Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_4518_Библиотеки_им_академика_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

31.08.2026

Размер:

30 Мб

Скачать

☆

<<< < Предыдущая 1 23 / 503 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 > Следующая >>>

https://t.me/medicina_free

Posterior pharyngeal wall augmentation—fat, hyaluronic acid, calcium hydroxylapatite. Furlow Double-opposing Z-plasty—use with submucous cleft, reorients palatal musculature, and lengthens palate.

A. F. Karas and J. W. Lee

Cleft Lip (CL) andCleft Palate (CP)

• Cleft palate results from failure of bilateral palatine shelves (from maxillary processes) to fuse at midline with developing nasal septum (from frontonasal process and bilateral medial nasal processes).

• Cleft lip results from failure of fusion of maxillary swelling with medial nasal process.

• Bony septum deviated to the cleft side; retrodisplacement of lower lateral cartilage on cleft side and nasal tip; and columella deviate toward non-cleft side.

• Signs of submucous cleft palate:

– Bid uvula. – Zona pellucida. – Notched hard palate. – Dehiscence of palatal sling including levator veli palatini leads to signicant

Eustachian tube dysfunction and nearly universal incidence of chronic otitis media.

• Wide range of congenital insults and genetic errors have been linked:

– Drugs: phenytoin, vitamin A derivatives, folic acid antagonists. – Smoking and alcohol use in rst trimester. – X-linked cleft palate syndrome has been described.

• Incidence of CL+/− CP is about 1/700 live births overall; increased in Native American and Asian populations and decreased in Caucasians and African Americans

• More common in males (2/3).

• 80% of clefts are unilateral, more common on left (2/3).

• Surgical repair of cleft lip and palate:

– Lip adhesion: if done, performed at 2–4weeks of age with denitive repair at

4–6months of age

– Cleft lip repair: if no contraindication and no previous lip adhesion, repair

performed at 10–12weeks; rule of 10’s (10weeks old, 10kg weight, hemoglobin of 10)

Straight-line closure (rarely used) Millard rotation advancement technique Tennison-Randall (single) triangular ap interdigitation Bardach (double) triangular ap interdigitation Bilateral cleft repair (Millard)

1 Embryology

https://t.me/medicina_free

– Cleft palate repair: performed 9–12months up to 18months of age if child is

growing and gaining weight; restoration of soft palate sling incorporating tensor veli palatini and levator veli palatini

Schweckendiek: closure of soft palate only Von Langenbeck Bardach two ap palatoplasty (for complete CP repair) Furlow Double-opposing Z-plasty (for secondary CP repair) V-Y pushback technique (for secondary CP repair)

Craniosynostosis

• premature closing of bony suture

• Scaphocephaly—sagittal suture

• Trigonocephaly—metopic suture

• Plagiocephaly—unilateral coronal or lambdoid suture

• Brachycephaly—bilateral coronal sutures

Further Reading

Bajaj Y, Ifeacho S, Tweedie D, Jephson CG, Albert DM, Cochrane LA, etal. Branchial anomalies

in children. Int J Pediatr Otorhinolaryngol. 2011;75(8):1020–3.

Goff CJ, Allred C, Glade RS.Current management of congenital branchial cleft cysts, sinuses, and

stulae. Curr Opin Otolaryngol Head Neck Surg. 2012;20(6):533–9.

Triglia JM, Nicollas R, Ducroz V, Koltai PJ, Garabedian EN. First branchial cleft anoma-

lies: a study of 39 cases and a review of the literature. Arch Otolaryngol Head Neck Surg. 1998;124(3):291–5.

Chen EY, Inglis AF, Ou H, Perkins JA, Sie KC, Chiara J, etal. Endoscopic electrocauteriza-

tion of pyriform fossa sinus tracts as denitive treatment. Int J Pediatr Otorhinolaryngol. 2009;73(8):1151–6.

Service GJ, Roberson JB Jr. Current concepts in repair of aural atresia. Curr Opin Otolaryngol

Head Neck Surg. 2010;18(6):536–8.

Bly RA, Bhrany AD, Murakami CS, Sie KC. Microtia reconstruction. Fac Plast Surg Clin.

2016;24(4):577–91.

Zapata S, Kearns DB.Nasal dermoids. Curr Opin Otolaryngol Head Neck Surg. 2006;14(6):406–11. Cedin AC, Atallah AN, Andriolo RB, Cruz OL, Pignatari SN.Surgery for congenital choanal atre-

sia. Cochrane Database Syst Rev. 2012;2:CD008993.

Visvanathan V, Wynne DM.Congenital nasal pyriform aperture stenosis: a report of 10 cases and

literature review. Int J Pediatr Otarhinolaryngol. 2012;76(1):28–30.

Ruda JM, Krakovitz P, Rose AS.A review of the evaluation and management of velopharyngeal

insufciency in children. Otolaryngol Clin N Am. 2012;45(3):653–69.

Jayaram R, Huppa C.Surgical correction of cleft lip and palate. Front Oral Biol. 2012;16:101–10. Schroeder JW Jr, Mohyuddin N, Maddalozzo J.Branchial anomalies in the pediatric population.

Otolaryngol Head Neck Surg. 2007;137(2):289–95.

Kajdic N, Spazzapan P, Velnar T.Craniosynostosis– recognition, clinical characteristics and treat-

ment. Bosn J Basic Med Sci. 2018;18(2):100–16.

Chapter 2

https://t.me/medicina_free

General Pediatric Otolaryngology

AnatoliF.Karas andJanetWaiminLee

Pearls

• Croup-like symptoms on presentation for the child <6months of age should be of concern for possible subglottic hemangioma.

• After maximization of medical therapy, adenoidectomy is the rst-line surgical options for recurrent, acute sinusitis/adenoiditis in children.

• Consider adenoidectomy to help treat underlying Eustachian tube dysfunction, especially in children over the age of 4 years.

• Nasal polyposis in a child should prompt a workup for cystic brosis.

• Torticollis or decreased neck range of motion post-adenotonsillectomy should be suspicious for Grisel’s syndrome.

• Neck masses in children are most commonly the result of infectious process.

Adenotonsillar Disease

• Adenoid anatomy

– Blood supply

Pharyngeal branches of the internal maxillary (major supply)

A. F. Karas Department of Otorhinolaryngology, Head & Neck Surgery, Rush University Medical Center, Chicago, IL, USA

Department of Pediatrics, Rush University Medical Center, Chicago, IL, USA e-mail: anatoli_f_karas@rush.edu

J. W. Lee ( Department of Head and Neck Surgery & Communications Sciences, Duke University Medical Center, Durham, NC, USA e-mail: janet.w.lee@duke.edu

https://doi.org/10.1007/978-3-031-26048-3_2

https://t.me/medicina_free

Ascending palatine branch of the facial artery Ascending cervical branch of the thyrocervical trunk Ascending pharyngeal artery

– Innervations: cranial nerve (CN) IX and X

Histology: ciliated pseudostratied columnar, stratied squamous, and transitional epithelia present; presence of inammation increases specialized squamous epithelium proportion and decreases respiratory proportion.

– Indications for adenoidectomy (without tonsillectomy)

Airway obstruction

• Adenoid hyperplasia with chronic nasal obstruction or obligate mouth breathing

• Obstructive sleep apnea (OSA) or sleep disturbances

• Associated with cor pulmonale, failure to thrive (FTT)

Recurrent/chronic adenoiditis or sinusitis Chronic otitis media with or without effusion (children >4years) Craniofacial growth and occlusive abnormalities, i.e., “adenoid facies” Speech abnormalities including hyponasality Swallowing abnormalities Suspected neoplasm

A. F. Karas and J. W. Lee

– Tonsil anatomy

Blood supply

• Facial artery (tonsillar branch, ascending palatine branch)

• Dorsal lingual branch of lingual artery

• Internal maxillary artery (descending palatine, greater palatine artery)

• Ascending pharyngeal artery

Etiology of pseudomembranous tonsillitis

• Epstein-Barr virus (mononucleosis)

• Candidiasis

• Vincent’s Angina

• Neisseria gonorrhoeae

• Syphilis

• Corynebacterium diphtheria

• Group A β-hemolytic Streptococcus

Complications of tonsillitis

• Scarlet fever

• Rheumatic fever—arthritis, carditis (valvular insufciency/stenosis), skin lesions, abnormal movements (Sydenham chorea)

• Peritonsillar/retropharyngeal abscess (PTA/RPA)

2 General Pediatric Otolaryngology

https://t.me/medicina_free

• Lemierre’s syndrome—internal jugular vein thrombophlebitis, distant/ pulmonary septic emboli; Fusobacterium necrophorum

Indications for tonsillectomy

• Infection

– Recurrent acute infections ≥7 episodes/year in 1 year, ≥5/year in

2years, and ≥3/year in 3 or more years. Natural history of recurrent tonsillitis is spontaneous reduction in frequency of episodes— patients treated with observation have similar rates of infection after ~2years as those treated surgically.

– Recurrent acute infections with complications (cardiac valve disease,

febrile seizures).

– Chronic tonsillitis is associated with halitosis, persistent sore throat,

tender cervical adenitis, and unresponsiveness to medical therapy. – Streptococcus carrier. – Peritonsillar abscess (>1 PTA). – Tonsilloliths with persistent pain, halitosis, otalgia, and foreign body

(FB) sensation. – Tonsillitis with cervical abscess. – Mononucleosis with obstruction of tonsils; unresponsive to therapy. – Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA,

see below). – OSA—ask about hyperactivity, poor school performance, poor

growth, enuresis, and asthma. – Suspicion of malignancy.

• AAO-HNS recommends preoperative polysomnogram for patients with any of the following risk factors:

– Age <2years – Obesity (BMI ≥95%) – Down syndrome – Craniofacial abnormalities – Neuromuscular disorders – Sickle cell disease – Mucopolysaccharidoses

• AAO-HNS guidelines for overnight admission post-adenotonsillectomy

– Overnight observation recommended:

Severe OSA (apnea-hypopnea index (AHI) ≥10 and/or O2 nadir ≤80%) Age <3years

– Consider overnight observation:

Medical comorbidity (cardiac, genetic syndromes including Down syndrome, neuromuscular disorders, failure to thrive, craniofacial abnormalities) Obesity without previous polysomnogram for risk stratication

https://t.me/medicina_free

A. F. Karas and J. W. Lee

Behavioral concerns increasing risk for dehydration and/or difculty with postoperative pain management

• Complications of adenotonsillectomy

– Postoperative hemorrhage: 2–5%. – Dehydration. – Postoperative pulmonary edema: due to loss of auto-PEEP from chronic

obstruction and decreased intrathoracic pressure. Treat with diuretics, uid

restriction, and CPAP.Intubate if necessary to control O2 saturation. – Hypoxemia: loss of hypercapnic respiratory drive. – Velopharyngeal insufciency. – Nasopharyngeal stenosis. – Atlantoaxial subluxation (Grisel’s syndrome): decalcication of anterior arch

of atlas, laxity of anterior transverse ligament; Down syndrome children more

prone to this:

Diagnosis: magnetic resonance imaging (MRI) or computed tomography (CT) C-spine Treatment: muscle relaxants, benzodiazepines, spine consultation/traction, cervical collar, NSAIDs

• PFAPA syndrome:

– Periodic sudden-onset high fevers, aphthous stomatitis, pharyngitis, cervical

adenitis occurring every 3–5 weeks for at least three episodes, each epi-

sode <5days – Repeated negative throat and viral cultures – Medical management with steroids can shorten episodes but can also shorten

interval between episodes. Can be used for diagnosis. Denitive surgical

management with adenotonsillectomy

• Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS)

– Somewhat controversial, pathophysiology not fully proven – Rapid onset of obsessive-compulsive disorder (OCD) in association with

group A β-hemolytic streptococcal infections (GABHS) – Diagnosis: GABHS-Ig – Treatment: psychiatric medications for OCD, penicillin, or other antibiotics

2 General Pediatric Otolaryngology

https://t.me/medicina_free

Otitis Media

Please see section on “Otitis Media” in Chap. 5.

Upper Airway Infections

• Laryngotracheitis (Croup)

– Viral etiology (most commonly associated with parainuenza) – Slow onset with upper respiratory infection (URI) prodrome leading to barky

cough and inspiratory stridor – Presents in patients aged 6months to 3years – Anterior-posterior (AP) neck X-ray with “steeple sign” (subglottic narrowing) – Supportive care with humidication, racemic epinephrine, ±steroids – Intubation rarely required and should be avoided if possible

• Supraglottitis (epiglottis)

– Bacterial etiology (classically H. inuenza B). – Rapid onset with high fevers, dysphagia, drooling, and toxic appearance. – Presents most commonly in patients aged 1–8years old. – Lateral neck X-ray with “thumbprint sign” (swollen epiglottis). – Flexible laryngoscope can be considered, but care should be taken as it may

exacerbate symptoms. – Secure airway; IV antibiotics.

Intubation (may require rigid bronchoscopic instruments) in OR with tracheotomy equipment available; extubate once edema decreased and air leak is present.

• Bacterial tracheitis

– Can be difcult to differentiate from croup. – Bacterial etiology (S. aureus, S. pyogenes, H. inuenza, M. catarrhalis). – May be bacterial superinfection after viral laryngotracheitis. – URI prodrome with rapid escalation to toxic symptoms with high fevers,

cough, hoarseness, and respiratory distress. May have productive cough and

odynophagia.

https://t.me/medicina_free

– Lateral neck X-ray may show “candle-dripping sign” (tracheal mucosal irreg-

ularity could indicate exudate/pseudomembrane). – IV antibiotics, humidied air, trail of racemic epinephrine. – Intubation/bronchoscopy in OR with therapeutic removal and culture of tra-

cheal exudates traditionally is required for both diagnosis and treatment, but

in less symptomatic patients, exible laryngoscopy and medical management

may be reasonable.

• Retropharyngeal abscess

– Mixed aerobic/anaerobic bacterial etiology – URI prodrome with slowly progressive sore throat, dysphagia, drooling, and

decreased neck range of movement – Lateral neck X-ray (widening of pre-vertebral soft tissues) vs. CT scan – IV antibiotics—may prevent the need for surgical drainage in small abscesses – Secure airway as needed; possible OR drainage (trans-oral vs.

trans-cervical)

A. F. Karas and J. W. Lee

Pediatric Sinusitis

• Major criteria for chronic pediatric sinusitis

– Nasal obstruction – Purulent nasal discharge

• Other presenting symptoms

– Headache – Chronic cough – Behavioral change, irritability – Halitosis – Postnasal drainage – Daytime cough with exacerbation at night

• Predisposing factors

– Environmental – Allergy – Tobacco smoke – Gastroesophageal reux disease (GERD) – Immunodeciency – Cystic brosis (CF)

Nasal polyps in a pediatric patient suggests CF until proven otherwise.

2 General Pediatric Otolaryngology

https://t.me/medicina_free

– Ciliary dyskinesia – Infections—viral, etc.

• Acute bacterial sinusitis

– Persistent illness (10+ days without improvement) – Worsening course after initial improvement – Severe onset (concurrent fever ≥39°C/102.2°C) and purulent nasal discharge

for 3 consecutive days

• Complications for pediatric rhinosinusitis

– Meningitis – Epidural/subdural/intraparenchymal brain abscess – Orbital complications

Chandler classication

• I: Periorbital cellulitis (pre-septal)

• II: Orbital cellulitis

• III: Sub-periosteal abscess

• IV: Orbital abscess

• V: Cavernous sinus thrombosis

Stage I and II can generally be managed with intravenous antibiotics and nasal saline irrigations if tolerated. Stage IV and V require urgent surgical intervention. Small medial sub-periosteal abscesses may be treated with a trial of intravenous antibiotics with close observation and a low threshold for surgical intervention if clinical improvement is not seen.

• Indications for CT scanning

– Severe illness or toxic condition – Acute rhinosinusitis that does not improve with medial therapy in 48–72h – Immunocompromised host – Concern for orbital or central nervous system (CNS) complications—eye

pain, proptosis, severe headache, photophobia, etc.

• Bacteriology of acute pediatric sinusitis

– Aerobes: Pneumococcus, Moraxella catarrhalis, Haemophilus inuenzae,

Staphylococcus aureus, α-hemolytic Strep, Pseudomonas – Anaerobes: Peptococcus, Peptostreptococcus, Bacteroides

• Bacteriology of chronic pediatric sinusitis

– Aerobes: S. aureus, Streptococcus pneumoniae, H. inuenzae – Anaerobes: Prevotella, Porphyromonas, Fusobacterium

• Treatment of pediatric sinusitis

https://t.me/medicina_free

– Medical therapy: topical steroids, nasal saline irrigations, antibiotics (IV if

complicated acute sinusitis) – Surgical therapy

First line in children with recurrent acute sinusitis is adenoidectomy. Endoscopic sinus surgery has been shown to be effective in children. Patients with CF may require multiple revisions.

A. F. Karas and J. W. Lee

Pediatric Head andNeck Masses

• Differential diagnosis

– Inammatory adenitis – Branchial cleft anomaly – Thyroglossal duct cyst – Teratoma – Dermoid – Lymphatic malformation – Plunging ranula – Thymic cyst – Hemangioma – Salivary gland mass – Malignancy

• Most common neck mass in a child is inammatory adenitis:

– First-line treatment with antibiotics. – Suppurative adenitis likely will require incision and drainage. – Deep-space neck infection may present with neck mass/fullness. – Cat scratch fever:

Bartonella henselae

History of cat exposure Dx: serum titer measurement

– Atypical mycobacterial infection:

Childhood disease, non-tender slowly enlarging neck mass, skin discoloration (violaceous), no pulmonary or systemic involvement, empiric antibiotic therapy usually ineffective (clarithromycin may be effective.) Tx: incision and drainage/curettage, may cause stulization

<<< < Предыдущая 1 23 / 503 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 > Следующая >>>

Соседние файлы в папке Библиотека им академика М.И. Перельмана

#
31.08.202634 Мб0Книга_4506_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202634 Мб0Книга_4507_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202632 Мб0Книга_4510_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202631 Мб0Книга_4512_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202631 Мб0Книга_4517_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202630 Мб0Книга_4518_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202630 Мб0Книга_4520_Библиотеки_им_академика_М_И_Перельмана.djvu
#
31.08.202630 Мб0Книга_4522_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202630 Мб0Книга_4523_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202630 Мб0Книга_4524_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202630 Мб0Книга_4525_Библиотеки_им_академика_М_И_Перельмана.pdf