The ENT issues of adolescence are different from those most often seen in younger children. In this talk for PCPs, pediatric ENT surgeon David Conrad, MD, provides keys to thorough examination of the neck, throat and ear; explains how he distinguishes the swollen tonsils of chronic tonsillitis from those of mononucleosis; discusses head and neck cancers sometimes overlooked in older kids; and gives a lesson in eardrum appearance that will have daily value in the clinic. Included: how to be on the lookout for dangerous complications of sinusitis.
great thank you so much. It's thank you for your time and um it's wonderful to speak to everyone today. I uh sorry about the title change, although I'll be going through a lot of things that are relevant to just common disorders um that we see in both young Children and teenagers and adolescents. So it's a pleasure to talk to you today. So I'll be speaking about common things. Um tonsillitis, para counselor abscess. Uh some less common things as well. Head neck cancers and adolescents and teenagers. And just some red flags to be aware of when you're seeing the patient complications of sinusitis disorders of the airway will of course cover otitis media, ear tubes and nosebleeds as well. And we're gonna start by talking about just infectious and inflammatory diseases of the airway. So this includes a host of various infections from mono to chronic tonsillitis and when and when we don't do a tonsillectomy, we'll start with mono. It's very common. I see this on a semi regular basis. It's often confused with the perry counselor abscess or just executive tonsilitis. But um in fact, we are always on the lookout for mono kind of as a red herring. And um, this is a non surgical problem. We rarely ever need to do a tonsillectomy in the setting of mono, but if you ever have an adolescent or teenager with really swollen tonsils and they have this classic appearance of exhibits on the tonsil. Um, I really recommend doing a mono spot test um and ruling that out before given antibiotics and we kind of see it come in waves. Uh sometimes these patients need to be sent to the emergency department and sometimes they need to be admitted. And I've even seen it where a child needs to be intubated for such swollen tonsils. And again, it's usually adolescents or teenagers. Sometimes a nasal trumpet is enough to bypass the obstruction and you know, can certainly be very severe but often confused with the pair of counselor abscess. So I just want to talk about mono briefly. Next we'll talk about chronic tonsillitis. Um this is less common under the age of eight. Um, but very common and later adolescents and teenagers, chronic tonsillitis is a state of chronic inflammation within the tonsil itself. Oftentimes these patients have stones and uh, it's important to kind of look out for these, uh, they don't extrude out of the tonsils very easily and it's gonna be a perpetual source of inflammation for the patient. Um We rarely or less commonly do tonsillectomy for chronic tonsillitis. Most of the tonsillectomies we do are for Children who have sleep apnea, but there is the subset of patients who just chronic throat irritation. Um Miss school days because of it and it takes about six infections per year for one year, more than five infections per year for two consecutive years, More than three episodes per year for three years where they require antibiotics for us to consider tonsillectomy and then a child who's ever had one or two perry counselor abscesses, they kind of automatically become a candidate for tonsillectomy. And so most of the time I'll treat these patients with two weeks of antibiotics usually Augmentin or kalinda. And oftentimes that will reduce the size of the tonsils and these stones will actually extrude out and it is safe to try to pick them out or use a water pick. Um But surgery is generally a last resort um and Children who are missing school because of this have chronic halitosis that their um self conscious about or just visibly seen these stones back there that is sometimes an indication for tonsillectomy. So if you're seeing stones and someone who has also pain, I do recommend sending them to an E. N. T. To see a tonsillectomy would be helpful. A lot of different ways to do a tonsillectomy. These days we favor an inter capsule er tonsillectomy which is shaving down the tonsils about 90% of the way we're fairly aggressive about how much tonsils were removed because there is a risk of regrowth of the tissue. And um the picture on the right down here is shown using a co glider where we actually remove the entire Tunsil. This works quite well for chronic tonsillitis and it works well for sleep apnea. But in a patient with chronic tonsillitis were more likely to reduce the entire Tunsil for sleep apnea were more likely to shave these tonsils down And um why why shave them down? Well we accomplish the same thing by removing the vast majority of tonsil tissue. But it cuts the bleed rate in half. Which is the biggest risk of the surgery. So we go from a bleed rate from about 4%. Which generally happens a week after surgery. Um down to 2% or even some say 0.5%. So it's rare to get a tonsil bleed if you do the shaving method it's somewhat you know it's not too uncommon to have bleeding with the complete selecting removal. Um so for inter capsule tonsillectomy was introduced in the late 90s actually at Stanford they borrowed technology from orthopedics which is this swiveling blade that has suction on it to kind of munch up the tonsil tissue. And so effectively we're shaving down the tissue. Um the extra capsule er method or total tonsils, tonsils method has been around since the ancient Egyptians and the ble rate is higher and the post op pain is actually much higher. And so in our studies um childhood has an inter capsule tonsillectomy. They usually return to their activities within 5 to 7 days. But total tonsillectomy takes about 10 days for them to return to their usual activities without much pain. So in general I do favor inter capsule tonsillectomy method, patients have to be counseled appropriately on this chance of regrowth and And basically tonsor recruitment after some is left behind the chance that we need to do another surgery related to their swollen tonsils that have returned. It's only about 2% of the time. So only about 2% of patients would have regrowth significant enough to require another surgery. So it's kind of a surgery for the greater good and it's kind of our standard of care here at UCSF the tonsil bleeds are again the most common concern. Um they can be quite severe and life threatening at times again with, with um shaving down the tonsils that risk goes way down. But if you ever seen a patient who's had their tonsils out, you know, we we want to see them for post op and I never want to burden with that. But um from time to time you may come across this um we generally take them back to the operating room or at least admit them overnight for close observation. And a scary thing can happen with these bleeds, which is where I've seen it happen many times. A child will come in who's had a tonsillectomy and they bled a lot at home, but then they come to the emergency room and they're not bleeding. And essentially what's happened is the child has lost so much blood volume that their blood pressure is low and then in the emergency room they get rehydrated fluids and their blood pressure slowly creeps up back up to the point where they can actually bleed again. And so we take this very seriously. We almost always admit them for close observation and bleeds usually happen seven days 7 to 12 days after surgery, that's the most common time. The reason is because the moist scab forms on the tonsil fossa and usually slips off at that time and that can uncover bleeding. So no air travel or anything for two weeks after a tonsillectomy due to that risk of bleeding. And it's something that we don't see as often now with the inter capsule er or partial tonsillectomy method. Perry consular access I think is very relevant for teenagers and adolescents. Um you know, we see this with regularity um you know, it's it can be challenging to diagnose, but really a child with tubular deviation, um interest mus, so a tight jaw and a hot potato voice, that's kind of a perry counselor abscess until proven otherwise. And it usually happens in the setting of tonsillitis that's been either trees are not treated, but um these can be pretty significant and I'd say under the age of eight, we're generally going to the operating room um older than that, certainly a teenager, we will try to do it at bedside and we're pretty, pretty successful with treating that a pair of consular access is a collection of plus beside the tonsil. And so if you can imagine that this great oval is all pus, it actually acts like a mass and shoves the tonsil more medial and that then shoves the villa to the side. And so if you see a bulge on one side of the tonsil area that's generally a pair of consular access and they don't always have to have such deviation. But this kind of tells you why this this kind of happens. And so when we drain a consular access, we generally insert a needle or make an incision dissect down and remove all the plus and they generally feel better right away. And then we'll see this patient for follow up to consider having their tonsils removed because there's an ongoing risk that this will happen again, they're just kind of set up for it. Um And so that's a peritoneal abscess in a nutshell, be fairly rapid fire. And please, you know, ask any questions about kind of more common things. If you ever see a child with a midline neck mass, it's either one of two things. Usually it's either a dermal cyst or a thyroid glassell duct cysts and this is kind of a ticking time bomb these patients, all it takes is a cold and then they can develop an abscess which then has to be drained and then later on we will do something called a Sistrunk procedure where we actually remove the cyst, but more importantly, we remove the central portion of the hyoid bone Um to ensure that the cyst doesn't want to come back because they're generally attract associated with it. One little trick that can do is to have the patient stick out their tongue and if you see this lump elevate, that's a sign of a thorough glassell duct cyst. If it doesn't really elevate with tongue protrusion, it's often a dermal cyst treatment is effectively the same. It's really surgery and this can remain dormant and appear, you know, at age 30. But usually we're seeing it from age 5-18 in that range. Let's talk about thyroid and endocrine disorders of the head and neck in this patient population, it's kind of rare. But some of our patients have thyroid goiter and often often there's a family history of it. This will be kind of a slow, relentless growth of the thyroid gland that becomes visible. And so sometimes a parent will come in and and see it's just say that the neck looks fuller. And um sometimes the patient has difficulty with swallowing will often do a biopsy, a needle biopsy and we have Jacqueline weinstein who's a wonderful thyroid surgeon here at UCSF, she's mostly on the Children's Hospital Oakland side. But we both cover Mission Bay as well. These are really interesting cases for us. But there's somewhat less common but really you do want to check the central neck of the uh in any patient to see if you're feeling any fullness around the thyroid gland itself. We do see well differentiated thyroid carcinomas papillary is one of the most common um You know, I like to think of these in age groups. So a child, you know at three years old with a neck mass that's more likely to be reactive when fat, no empathy. But as they age and a neck mass in a 14 year old is really concerning for most likely papillary thyroid cancer. It could be a reactive node but their immune system is much more mature at that time. So a neck mass in an older child much more it's always concerning but much more concerning um than a younger child who's just going through the throes of um you know, development in their immune system. And so we're always on the lookout. We do a very thorough neck exam. Um I run my fingers along the external quantum asteroid muscle bad things generally happen in that region and and thorough neck exam is you know, always always important. Any child with a neck mass that's been there longer than four months generally deserves evaluation by an E. M. T. To rule out, you know, a host of different things. Um A lot of lot on this side here. But in general popular thyroid cancer is likely to spread to lymph nodes. However that spread doesn't seem to impact their own survival rate which is well above 95%. Very treatable cancer. Um and there's very there's variance, you know, some are more aggressive but really we remove the entire authority Gland vocabulary and sometimes we'll do a lymph node dissection for this as well. Medullary thyroid cancer, you know um can be associated with M. E. N. two a.m. E N. Two B. We don't see this as often but sometimes we do fortunately at UCSF. We are we have a wonderful relationship with our adult colleagues and who see this with kind of regularity. And so sometimes we'll team up with our um U. C. S. F. E. N. T. Oncology surgeons to manage these and they get excellent care that way. Let's talk about malignant cancers of the head and neck um besides thyroid cancers. So we split the head and neck into various cavities. Um So nasopharynx at the back of the nose. Oral pharynx is from the tonsils down to the base of the tongue. And hypo pharynx is essentially below the base of the tongue. Down to the voice box. Oral cavity is everything you see when you open your mouth, Behind the tonsils is the oral pharynx. And there are small salivary glands on the floor of the mouth and of course the nasal cavity and sinuses right by there. Let's just talk about squamous cell carcinoma. This is thought to be a disorder of you know adults who have smoked or drink and um but we actually see it in Children and it's easy to miss and kind of undervalue. Um you know I've seen some some really kind of sad cases of this throughout residency um in Children who are 16 and have a squamous cell carcinoma of the tongue and their survival rates aren't actually that great and it can be very difficult. Um So just be on the lookout for any kind of zebra like that. Um because squamous cell carcinoma can be triggered by HPV. We're seeing a decrease in rates of this with vaccines, but HPV associated tumors, you know, a child who's 18 hasn't had a chance to kind of injure their mouth due to decades of smoking or drinking. And when we see a child with squamous cell carcinoma, it's really likely to be caused by HPV. And um these tumors actually do much better than a patient who has a tumor due to smoking or drinking um or both, which is synergistic. And so they do quite well. And at UCSF we have such a tremendous cancer center um with our adult colleagues that we can really manage these quickly and effectively. Um HPV is uh you know, causes um issues throughout the body obviously and and in the mouth certainly and it's usually the sides of the tongue or tonsils that will get affected. So we tend to catch these in the early stage usually. And then just surgery um is effective if there's positive margins will receive multi modality therapy of chemotherapy and radiation. Um here's a picture of what a typical squamous cell carcinoma could look like. Um one of the first signs is just halitosis, very bad breath, a non healing sore on the side of the tongue. Um We would biopsy this potentially in clinic because it's usually fairly numb or take them to the operating room. We can get an answer very quickly and um again some of these patients need uh quick surgery. One of the saddest cases I saw was a 16 year old male who um had a growth on his tongue, didn't tell his parents for about eight months and it eventually grew into his job and um the entire tongue had then you know, there's a bit of denial going on and obviously it's it can be difficult. I've seen also people hiding neck mass from their parents with their with long hair for eight months. You know, Children will do things to kind of conceal. Um But you know that patient ended up passing away after very difficult surgery and it was kind of non survivable. So rare things can still happen in Children especially as they get older over the age of 10. We start to get worried about any kind of um lesion in the mouth and want to biopsy rob sarcoma is somewhat rare but we actually see it from time to time. We have a patient right now admitted who had a very difficult sinus rhabdomyolysis. Sarcoma. Um You know these these patients um I have to be treated aggressively. The most common sight is the I second most common sight is the head and neck and sinus and so bleeding facial swelling, nasal obstruction, those kind of things. While common things are common, we always on the lookout for anything strange. And we use a fiber optic camera to search the nose or any tissue that looks abnormal. It's just part of our general work up. There's this thing called a juvenile nasal for angel Angela fibromyalgia and this is only happens in males were always on the lookout for this, especially in teenagers. So especially bleeding from one side in the setting of nasal blockage. We really want to scope them to make sure that they don't have this tumor, which we see starve all year. You know, 5 to 10 actually on both sides. Mission Bay and Children's Hospital Oakland. So we'll generally scope any male who's having nose bleeds over the age of 10 and adjust to relate this type of tumor. Um Usually surgery is effective and then after puberty, they often regress um switch gears and talk about the sinuses and the and the nose, the nasal cavity. We see a lot of sinusitis. Um It's and you know, it can happen quickly generally where a patient and this happened in younger patients as well will wake up with a swollen eyelid and um a little bit of redness over the eyelid. It's usually in the setting of a cold. Um This can progress all the way from just a little bit of cellulitis around the eye to causing a cavernous sinus thrombosis where the infection actually goes posterior and starts to irritate the veins and then cause a complete thrombosis. Um And these patients are most of the time admitted and treated with antibiotics. But I will say the adolescents and teenagers, they do much poorer than the child who's three or four with this and often times they do require sinus surgery to drain the sinuses. Um Here is a CT scan of a patient with what's called a sub periodical abscess. So you can tell that the patient's left eye it's gonna flip on the cat scan. Left eye is prop topic and bulging out more. The reason is because they have developed an abscess that's effectively pushing the eyeball out. And so what do is clean out the sinuses in between the nose using small cameras and small tools and then drain that abscess. And they do very well. But any child with a swollen eyelid and the setting of a cold is generally a sub periodical abscess or orbital cellulitis or orbital abscess until proven otherwise and it can be fatal. Um especially in teenagers who do not as well as um you know with two or three year old. So we take this very seriously. I recommend sending into the emergency room if you ever do notice this, they can also get an epidural abscess. We see this in teenagers who have their frontal sinuses When you're born, you only have a thyroid and maxillary sinuses as you age you start to get a frontal sinus, especially during puberty. Sometimes that doesn't um drain very well. And so these patients can get what's called Potts, puffy tumor where their forehead bulges out or they're having frontal headaches. Um, and these patients are, are prone to frontal sinusitis, which is a big deal and a teenager. And um we take it very seriously and often offer surgery because there is such a risk that that infection can spread into the brain and cause a walled off abscess. There's this thing called allergic fungal sinusitis. It's kind of strange, you know, if you've never dealt with it, you really wouldn't know about it. We see this a lot in the central valley, so around sacramento and we're a bit different kind of climate. Um and different spores floating around were subjected to uh fungal spores every day as we breathe. But some people have a vicious reaction to those spores and they create this kind of stuff called allergic musician and nasal polyps. And this news in that we call it is almost like peanut butter. And when we scope someone, we're always on the lookout for it. Um, these patients generally need surgery, antifungal, do not work and um it's just kind of an interesting thing that we see um with fair regularity actually. Um, this can happen in adults by the way. It's actually quite more common in adults. But um, it is something that we see from time to time. This is what allergic fungal sinusitis can do. This isn't like a fungus ball or anything. Although that can happen. It's more the body's reaction to the fungus and they create this thick musician that then kind of expands the bone. And so here's a normal and it generally happens on one side. So here's a normal sinus anatomy. Here's the maxillary sinus and that music can generally drain. But what happens on one side is just starts expanding. You can see the difference between this width and this width right here. Um And so these patients need surgery and again nasal scopes are really important to identify this. There's also this thing called invasive fungal sinusitis music or psychosis or aspergillus. Um And for your uncontrolled diabetics there are some risk for this and it is so aggressive and and the mortality rate is actually quite high. So it's usually in the setting of a child who has uncontrolled diabetes. Whatever reason with high blood glucose and blood levels. And um that puts them at an immuno compromised state. They can then get new core psychosis or aspergillus and that can eat away it's essentially a flesh eating organism. It will just borrow you know tunnel and invade and we have to get all of it out to improve the chance of survival. The saddest case I ever saw. I saw a child on a thursday. I was doing a rotation at U. C. Davis. The child came in on a thursday with you know, sugars in the seven hundreds basically. DK but looked well. Actually. All you had was a little bit of swelling in the face. They diagnosed invasive fungal sinusitis and that patient passed away within 72 hours after a massive surgery. Um It has spread to the brain at that point. So it's just you know, something to be aware of especially in uncontrolled diabetes. And also any patient who's had chemotherapy will scope them. Will biopsy will get an M. R. I. And then go to the operating room if you really suspected what you tend to see is just complete necrosis and death of tissue. Um And sometimes you see you know kind of fungal elements. Um And it's something that we take very seriously. We're always on the lookout for let's talk about nasal polyps. Um polyps are common in the adult population. If we see a nasal polyp in a child, our next test would be assisted fibrosis. Study to see if they have CF. Because it's they tend to go hand in hand and you know at UCSF we I think all have a slew of polyp patients that we follow. Um these actually have to be removed but they tend to grow back quickly. So a medicine called depiction is often helpful and also allergy therapy will help these are non cancerous growth but they're very problematic. They block the entire nose. They often cause sleep apnea and they're just really uncomfortable. So um sometimes we'll get you know when you open the nose or looking at you'll see a turbine it, right and that's a normal structure or conscious. Some people say normal structure and that is not a politician. You know that question polyps um tend to look different than the turbine. It's and they're kind of these like translucent things and they kind of grow like a bunch of grapes from the top of the nose down. And these patients do really well after surgery because it just, you know improves their nasal breathing so much so now we'll go to the adolescent airway. Um look at that kind of larynx and airway type of disorders. There's something called recurrent respiratory papilloma ketosis. This is the same type of papilloma that can involve the um you know, vagina or penis or anywhere, frankly. Um it's HPV types six and 11. Um most of these cases actually present before the age of 15, they think it's contracted during delivery. Um so in C section does seem to be protective. However, they don't recommend C section just for papilloma on the mother. Um and so it's very sad. These papilloma will coat the entire voice box and oftentimes these patients will be sent to us thinking that they are going to Malaysia which is the number one cause of strider. Then we scoped them and we find these papilloma growths on the voice box around the vocal cords and we'll take them for removal because they need to breathe better. And then sometimes we'll administer the HPV vaccine which creates an immune response to help fight the papilloma. But we'll use a C. 02 laser to laser this material off and they may need surgery about five times a year and then generally these regress over time. But some patients have ongoing issues and need to see any anti essentially for the rest of our life to kind of manage this as it comes and goes. And um again treatment this is the case that I did with the C. 02 laser. We had papilloma growing here and onto the sides of the vocal cords. Um Their voice will be really affected by this. So a child who is having breathing difficulty which can happen as soon as three months after their delivery. Um And also a weak cry. Over the course cry will always scope them um to look out for this and of course diagnose scoring Malaysia or whatever else could it be. Um We tend to not do a tracheostomy because that can actually see the lower airway with papilloma. And what can be scary is that the papilloma may want to grow down into the trachea and then it grows into the bronchus bronchus and then it's kind of hard to reach that and that's that's kind of it can be very scary. So we want to treat these patients aggressively to limit the spread, There's this thing called paroxysmal vocal chord motion or pseudo strider and we'll see this in Children who are over the age of 12. Um it's more common in females than males and we tend to see it with certain personality types, it can be a manifestation of anxiety um but if you think about it, you can create your own sound of strider, like I'm doing it now, you can actually close your vocal cords and some some people um you know, it's kind of like a conversion disorder um basically almost like a panic attack where um you know, adolescent, a teenager will do an event or something or you know, um be at a track meet and then have just uncontrollable strider. Um and that can happen anyhow, we want to make sure that there's nothing more serious going on, but oftentimes when we see them in our clinic will ask them to replicate the strider or if they're having an episode then and what we'll see is paroxysmal vocal cord motion with chords actually close when they're breathing in, when they actually should be open and and then we'll talk to them, you know, in a very good way about supporting um you know, their issues and if they have any stressors in their lives and and kind of a comprehensive um evaluation about it and um these patients do very well and you know, we want to make sure there's nothing else more serious going on but it's good to diagnosis with a scope exam. We're gonna switch gears now and talk about ears. Um which is obviously so common for us. It's one of the most common complaints. Um You know in your ear tubes are the most common reason. A child still receives anesthesia in the United States, although we look for ways to avoid them. I try to talk patients out of surgery all day. Um But Youtube's just sometimes there's nothing that replaces you know getting a tube in the ear drum and equalizing pressure and moving fluid. But um you know we see different disorders of the ear canal but um it's really important to get a good look at an ear drum and you can think of the eardrum as kind of like frosted glass or a hazy window that you kind of look through and see certain things. And one of the best um One of the most useful things is determining if there's fluid filling in the middle ear space or not. And you can do that with a timpano graham. You can do with um by using the pressure and squeezing the bulb and seeing if the eardrum moves and but I think S. E. N. T. S. We often just look at the eardrum and we kind of have this like sixth sense where we can just see if there's fluid on the immediate other side of it. Sometimes you see a little air bubbles and sometimes not. Um and sometimes you see a kind of a dull yellow appearance to it. So we get pretty good at deciding if there's fluid or not and then we'll do a sonogram to confirm. But if you're, you know, by by definition, if you have an ear infection, your middle ear is filled with pus and that patient has lost about 20 decibels of hearing and I'm sure this has happened to everyone or you know, you fly with a cold or something and then kind of ear fluid sloshing around and feels dull and then over time get your pops and you clear the fluid and doesn't necessarily hurt, but it's uncomfortable. So we've all had this happen to us uh different times and so um you know, an ear infection is painful, but what can also happen is kind of a silent ear infection where it's just middle ear fluid infusion and it's, it's like mucus and called, you know the old terms glue here because literally when we're doing a tube and suction out the fluid, it's so viscous, it's almost like sucking honey out of the middle ear. It's just like strands of it are coming out and it's really good to do a thorough exam. We don't rely on the light reflex as much. But um you know, here looks, this looks like a garden variety eardrum, but just looking at, you know, I can tell a lot of things, I automatically know that this is a right ear drum because Marius is slanted back. We have this fold here where the temporomandibular joint is inside and um you can think of it in quadrants, so anterior superior, anterior inferior, um posterior inferior, posterior superior. I'll say that the business end of the ears and this quadrant and what you're seeing is the tip of the iceberg. Um This is the malice, but actually the bulk of the malice is actually up here behind this tissue called the far. Um This is the past tense apart classes. So you're seeing the tip of the iceberg and here's the Marius, here's our good light reflex which is it's kind of a guide for us but is useful. Um And I can see that this is the focus. And in my mind's eye I can imagine that this is a core of the state. These actually. And let me see it but this right here could be the court of tympani nerve carrying taste fibers to the anterior third of the tongue. Um I can tell that this is a cochlear promontory. I see a deep shadow here and I think that that's a new station tube where it is. Um And this is probably tensor tympani right here. So we'll take our time and really look at the ear and it's just you know, we see so many eardrums and um of course we have to clean out wax to try to see it. There's nothing like seeing the drum for yourself. Um and do the best you can with that. It can be hard, you know, we try to kind of sneak around earwax, but norman knowing what a normal ear drum looks like is so helpful and kind of being systematic about it and see what we can see and what we can't by understanding that most issues are up up in this quadrant, like cholesterol, toma and other things. And then we tend to put a tube here because it's the safest area. There's not much to hurt on this side of the drum, but there is a lot if you put a tube here, you could make someone death by pushing down the ST bees and pushing it into the inner ear. So we always put our ear tubes down here. Sometimes he's migrate with time. Um and that's okay, but that's why we put it to in the anterior inferior quadrant of the some other photos of ear drums. Um Again, you see how the malice and pincus are above the level of the ear drum, that's because it's a lever. Um and we get a, you get a kind of a mechanical advantage, here's the state peace and it's like the strip. Um and so we'll be able to see these structures uh pretty well actually. So we can even see it better when someone's ear drum is effectively gone. This is a child who probably had lots and lots of otitis media eventually burst the eardrum. The eardrum got so thin and just never regroup. But here's the Incas down to the stay peas and here's the malice and this is their cochlear behind this dense bone is the cochlear to um And this is the oval window. I'm sorry round window and this is connected to the oval window. And um this little nerve is the reason that when your ears hurt, your throat might hurt when your throat hurts. You might get referred to tal jah this little uh Jacobson nerve part of the glass referential nerve. It's kind of interesting to see. And again sorry this is the new station tube down. Um So you stationed to dysfunction is the root of all your issues. It really is um If you were to compress the station tube it only takes about 10 minutes for your middle ear to fill up with fluid. And so pressurization or constant equalization of pressure is really important for patients and you know we're chewing or swallowing or yawning and our ears are always equalizing pressure. But for younger Children who don't have great communication here, they tend to fill up with fluid and no this doesn't need antibiotics or it's not an infection. It's just a simple infusion. But over time this will deaden the vibrations of the eardrum enough to cause hearing loss which then can result in speech delay and it comes in different flavors. Some fluid is thin and they tend to create little air bubbles and some is thick like thick like honey glasses and that's called blue here. Um, and then here's a normal ear drum. And so we'll be looking out for a little air bubbles. We'll be looking out for kind of a dull yellow appearance, the eardrum risk factors for otitis media. Secondhand smoke for sure. It's really impressive how much how irritated that is. Even just on clothes and you know, that could be marijuana smoke or cigarette smoke or um even infant like that or wildfire smoke pacifier use the negative, the constant suckling creates negative pressure that then closes off collapses the station tube and that's why they fill with fluid of course daycare. Um just such a strong um relevance, absence of breastfeeding and the family history of your infections. I'll ask a mom or dad, you know, um if I see glue ear or middle ear effusions, you know, did anyone else have your tubes in the family? About two thirds of the time it's either, oh, I came really close to your tubes or Yes. You know, my my husband had ear tubes, you know, two sets of them And family history is actually really strong. Let's talk about tIM panic, membrane preparations. Um, you know, these holes can be different sizes and shapes, but sometimes someone we're missing the entire ear drums, sometimes just a little bit most commonly a patient had ear tubes and it's you know the double edged sword of your tubes every time we put a tube in we're disrupting mother nature. We're putting the tube within the eardrum. That tube eventually extruded out over the course of a year, year and a half. But what can be left behind in about 5 to 10% of patients are as a whole and sometimes these clothes on their own but they have to be small if they don't close we will offer a surgery um called the Marengo Classy or timpano. Plasticky. Sometimes we put fat in this area and it's amazing how well it works. It just integrates and heels and it's like you could never tell that anything was done. And then other times we use a synthetic graft to create um to cover the hole and sometimes we pick up the eardrum and slide it underneath. It's called underlay graft. But a preparation, Well you can go on in life with the preparation, it's likely to cause at least a 20 decibel hearing loss, wind is gonna be uncomfortable. You know this person is never gonna go sailing or anything, we're gonna cover their ears if it's windy um and drainage. So if water gets in it can cause a broth for bacteria to grow and then they get past straining out of your ear. Um it's unlikely to ever go kind of like death from this or anything it's conductive hearing loss. But we want to treat preparations if if they're happening. So yeah, what we'll do is often put on the graft and sometimes we'll borrow fashion from above the scalp, the scalp area and to re create a new eardrum. It's amazing how well it works. It's incredible. And if you have a small perf, let's say a child has otitis media, they rupture their drum Plus leaks out, they get treated it dries up 90% of the time that's going to close on its own. But if that happens like six times the urgent will get so thinned out, it just doesn't care to repair itself. It can't even, it doesn't have the blood supply anymore. So sometimes they will need surgery to repair that. Let's talk about something called cholesterol toma. Um This is kind of rare and you know, I'm not sure how familiar you are with it, but it's it's something that we're always concerned about, especially after the age of 10. So a child who comes in who's three years old and there has been draining um that's less, much less likely ACL esta toma. But boy a 14 year old coming in with a draining year that's a cholesterol toma until proven otherwise, especially if it's been going on for months and especially if it doesn't hurt. And so this thing called a classy toma is always concerned, patients can be born with it. And of course we see this kind of white pearl mass within the number behind it. The patients can also develop it. And these patients often are ones who have had ear tubes, multiple tubes. They've always had ear troubles. This is this white kind of cyst material that can develop and then once it's there it doesn't it's not cancer but it kind of behaves that way. It will just kind of slowly erode bone. It can cause a paralyzed nerve. It can go up into the brain and cause meningitis. And these types of patients have often on drainage for years. Generally in the trio drops dries up and then come back and of course have hearing loss. So we'll need to do a timpano timpano mastectomy. It's we have to get rid of all of it. Otherwise they'll come back and sometimes it requires 2 to 3 surgeries and patients generally temporary lose hearing until we put in the titanium prosthesis to recreate their hearing bones. And so you know this can be hard but the telltale sign is if you see just wax that's always stuck on the eardrum or just it looks really funky. You don't have to see this pearly mass. It can just be dark crusting as well, especially over the age of 10. That's a concern. And the patient had a lot of ear problems earlier on. That's really a concern. So we do a surgery for these generally called a mastectomy. We make an incision behind the eardrum. We have to drill down, we avoid the all important facial nerve during that and nerve monitor. It's a pretty intense surgery but we do it a lot here at UCSF. So we're gonna switch gears now to something more common at the stacks. Is very common in hot weather and also in the winter when the heaters turn on and dry out the air. Um we see this especially on the east coast, but basically 90% of the time it's happening on the septum in the front of the nose. And the reason is there's a rich blood supply there. Um and sometimes it does happen in the back of the nose about 10% of the time. But common things are common. It's usually just a normal child who has a dried out nose. Either from a slightly deviated septum or they're just kind of prone to this. Um and we will do various things. So I think it's kind of a stepwise approach. Um If you pinch on the top of the nose over the bones that will never do anything that you have to do is slide your fingers down to the soft part of the nose near the nostrils where it can collapse and effectively what you're doing is squishing the nostrils against the septum to hold pressure and that and chin down to to allow the blood to collect. And then you can gently try to blow it out or unfortunately swallow it. But pinching down here rather than up here, it's critical and gosh, if we did an education campaign for all the United States and everyone knew where to correctly pinch. I bet we've watched our nosebleed rates go way down and so most people are mistaken about up here and ice. I don't think there's anything. Unfortunately, it's really just pressure for five minutes by the clock shin down. Try to calm them down, try to get their blood pressure down and that generally takes care of it. Um We'll use nasal decongestants like Afrin sometimes, but really humid. Ification is the name of the game. So after band appointment for two weeks is really effective because oftentimes these patients have um a concurrent staph colonization which is causing a festering state of the anterior nos. So we'll treat them with Bactrim and which also hydrates the septum and then a saltwater spray and then the humidifier in the bedroom will be helpful. Yes, we do pack the nose with various things if if it's really that severe, although I have to say it's not common that we need to pack and we can also put in dissolvable um medication called Flonase which is has thrombin in it, which often helps. And so um you know, if a patient comes in, we have a stepwise approach, we can do surgery on this. Sometimes we use laser sometimes just bipolar Kateri and then we'll do pottery in the office as well with silver nitrate and I'd say after age seven, those are the patients who can tolerate it. We spray the septum with lidocaine to numb it up and then do a silver nitrate colorization in the on the same day as the appointment, it's often effective and it usually cuts bleed rates by half. So um and I've kind of blown through our our talk and we'll have some time left. Um But my conclusions are, you know, um a thorough head and neck exam is really important. Um You know, be systematic about it. Um A lot of things can present in the head and neck, you know, from the clavicles and above. And a good ear exam is also really important. Um So you know, sometimes if you get an ultrasound that's really helpful if there's a neck mass and we have that to read. Um We'll often order a ct and lab work to look further into something and then recognize the middle ear pathology early can save hearing in the long run and so that might be a questa toma or preparation or a patient just has had a lot of ear drainage um or patients who is just getting a lot of ear infections the sooner that we can address that um it sets them up for success down the road because a lot of patients turn into what we call a chronic ear and that is just essentially ear drum or middle ear that's just draining fluid that doesn't have a chance to heal. Um That's already been perforated now that's already having hearing loss and the ripple effect of hearing loss and a child is vast. We see it all the time. A child who is acting out who isn't isn't connecting well with peers who feels isolated, who has to go in and out of the doctor to have ear infections treated. Um You know we see in adults the rates of depression, anxiety and people with hearing loss for a child who's trying to connect with others who might be hard of hearing, who might get treated differently by parents and others parents and teachers who is kind of you know a difficult child. First thing we look at is the ears. Second thing we consider sleep apnea or a. D. H. D. Behavior and so middle ear stuff and just your disease is just so important to um to recognize that we can and so a red flag a good general rule is any child has had more than three year infections in six months, more than four ear infections in one year. Um They should be seen by any anti because that's rare. It's not rare but it's really not ideal. It's gonna interrupt their speech development and therefore their self esteem most likely and ability to communicate. I really think globally about the child. Um I really like to kind of delve into the psychology of it and talk to parents a lot about that. Um It's just kind of an interest in mind. So we really try to personalize our care and um and obviously take good care of our patients and just some basic things about any any time you're really worried about a patient's airway um you know uh breathing, you know abc is obviously and we deal with a lot of airway issues. Um and so any time you feel that a child is really working hard to breathe um or whether that be in Malaysia or you know paris is more vocal cord motion, a teenager whose squares that they can't breathe. Well we often can that out either between us or demonology and we work closely together. Um And so you know I'll kind of wrap up there and I'm more than happy to talk about just my thoughts on you know, my one second blurb on tongue, tie your tubes, tonsillectomy, anything. So it's all fair game. And I do have a team slide that I wanted to share. Um We have a wonderful pediatric division and it's not just me, obviously it's um we have Dylan chan who is our main hero surgeon for cochlear implants, dr josephine checa Wittes via Jacobson, our former fellow Jordan verbals who heads our cranial facial team or the anti aspect of it dr liu who does a lot of head and neck cancer surgeries um on a meyer who also does cochlear implants and garden Nadarajah, our section chief and Christina Rose, br division chief and then Jacqueline Weinstein who does a lot of thyroid surgery as well. So we have it really all of it covered. And we have a new addition, Grace Panic who just joined us as well. So it's a big team with a large collective mind and we really enjoy seeing anything. We're really not above any kind of E. N. T. Disorder in a child. So um while we do complex surgeries and perhaps like those more, you know happy to see your issues that don't even require anything. So I just want to make sure you all know that and thank you so much for allowing me to speak to you today. I'll take any questions.