Otolaryngology

Nasal fractures are one of the most common facial fractures in the pediatric population. The decision to perform a closed reduction procedure in the operating room is based on factors such as breathing difficulty and external deformity, which are not assessed effectively by x-ray. Plain film x-rays are unable to accurately evaluate nasal fractures given its low sensitivity and specificity, at 72% and 73% respectively. Physical examination is often sufficient to make a diagnosis for children with displaced nasal fractures. Overall, x-rays do not add value to the diagnosis or treatment plan for children with nasal fractures and should not be ordered to avoid their associated costs and radiation exposure.

Acute bacterial sinusitis (ABS) is a diagnosis that is made based on clinical criteria and has a low prevalence amongst children presenting with respiratory symptoms. Although a normal radiograph, CT, or MRI can help to rule out ABS, an abnormal result does not confirm the diagnosis. Given that many children will have abnormal imaging due to a viral upper respiratory infection during certain times of the year, combined with the potential for exposure to radiation, routine imaging is not recommended. Instances in which imaging would be warranted include if the child is immunocompromised, or if orbital, central nervous system, or other suppurative complications are present.

The American Academy of Pediatrics recommends diagnosing pediatric ABS when (1) cough, nasal discharge or both are persistent for >10 days without improvement; (2) there is worsening or new onset of cough, nasal discharge, or fever; or (3) there is a severe onset, with a fever greater ≥39℃, concurrently with purulent nasal discharge for at least 3 consecutive days.

Although tympanostomy tube insertion can be associated with short-term quality of life improvements, the natural history of otitis media with effusion (OME) is sufficiently favorable and most OME in children will spontaneously resolve within 3 months. Cases of OME which last longer than 3 months are typically chronic in nature, and less likely to resolve without intervention. Limited data exists regarding the efficacy of tympanostomy tube insertion in children with OME for less than 3 months. By delaying the consideration for tympanostomy tube insertion, potentially unnecessary procedures are avoided, along with the associated risks, tube related side effects, and costs. Children excluded from this recommendation include those who have risk factors for developmental difficulties such as trisomy 21, Autism-spectrum disorder, blindness, and permanent hearing loss independent of OME.

In most cases, medical treatment using antihistamines, decongestants, systemic antibiotics and steroids have shown little to no effect on the long-term outcomes of uncomplicated otitis media with effusion (OME) in children. Because of this, and the costs and potential side effects, it is not recommended to prescribe these medical treatments for children with uncomplicated OME. The exception to this would be for children with coexisting conditions in which these medications are indicated for primary management.

The use of oral antibiotics where they are not necessary can promote antibiotic resistance and increase the risk of opportunistic infections. Topical antibiotics achieve higher concentrations in the ear canal, demonstrate improved patient satisfaction, are associated with fewer adverse events, and are shown to have equal efficacy for treatment of acute tympanostomy tube otorrhea (TTO) and acute otitis externa (AOE) when compared to oral antibiotics. For these reasons, topical antibiotics rather than oral antibiotics should be prescribed as first line treatment for acute uncomplicated TTO and uncomplicated AOE.

Codeine has been associated with a high rate of adverse drug reactions in children. This includes life-threatening respiratory depression. Appropriate dosing of codeine is challenging due to the genetic heterogeneity amongst patients for the CYP2D6 enzyme, which is responsible for codeine metabolism. Genetic screening of CYP2D6 is not routinely performed and can not reliably identify variations in codeine metabolism rates amongst patients. As such, children who are ultra-fast metabolizers of codeine are placed at increased risk of severe adverse drug reactions. Alternative analgesia should be used post-tonsillectomy/adenoidectomy.

Administration of perioperative antibiotics for children undergoing tonsillectomy shows no significant benefits in regard to common post-tonsillectomy morbidities. Overuse of systemic antibiotics increases bacterial resistance and the risk of adverse drug events unnecessarily. These concerns outweigh the reduction in postoperative fever which is the only potential benefit of perioperative antibiotic administration for elective tonsillectomy. Therefore, perioperative antibiotics are not indicated for children undergoing elective tonsillectomy, unless specific indications are present (e.g., cardiac conditions or those with a peritonsillar abscess or acute infection).

For children who have a lower number of recurrent throat infections, tonsillectomy has significantly less benefits when compared to those with more frequent infections, and many children with recurrent throat infections naturally improve without intervention. Therefore, where safely possible, avoidance of tonsillectomy for children with lower numbers of acute infections is recommended. This avoids unnecessary tonsillectomy and the costs and complications associated with the procedure (i.e., bleeding, pain, infection). If tonsillectomy is not indicated, children should be closely monitored and reconsidered for tonsillectomy if the infection frequency increases, as they would be less likely to naturally improve, and more likely to benefit from tonsillectomy. Families should be counselled on the limited benefits and potential harms of performing tonsillectomy for children and adolescents with low rates of recurrent throat infections. Shared decision making is of importance when considering tonsillectomy as individual patient and family factors can impact the decision.

While endoscopic sinus surgery (ESS) has been found to be an effective therapy in children with chronic rhinosinusitis, comparable outcomes can be achieved with medical therapy and adenoidectomy. A stepwise approach of medical therapy, progressing to adenoidectomy, then to ESS allows children to be treated with a less invasive and more cost-effective interventions as initial therapy, while saving ESS for those who are refractory to primary interventions. Maximal medical therapy should be exhausted prior to surgical intervention for uncomplicated patients. In cases with complications such as orbital or skull base involvement, ESS can be employed more readily.

Waste in procedures from reusable surgical instruments and disposable surgical supplies can be reduced through tray optimization. Tray optimization aims to only include surgical instruments and supplies that are necessary and remove instruments and supplies that are rarely or never used. At one hospital, optimizing tonsillectomy/adenotonsillectomy trays was projected to decrease annual waste by 1.48 tons and save $830 in waste disposal costs annually (Penn et al.). In a 2023 UK study, which looked at five of the most common surgeries, the three highest carbon footprint contributing products for tonsillectomy included the single-use instrument table drape, single-use suction tubing, and reusable tonsillectomy set container (Rizan et al.) Most studies in the Otolaryngology-Head and Neck surgery literature on surgical instrument tray optimization have focussed on tray size reduction, improved OR efficiency metrics, reduced OR and turnover time, reduced tray processing and rebuilding times, and cost reduction/savings. Carbon footprint savings can be extrapolated from these results although it may not be explicitly stated in the present studies.

The prevalence of a bacterial infection during acute rhinosinusitis is estimated to be 2%–10%, whereas viral causes account for 90%–98%. Management of viral rhinosinusitis is primarily focused on symptomatic relief, which may include use of intranasal corticosteroids, analgesics, nasal saline rinses, oral or topical decongestants, and mucolytics. Antibiotics are ineffective for viral illness and do not provide direct symptom relief. Despite this, 82% of Canadian patients diagnosed with acute sinusitis received a prescription for antibiotics. Differentiating viral rhinosinusitis from acute bacterial rhinosinusitis (ABRS) is challenging because the symptoms are overlapping, but is critical to avoid inappropriate antibiotic prescriptions.

The “PODS” clinical criteria suggest ABRS with two or more of facial Pain/pressure/fullness, nasal Obstruction, nasal purulence/discoloured postnasal Discharge, decreased/absent Smell that persist for more than 7-10 days (Canadian Clinical Practice Guidelines for Acute and Chronic Rhinosinusitis for full details). A bacterial infection is so unlikely prior to this timeframe that antibiotics generally should be avoided unless symptoms have persisted for at least 7 days.

In patients who meet the criteria for ABRS with mild or moderate symptoms, intranasal corticosteroids alone are often sufficient. Antibiotics can be considered for patients with severe symptoms or those who fail a 72 hour trial of intranasal corticosteroids after the diagnosis of ABRS* has been made.

*This table outlines how ABRS diagnosis requires the presence of at least 2 persistent or worsening symptoms.

Radiographic imaging for patients presenting with uncomplicated acute rhinosinusitis to distinguish acute bacterial rhinosinusitis (ABRS) from viral rhinosinusitis is not recommended, unless a complication or alternative diagnosis is suspected. A sinus CT scan is a highly sensitive test for rhinosinusitis, and a normal study confidently rules out active sinusitis of any etiology. However, abnormal sinus CT imaging findings, including air-fluid levels, mucosal thickening, and complete sinus opacification, are nonspecific and can be seen with both bacterial and viral sinusitis, as well as in up to 42% of asymptomatic healthy individuals. In a prospective study of healthy young adults experiencing a new cold, CT scans showed that 87% of the subjects had significant abnormalities of their maxillary sinuses. Therefore, in acute rhinosinusitis, a CT scan has minimal utility because its findings are not specific to a diagnosis of acute rhinosinusitis, and does not help guide the need for antibiotics since it cannot reliably distinguish viral from bacterial rhinosinusitis. Consider CT imaging of the sinuses when a complication of ABRS is suspected based on severe headache, altered mental status, facial swelling, cranial nerve palsies, proptosis of the eye, or other clinical findings.

Plain film x-rays of the sinuses should not be ordered in the work-up of sinusitis. Plain films have poor sensitivity and specificity and they cannot be relied upon to confirm or reject the diagnosis of either acute or chronic sinusitis. Findings such as air-fluid levels and complete sinus opacification are not reliably present in rhinosinusitis, and cannot differentiate between viral and bacterial etiologies. The complicated anatomy of the ethmoid sinuses and critical sinus drainage pathways are not delineated effectively with plain films, and are inadequate for operative planning. Given that the findings of a sinus x-ray cannot be relied upon to diagnose rhinosinusitis, guide antibiotic prescribing, or plan surgery, they do not provide value in patient care and should be avoided.

Acute bacterial rhinosinusitis is a clinical diagnosis that does not require proof of a culture-identified pathogen. When patients meet criteria for uncomplicated ABRS, empiric antibiotic selection should be based on typical causative pathogens (i.e. Streptococcus pneumoniae, Hemophilus influenza, Moraxella catarrhalis, and Staphylococcus aureus), local bacterial resistance patterns, and patient factors. Nasal swabs are contaminated by normal nasal flora and results correlate poorly with causative pathogens in rhinosinusitis. In many hospitals, a nasal swab will only be processed to report on the presence or absence of S. aureus, rather than a full culture for speciation. In situations where cultures are required, such as intraorbital or intracranial complications, endoscopically-guided culture of the middle meatus or a maxillary sinus aspirate are the preferred methods for obtaining samples of the causative pathogen.

Plain film x-rays should not be ordered as part of the management of nasal fractures. The decision to reduce a nasal fracture depends on numerous factors including patient preference, external deformity, and breathing difficulty, none of which are effectively assessed by an x-ray. They have a very low sensitivity and specificity, with 63.3% and 55.7% respectively.  As such, plain x-rays are unable to accurately diagnose occult fractures.  Despite being commonly ordered for medicolegal documentation of nasal fractures, the poor sensitivity and specificity brings into question their value in medicolegal proceedings. In studied cohorts, no unsuspected facial fractures were identified solely on nasal x-rays, and no negative effects on management occurred when an institution instituted a “no nasal x-ray policy”. Overall, nasal x-rays do not contribute to diagnosis, documentation, or management decisions, and should not be ordered.

Many patients presenting with hoarseness do not have an underlying head and neck malignancy. Hence, ordering imaging initially does not help to make a diagnosis. Persistent hoarseness, lasting greater than 6 weeks, can be one of the first signs of malignancy of the larynx or voice box. This is particularly true in current or ex-smokers and individuals with a current or previous history of alcohol abuse. Laryngoscopy as part of a thorough physical examination is the best initial investigation of persistent hoarseness.  If the laryngoscopy demonstrates a vocal cord paralysis or a mass/lesion of the larynx, imaging to further evaluate is evidence-based.

A fine needle aspiration biopsy (FNA) is the gold standard for initial work up for a neck mass and has numerous advantages over an open neck biopsy. FNA holds less risk and avoids the chance of seeding cancer cells in the neck and making subsequent treatment of a confirmed malignancy more challenging.  It is also inexpensive, quickly obtained without a general anaesthetic, and can be performed with or without the use of imaging to assist with the placement of the needle depending on the location of the neck mass, particularly if it is partially cystic or near vital structures. Open neck biopsies should only be considered for a neck mass if the result of a FNA biopsy is non-diagnostic and no primary carcinoma is identified upon a complete head and neck examination. If there is a strong suspicion of lymphoma (previous history of lymphoma, night sweats, weight loss, wide spread lymphadenopathy) an open or core biopsy can be considered in lieu of a FNA.

Odynophagia and globus sensation are common symptoms and the differential diagnosis can be extensive, including inflammatory, infectious, neoplastic, autoimmune and traumatic causes.  Odynophagia and globus sensation are infrequently due to an underlying neck mass, and if so, the underlying lesion is usually quite apparent on physical examination. Neck or thyroid ultrasonography ordered to investigate patients with odynophagia and globus sensation are more likely to detect other entities such as benign thyroid nodules, rather than confirming a diagnosis  that explains the patient’s symptoms and can lead to a cascade of other unnecessary tests that can be harmful to patients.  Unfortunately, using tests to exclude conditions, can sometimes identify other diseases such as thyroid nodules, leading to further testing such as a FNA or repeat ultrasounds and in some cases treatment in the form of a thyroidectomy that may be unnecessary or harmful to patients.

The diagnosis of the dizzy patient should be guided by the presenting symptoms and office examination. Tests such as ABR (auditory brainstem response), ECOG (electrocochleography), ENG/VNG (electronystagmography/ videonystagmography), VEMP (vestibular evoked myogenic potential), vHIT (video head impulse test), CDP (computerized dynamic posturography) and RCT (rotational chair testing) should only be ordered if clinically indicated. In general, advanced balance tests should be ordered and interpreted by otolaryngologists with specialized training in the diagnosis and treatment of vestibular disorders (otologists/neurotologists). Clinical indications for testing can include: side localization and stage of progression for Meniere’s disease, assessment of central compensation for acute vestibular loss and confirmation of superior semicircular canal dehiscence syndrome. Specialized tests are rarely indicated in the management of benign paroxysmal positional vertigo.

Blood work which typically would consist of a CBC, differential and electrolytes along with an autoimmune panel are often normal and would not change initial clinical management if abnormal. The CT scan which is done to rule out central causes is not sensitive enough to pick up most cases of retrocochlear pathology. MRI scans should be considered instead. If verified to be sensorineural with audiometric testing, urgent treatment with steroid therapy can be initiated. There is no role for antiviral treatment, thrombolytics or vasoactive substances.

If there is no obvious cause of the asymmetry such as unilateral trauma or unilateral noise exposure like gun blasts, a MRI should be ordered. MRI scans are superior in sensitivity for detecting retrocochlear pathologies such as vestibular schwannoma when compared to ABR testing.

First line therapy constitutes a short course of topical antibiotic/steroid drops. The potential ototoxicity of any topical medication entering the middle ear space should be considered in selecting an appropriate agent. Where available, fluoroquinolone combination preparations (e.g., ciprofloxacin and dexamethasone) should be used as a first choice and caution should be exercised in using topical aminoglycosides. Microdebridement and further assessment should be considered in the following circumstances: (a) failure to respond after a 7 day course, or (b) where follow up does not permit a clear view of a normal tympanic membrane allowing the exclusion of more sinister middle ear disease such as cholesteatoma.

Posterior semicircular canal benign paroxysmal positional vertigo should be diagnosed and confirmed with a positive Dix-Hallpike test, and only then should a particle repositioning maneuver be performed. If a patient with positional vertigo has a Dix-Hallpike test that is repeatedly negative or results in atypical nystagmus, less common BPPV variants or central positional vertigo should be considered.