks
Oral cavity
Tongue size
Palate—any clefts?
Tonsil size
Intercostal recession
Tracheal tug
Stridor—time stridor relative to breathing cycle. Is it inspiratory or expiratory?
Laryngomalacia
is the commonest cause of stridor in children. It is usually benign and self-limiting. This is often the presumed diagnosis in children with stridor. ( See ‘Congenital laryngeal lesions’, p. 218.)
Examination under anaesthetic in children less than 12 months of age is associated with an increased mortality.
Indications for microlaryngoscopy and bronchoscopy (MLB)
Failure to thrive
Cyanosis
Prolonged apnoeic episodes
| Stridor | Voice | Cough | |
|---|---|---|---|
Nasal/oropharyngeal region | Stertor | Muffled | – |
Supraglottis, glottis | Inspiratory | Hoarse | Barking |
Subglottis, extrathoracic tracheal | Biphasic | Normal | Brassy |
Intrathoracic tracheal, bronchi | Expiratory | Normal | + |
| Stridor | Voice | Cough | |
|---|---|---|---|
Nasal/oropharyngeal region | Stertor | Muffled | – |
Supraglottis, glottis | Inspiratory | Hoarse | Barking |
Subglottis, extrathoracic tracheal | Biphasic | Normal | Brassy |
Intrathoracic tracheal, bronchi | Expiratory | Normal | + |
Reproduced with permission from Warner et al., Otolaryngology and Head and Neck Surgery, 2009, copyright, Oxford University Press.
Feeding problems
Is this a primary feeding problem or secondary to an airway problem?
Investigations are usually conducted with the help of a paediatrician and paediatric SALT.
History
When did it start?
Regurgitation present?
Choking?
Aspiration?
Weight/height gain?
Stridor present or absent?
Examination
Nasal airway—clear or obstructed?
Mouth and tongue—any enlargement or tongue tie?
Palate—any clefts present?
Tonsils—are they enlarged?
Investigation
Watch bottle or breastfeeding
Nasal endoscopy to examine larynx and vocal cord movement
Barium swallow with paediatric SALT in attendance
Consider examination under GA if no obvious cause and child is failing to thrive
Management
Nutrition and fluid intake may necessitate NG feeding
Depends on underlying condition
Snoring and sleep apnoea
This is a common problem in children. Commonest age is from 3–8 years when adenoidal hypertrophy is greatest. The aetiology is different to that in adults.
History from parents
Mobile phone video often documents episodes
Apnoeic episodes
Daytime sleepiness is often not a feature
Irritability is probably the manifestation of inadequate sleep
Examination
Nasal obstruction not relieved by vasoconstrictor
Large tonsils
Sleep studies
Developmental or syndromic children may have central apnoea as the cause of their snoring and sleep apnoea. Sleep study will show apnoea is not associated with respiratory efforts.
History of cardiac disease can be associated with central apnoea.
Medical treatment
Useful for children with obvious rhinitis and hypertrophied turbinates. May also decrease the size of the adenoidal pad.
Use intranasal steroids, e.g. fluticasone 1 spray into each nostril od for at least 6 weeks.
Surgery
Adenotonsillectomy is usually curative. However, it carries the risk of postoperative haemorrhage and is uncomfortable.
Speech development problems
Speech production
Cognitive ability interacts with the physical method of speech production:
Pulmonary phase
—generates constant airflow to the larynx
Laryngeal phase
—production of sound occurs via opposition of the vocal cords and mucosal wave of the vocal fold
Oral phase
—modification of the laryngeal sound by the tongue, oral cavity, and sinuses
ENT assessment is mandatory in children who are failing to develop speech properly.
The role of the team investigating the child is to identify the barrier to speech development. Often more than one factor can be responsible and may need to be addressed.
Is this part of a global developmental delay?
Neonatal history
Developmental landmarks
Any family history of developmental problems?
Is there a hearing problem?
Neonatal history
Any risk factors?
Familial hearing problems?
Syndromic child
Physical examination
Microtia
EAC development
Tympanometry
Audiology
Dual pathology
Is there an anatomical impediment to speech?
Oral cavity
Tongue tie
Cleft palate
Bifid uvula
Massive tonsils
Examination of larynx
Examination under anaesthesia
Treatment
It is important to treat any hearing problem with hearing aids or surgery, e.g. grommets for glue ear. This is particularly important for children with global developmental delay. Any language development is going to be improved by normal hearing.
