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Pediatric Speech Disorders

Speech and language disorders in children comprise a variety of conditions with overlapping features. Pediatric otolaryngologists are often one of the first professionals to see these children, often to rule out hearing loss as a potential contributing factor. Parents may report their child does not respond when called by name, or does not acquire vocabulary as rapidly as they would expect. Outside of hearing loss, other…

Pediatric Facial Fractures

Key Points Trauma is the leading cause of pediatric morbidity and mortality in the United States. The patterns of facial fractures in children are age dependent because of developmental, anatomic, and behavioral considerations. Pediatric facial fractures are associated with higher rates of comorbid injuries, including intracranial complications, which necessitate multidisciplinary care. A high index of suspicion must be maintained when evaluating for possible nonaccidental trauma. Computed…

Craniofacial Surgery for Congenital and Acquired Deformities

Key Points Craniofacial anomalies occur in as many as 1 in 500 to 1000 live births for cleft lip and palate, 1 in 2000 for isolated craniosynostosis, and 1 in 20,000 to 50,000 live births for some syndromic types of craniosynostosis. Many of these deformities may be treated by the otolaryngologist (head and neck surgeon) with pediatric and/or facial plastic training. Craniofacial defects are often part…

Congenital and Acquired Malformations of the Nose and Nasopharynx

Key Points Most congenital nasal lesions occur secondary to developmental errors in one of three embryologic zones: the anterior neuropore, the central midface, or the nasobuccal membrane. Encephaloceles, gliomas, and dermoids share a common embryologic origin and frequently manifest as midline nasal masses. These lesions require surgical management. Appropriate preoperative imaging with computed tomography and/or magnetic resonance imaging and careful intraoperative dissection are required to determine…

Nonobstructive Pediatric Sleep Disorders

Key Points Although most otolaryngologists are familiar with pediatric obstructive sleep apnea, nonobstructive sleep disorders are also common causes of morbidity in children. A dyssomnia is a primary sleep disorder characterized by an abnormality in the amount, quality, or timing of sleep that results in difficulty in initiating or maintaining sleep. A parasomnia is an undesirable event that occurs during entry into sleep, within sleep, or…

Evaluation and Management of Pediatric Obstructive Sleep Apnea

Key Points Sleep-disordered breathing is an important cause of morbidity in children and may lead to growth failure, neurocognitive and behavioral abnormalities, cardiovascular dysfunction, and rarely death. Workup includes a comprehensive history and physical examination. Polysomnography is recommended prior to adenotonsillectomy for selected children with premorbid conditions and for otherwise healthy children for whom the need for surgery is uncertain or for whom there is a…

Anesthesia in Pediatric Otolaryngology

Key Points Pediatric otolaryngologic procedures often require a shared workspace between the surgical and anesthesia teams. Excellent perioperative outcomes depend on professional trust, collaboration, and teamwork. Pediatric patients undergoing otolaryngologic procedures have significantly different physical characteristics, physiology, pharmacology, coping strategies, and needs for emotional support and care coordination compared with adults. When examining anesthetic risk as a function of age, younger children (<1 year) have the…

General Considerations in Pediatric Otolaryngology

Key Points Children are physiologically different from adults, especially in the early stages of life. The practice of pediatric otolaryngology relies on close collaboration with other disciplines to manage children with complex medical issues and often with complicated family networks. Pediatric otolaryngology often requires the unique resources and facilities of a dedicated pediatric hospital, including access to intensive care, anesthesiology, and other allied health professionals with…

Otosclerosis

Key Points Otosclerosis is the most common cause of progressive conductive hearing loss (CHL) in adults. The prevalence of otosclerosis is greater in women, with a 2 : 1 female-to-male distribution. The typical age of onset of noticeable hearing loss is in the third decade of life, and hearing loss is bilateral in 75% of cases. Otosclerosis is transmitted in an autosomal dominant fashion with variable penetrance. The…

Clinical Assessment and Surgical Treatment of Conductive Hearing Loss

Key Points Impedance matching of sound pressure delivered to the inner ear through the auditory conductive pathway results from the interaction of the catenary, ossicular, and hydraulic lever systems housed in the middle ear. Sound amplification from the middle ear impedance-matching system is 35 dB. The pinna and external auditory canal can add up to an additional 15 dB of amplification, depending on the azimuth of sound delivery.…

Middle Ear Endoscopic Surgery

Key Points Endoscopy of the middle ear provides improved visualization compared with the microscope and allows surgeons to look around corners to identify and remove middle ear disease. Preoperative computed tomography scans are important to assess the extent of disease and determine if a totally endoscopic approach is feasible. Disease extending posteriorly beyond the dome of the lateral semicircular canal will likely require mastoidectomy for complete…

Mastoidectomy: Surgical Techniques

Key Points Although all major components of the temporal bone are present in infants, the mastoid tip has yet to develop. The stylomastoid foramen is located more superficially, which makes the facial nerve vulnerable to surgical trauma. The temporal line approximates the level of the middle cranial fossa dural plate. The position of the tegmen and the degree of mastoid pneumatization can vary. An important landmark…

Tympanoplasty and Ossiculoplasty

Key Points The ultimate goals of tympanoplasty are to restore middle ear function by eradicating infection and middle ear pathology, to reestablish a tympanic membrane (TM) that resists infection and epithelial ingrowth, and to secure a durable connection between the TM and the inner ear. Medial and lateral techniques refer to the placement of the graft either medial or lateral to the TM remnant. The graft…

Complications of Temporal Bone Infections

Key Points Although declining in incidence, the complications of temporal bone infections continue to carry the potential for extensive morbidity and mortality. The management of infectious intratemporal complications that are suppurative in nature or related to cholesteatoma can be facilitated by recognizing patterns of extension within the temporal bone and patterns of neurovascular involvement. The management of intracranial complications of temporal bone infection should be guided…

Chronic Otitis Media, Mastoiditis, and Petrositis

Key Points Otitis media is one of the most common diseases of childhood and may result in complications, including acute and chronic mastoiditis, petrositis, skull base osteomyelitis, intracranial infection, and the sequela of early childhood auditory deprivation. Acute otitis media (AOM) may result in persistent otitis media with effusion (OME), which is currently recognized as the leading cause of childhood hearing loss. Aural cholesteatomas are epidermal…

Topical Therapies of External Ear Disorders

Key Points An understanding of the efficacy and side-effect profile of prescription and nonprescription topical therapies is important for the successful management of the patient with a nonneoplastic condition of the external ear. Debridement under binocular microscopy (or otoendoscopy) in the otolaryngology office is both diagnostic and therapeutic for common conditions involving the external ear. Most ototopical therapies are safe for the management of uncomplicated infections…

Infections of the External Ear

Key Points The external ear and ear canal are affected by various bacterial, fungal, and viral infections as well as noninfectious inflammatory conditions. Meticulous debridement of the ear canal is a crucial first step in managing all infections. Most cases of external otitis should be managed with topical medications. Infections that have spread beyond the confines of the ear canal skin require culture-directed systemic antibiotics. Until…

Otologic Symptoms and Syndromes

Key Points Hearing loss, tinnitus, otalgia, otorrhea, and vertigo are symptoms of otologic disease. Queries into each of these symptom categories will assist the clinician in formulating a differential diagnosis. Taking a comprehensive history is critical for establishing a diagnosis for vertigo symptoms. Importantly, symptoms such as headache, visual aura, photophobia, phonophobia, extremity weakness or numbness, or other cranial nerve deficits suggest central and not peripheral…

Interventional Neuroradiology of the Skull Base, Head, and Neck

Key Points Superb equipment with which to visualize and perform image-guided neurologic interventional procedures is of paramount importance. The balloon occlusion test should be accompanied by an imaging procedure to evaluate the effects on cerebral blood flow during carotid occlusion. The goal of any interventional procedure, whether for presurgical or definitive therapy, must be defined at the outset. Preoperative embolization of vascular tumors of the head…

Neuroradiology of the Temporal Bone and Skull Base

Key Points Computed tomography (CT) evaluation of the temporal bone with and without contrast enhancement shows bony erosion and adjacent soft tissue inflammation and/or abscess in cases of malignant external otitis. Cholesteatoma has distinct imaging characteristics on magnetic resonance imaging (MRI). The lesion is isointense to hypointense on T1-weighted imaging, is intermediate on T2-weighted imaging, and does not enhance with addition of contrast medium. Most importantly,…