Dizziness and Imbalance in Kids

Dizziness is not the easiest thing to figure out in adults. It is even more difficult to figure out in kids who may not have the vocabulary to explain what they feel. Regardless of adult or child, a good history is required to help narrow down possibilities. A flowchart of questions to help come up with a diagnosis can be found here.

Given that, a review article published in 2014 went over the most likely diagnosis of a child who is dizzy.

Based on 724 subjects over 10 studies, benign paroxysmal vertigo of childhood (18.7%) and migraine-associated vertigo (17.6%) were the two main etiologies causing vertigo and dizziness in children. Head trauma (14%) was the third most common cause of vertigo. The mean (95% CI) rate of every vertiginous form was also calculated in relation to the nine studies analyzed with vestibular migraine (27.82%), benign paroxysmal vertigo (15.68%) and vestibular neuritis (9.81%) being the three most common forms.

Benign paroxysmal vertigo of childhood is not clearly understood with some researchers feeling it is a form of adult BPPV (benign paroxysmal positional vertigo) given similar symptoms whereas others feel it is more related to a neurologic vascular basis. With this particular condition, there is no established treatment protocol.

True BPPV occurred in 1.8%. Meniere's disease accounted for only 1.5%. Othostatic hypotension only 1.2%. Middle ear problems surprisingly only occurred in 3% which was felt by the researchers to be highly under-estimated.

Given the top 3 causes of vertigo in children all have a neurologic basis, an evaluation by a good pediatric neurologist is warranted.

Reference:
Prevalence and diagnosis of vestibular disorders in children: A review. Int J Pediatr Otorhinolaryngol. 2014 May;78(5):718-724. doi: 10.1016/j.ijporl.2014.02.009. Epub 2014 Feb 15.

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Why Do Babies Hate Getting Their Nose and Face Wiped???

I have often been asked this question by parents... and even more so by my wife as we try to clean the snot off our little kids' noses as they shriek as if we're torturing them.

Given it seems ALL young kids have this nose-wiping aversion across cultures and racial ethnicities, it would seem that this reflex reaction is hard-wired into human babies. But why would evolution favor this reaction?

I tried to find an answer to this question to see if any bright researchers actually studied this topic, but was unable to find any. So... here are my thoughts on this topic.

To warn other healthy humans

Evolutionarily, it may have been helpful for the human population as a whole if it was obvious to others when an individual was sick. To see a toddler with snot running out the nose, that would have been a pretty clear sign for other children and their parents to stay away lest they also get sick. This isolation of a sick child would have been nature's way of quarantining to prevent spread of illness to the rest of the human group.

To get eaten by predators

Not to be morbid, but predators tend to feed on the sick. It is nature's cruel way of removing the weakest in an animal population which over time will only strengthen the prey animal population as a whole (Darwin's theory of only the fittest survive). Back in the REALLY old days (caveman era), sick humans would have been just such a prey that would have been targeted by wild predator animals. To be not just a young human, but one that also shows signs of illness would be indicators to a predator of who to go after.

Protect the airway

This is my wife's favorite theory who feels the last idea to be horrible and inhuman (never mind that just because evolution is horrible and inhuman does not make it false). This airway idea is based on the fact that breathing is essential to life. Anything that covers the nose or mouth, even briefly, is a potential hazard that may lead to death. Evolutionarily, this reflex would be favored and strengthened over time... even if avoidance involves just a quick wipe. Who knows? Perhaps SIDS (Sudden Infant Death Syndrome) would be much more prevalent if the nose/face wipe aversion was not present.

Any other ideas? Even better, does anybody know of any studies that actually looked into this topic?

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Ear Tube Placement in Kids WITHOUT Sedation (Starting at 12 Months of Age)

A recent report describes how using a relatively old technology, ear tube placement can now be performed in children starting at 12 months of age with chronic ear infections or hearing loss due to fluid buildup without the need for sedation of any kind nor aggressive restraints (ie papoose). Historically, ear tube placement in the office without sedation is typically performed starting at around 12 years of age using standard local anesthesia techniques. Any younger, a child could not be trusted to stay still during the procedure due to presence of some discomfort.

In any case, a Texan ear group reports how they accomplished this simple procedure at such young ages.

First, the ear canal is cleaned as much as possible of all earwax and debris. The ear canal is than filled with an anesthetic liquid (concoction of lidocaine, epinephrine, and sodium bicarbonate). Over 10 minutes, iontophoresis was than used to induce profound local anesthesia to the ear canal and eardrum. The liquid was than suctioned out and ear tube placement was performed with a reported 90% success rate (78 of 86 ears; 17 subjects were 3 years old or younger; 8 were 12 months old).

The key to success required 3 "new" elements.

• Iontophoresis device made by Acclarent. There are other iontophoresis devices in the market (Medtronic and Otomed), but none adapted for simultaneous bilateral ear canal usage that works within 10 minutes. Iontophoresis works by applying a gentle electric current in order to actively move charged drug molecules into the skin. In this particular case, positively charged lidocaine and epinephrine.
• Optimal anesthetic solution for iontophoresis. Dubbed "EMGIM", it contains 1:12,000 epinephrine with 3.3% lidocaine hydrochloride and 0.7% sodium bicarbonate. The solution is prepared fresh prior to use by combining 10 mL of 4% lidocaine hydrochloride with 1 mL of 1:1,000 epinephrine. After mixing the lidocaine and epinephrine, 1 mL of 8.4% sodium bicarbonate is added.
• Ear tube delivery device and placement system. Typically, a competent ENT can place an ear tube in about 10-20 seconds. However, when dealing with kids who may potentially move unexpectedly and operating within a very small ear canal space, a faster and more reliable way of placing a tube was required. Hence, this new device. [link]

Of course, during the actual procedure, age-appropriate distraction was needed to minimize movement, especially given aggressive restraint was not used.

Sounds great as sedation is something to be avoided if at all possible. However, there is one problem... the Acclarent iontophoresis device is NOT yet FDA approved contrary to what the report states (direct communication with Acclarent executives October 1, 2013). Hopefully in 2014. As such, beyond a research setting, this in-office technique is not yet available for use in the United States.

As an aside, there are FDA-approved iontophoresis devices for use in pediatric head and neck surgical procedures mainly for sub-cutaneous mass excisions and abscess incision and drainage. Check out Phoresor for such applications using lidocaine infused electrodes. It's even sold on Amazon.


References:
Otologic Iontophoresis: A No-Papoose Technique. Annals of Otology. Rhinology & Laryngology 122(8):487-491. Aug 2013.

In-Office Tympanostomy Tube Placement Under Local Anesthesia Using a Novel Tube Delivery Device. Triological Meeting Poster. Dec 2012.

Iontophoresis: a needle-free, electrical system of local anesthesia delivery for pediatric surgical office procedures. J Pediatr Surg. 1999 Jun;34(6):946-9.

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T&A Helps with Pediatric Obstructive Sleep Apnea (But Watchful Monitoring OK Too!)

Researchers published in the New England Journal of Medicine that removal of the tonsils and adenoids absolutely helps with sleep apnea in kids along with improvements in behavior, quality-of-life, overall well-being as well as significantly greater reduction in symptoms... but apparently putting off surgery does no significant harm as well from a purely cognitive perspective.

464 children ages 5-9 years of age were randomly split into surgery or watchful monitoring groups (children with severe sleep apnea was excluded from the study). Although surgery helped in all measures tested, what surprised the researchers was that nearly half the children (46%) in the watchful monitoring group also spontaneous improved over a 7 month period of time without surgery. Furthermore, there was no difference between groups on a Developmental Neuropsychological Assessment.

Overall, surgery WAS beneficial, but it is notable that even without surgery, cognitive development was found to be no different than not doing surgery and nearly half improved to point surgery was no longer clinically indicated.

More relevant to clinicians and parents... what were the exact factors that led nearly 50% of kids with sleep apnea to improve over 7 months?

Was it a certain medication? Overall head growth? Treatment of allergies?

If there WAS an intervention, can it be replicated to all kids as something to try prior to surgical consideration?


Reference:
A Randomized Trial of Adenotonsillectomy for Childhood Sleep Apnea. May 21, 2013 DOI: 10.1056/NEJMoa1215881

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Top 3 Reasons Why Your Child Can't Shake that Cough

Guest Blog Post by Dr. Julie Wei

Any parent who has lived with a toddler or preschooler knows the pain of hearing a child’s endless cough, daytime, nighttime, all the time... It seems as if the cough never clears up in a day or two, or after a cold, but may last for weeks. Even if it does clear up, it always seems to return without much warning, and can be more stubborn than your 4 year old about eating vegetables! If you are wondering why cough medications can't stop your child's cough, or for that matter, why inhalers for "asthma", another 10 days of antibiotics, and/or allergy medications are all not working, then continue reading. Have you dragged your child all over town to see yet another specialist to find out why they just keep coughing?

Here is what I explain to all families who come to see me about cough. Cough is an involuntary reflex, or protective mechanism the body has to get unwanted particles or irritants out of our airway. So if dust got into our windpipe, or a droplet of liquid goes into the airway accidentally while your child was drinking and trying to talk at the same time, or the phlegm that he/she gets with a viral illness... all of these things can make our children cough. While most children are thankfully not intermittently or continuously inhaling dust, or running around drinking with their head tilted while talking at the same time, the one frustrating thing about young children is the fact that they get 7-10 viral upper respiratory track illnesses, or colds every year. Each one of these “colds” last 7-10 days, and so pretty quickly, you can have a child with cold symptoms for a third of the year!

So... without further ado... the top 3 reasons why the cough is still hanging on...

NUMBER 3: Post-viral neurogenic cough or habitual throat-clearing. Whatever the reason was, your child started out having a bad cold and coughed due to being sick. Even after the fever and acute illness goes away after 7-10 days, their throat and voice box somehow stays irritated and they continue to cough. At some point, your child may not even realize that he/she is "coughing". Often these are children who are throat-clearing and not really coughing (more often in short annoying bursts, as often as every few minutes). If you no longer hear them "coughing" during sleep, but only when they are awake, then this is likely what your child has. These children often show no other signs of illness or discomfort. It's a difficult diagnosis to make and usually after all other reasons have been rules out. I often offer strategies to families to help break these habits such as creating a game (older than 3 or 4 years of age can do this) whereby a kitchen timer is used to help suppress the urge to "cough" starting from 30 seconds and working up to 5 minute intervals. School aged children who do not appear ill but have a “dry” throat clearing do very well with this exercise. Another option is when they get into a coughing fit, to distract them with chewing gum, having them count backwards from 20, hopefully distracting them from this habit.

NUMBER 2: Chronic Rhinosinusitis (CRS). Your child may have developed true chronic rhinosinusitis which means inflammation from thickening of the lining inside their sinus cavities and their sinus "plumbing" is clogged up. Chronic sinus inflammation is NOT a bacterial infection so antibiotics will not make it go away completely, even if it seems to decrease the cough temporarily. This usually occurs in children older than 4, especially if they have underlying test proven allergies to common aero-allergens like trees, pollen, grass, dust-mites, and other environmental allergens. Sometimes this is bad luck and develops after your child has experienced a terrible viral illness, such that the mucous membranes inside the nasal passages were so swollen that the natural drainage points that lead each sinus cavity into the nasal passage are blocked, which then leads to the inflammation inside the sinus. Since there is a built-in mechanism called the "sinopulmonary reflex", children who have inflamed sinus mucous membrane lining will likely continue to cough until the nasal passage and sinus mucous membranes are no longer swollen and healthy again. The only way to truly know if your child has CRS is for him/her to get a CT scan, a special imaging of their sinus cavities which can involve some radiation exposure. These children tend to complain of a stuffy nose all the time along with the cough, and can't blow anything out of their nose even if they try. Mothers always tell me that their child is stuffy and can’t breathe well, leading to snoring, fatigue, sometimes headaches.

NUMBER 1: The Milk and Cookie Disease (MCD). Your child is coughing because day after day, night after night, their larynx (voicebox) is bombarded with stomach content backwash (gastroesophageal reflux and laryngopharyngeal reflux) coming up to and irritating the voicebox. The voicebox which enables humans to talk is also designed to "cough" as a way to keep unwanted materials from entering our airway. If it did not protect itself by coughing, then we would aspirate and possibly get pneumonia. Find out how your child can live and eat in "A Healthier Wei" and fight the Milk and Cookie Disease, by minimizing dairy and sugar in the evenings and then his/her voicebox can rest and not be in "fighting" mode all the time. I have met thousands of children who have chronic cough not because they are sick, but because they were eating a diet or drinking beverages containing too much dairy and sugar, as well as possibly greasy foods and processed foods. All these items increase likelihood of reflux or backwash and assault on the larynx. If the voicebox is always on “alert” and ready to “fight” and protect the body, then it really can’t relax and rest. I believe that when this happens chronically from MCD, and let’s not forget those 7-10 colds and how they also lead to an irritated overreactive cough, then together, this child has no chance and probably will cough, A LOT! By making changes in diet and dietary habits in children, we can decrease the chance of stomach backwash coming up to irritate the voicebox and cause cough, then hopefully your child only coughs when it is truly because of a cold. Don’t take my word for it, try “A Healthier Wei”. You will likely notice at least much less coughing, and coughing ending much sooner after a cold. I also ask parents to stop dairy/milk for up to 1 week during the time their child is sick. This is when digestion is not at its best, and things get sour and gross in the stomach increasing chance for reflux and more cough.

by Julie Wei, MD, FAAP

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Lithium Disc Battery Danger for Kids (and Hot Dogs)

In the last 10 years, 13 deaths related to swallowed batteries have been reported, 12 of which were due to disc batteries (20 millimeter lithium cells).

The danger is that when a disc battery is inserted into a nose (for example), a localized electric current is created between the positive and negative poles of the battery within the nose. This electric current basically "electrocutes" the lining inside the nose leading to tissue damage and ultimately necrosis (tissue death) within an hour. The same applies even if the battery is swallowed or put into the ear canal.

When swallowed, it can burn through the esophageal/intestinal lining causing a perforation which can lead to death if not promptly treated (or even in spite of it if too much time passes before treatment).

Treatment is IMMEDIATE removal... as soon as possible. Regardless of the day or time. STAT...

For illustrative purposes, lets see what happens to a hot dog when a lithium disc battery is placed inside it. This example was created by Dr. Stephen Marcus who is the director of the New Jersey Poison Information Center and published in the Pediatrics Blog here. You can also do this at home... give it a try (make a slit in the hot dog and push a lithium button battery into it... than watch).

Just 3 hours later, this is what you would see...

Keep disc batteries away from kids!!!

Please!!!

References:
A lithium battery in a hot dog is no picnic. Pediatrics Blog 7/2/2012

Pediatric Battery-Related Emergency Department Visits in the United States, 1990–2009. PEDIATRICS Vol. 129 No. 6 June 1, 2012 pp. 1111-1117

Preventing Battery Ingestions: An Analysis of 8648 Cases Published online May 24, 2010 PEDIATRICS (doi:10.1542/peds.2009-3038)

A Review of Esophageal Disc Battery Ingestions and a Protocol for Management Arch Otolaryngol Head Neck Surg. 2010;136(9):866-871. doi:10.1001/archoto.2010.146

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12 Years Old Girl Dies After Tonsillectomy

Tampa Bay Times reported on June 10, 2012 a 12 years old girl died after a tonsillectomy performed on Aug 13, 2010 for chronic tonsillitis. From the details provided from the news report, it seems that several independent issues all contributed together that lead to this child's unfortunate and tragic death.

This case was also complicated by subsequent non-medically related actions taken by medical personnel which will not be discussed here.

Strictly medically speaking...

Local Anesthetic With Epinephrine

It is unclear exactly when the local anesthetic bupivacaine (Marcaine) with epinephrine was injected into the tonsil region which may help with post-tonsillectomy pain control in the pediatric population. Also unclear is what concentration and how much got injected.

However, it is far from common practice (though not rare) and it is not something I personally inject in the pediatric population for a few reasons in spite of its well-known suspicion to minimize a sore throat after surgery. (There are plenty of papers that report such injection offers NO additional pain control in children. See references below.)

1) The risk of bupivacaine is toxicity to the heart leading to arrhythmias that may ultimately lead to a heart attack.
2) Epinephrine can result in hypertension as well as further exacerbate cardiac problems

Given report of "bloody froth" in the endotracheal tube along with acute onset of tachycardia and hypertension, I suspect the child suffered from pulmonary edema, most likely secondary to accidental intra-vascular injection of the local anesthetic (causing cardiac failure) and epinephrine (causing tachycardia and hypertension).

Given these risks and fact that kids are so much smaller and more susceptible to medication risks, I personally never inject this medication during/after tonsillectomy. Even in adults, I never inject routinely, though I do offer to adults undergoing tonsillectomy (but than I use bupivacaine alone without epinephrine).

The hypertension itself led to problem #2...

Congenital Cerebellar Vascular Anomaly

The child had a congenital cerebellar vascular anomaly that ruptured leading to a life-threatening bleed in the brain.

In and of itself, this anomaly would not have been a problem, but given the reported sudden hypertension, the rupture is akin to inflating a tire with too much air causing it to pop.

Most likely, if the child's cardiovascular compromise never occurred, this bleed never would have happened in the first place.

It's also entirely possible if the local anesthetic was never used, this death would not have happened as well.


Source:
Lawsuit claims doctors' mistakes caused Palm Harbor girl to die after tonsillectomy. Tampa Bay Times 6/10/12.


References:
Comparison of clonidine, local anesthetics, and placebo for pain reduction in pediatric tonsillectomy. Arch Otolaryngol Head Neck Surg. 2011 Jun;137(6):591-7. Epub 2011 Mar 21.

Preincisional bupivacaine in posttonsillectomy pain relief: a randomized prospective study. Arch Otolaryngol Head Neck Surg. 2002 Feb;128(2):145-9.

Control of early postoperative pain with bupivacaine in pediatric tonsillectomy. Ear Nose Throat J. 1993 Aug;72(8):560-3.

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Head CT Scans Increase Risk of Cancer in Kids

By how much?

Brain tumor/cancer risk was 3X greater than the general population in children who received two to three CT scans of the head.

And the chance of developing leukemia was three times as great for children who received five to 10 CT scans of the head.

In the study published in Lancet, the researchers examined 176,587 children who had received a CT scan before age 22 and looked at their medical history for an average of 10 years afterward.

Though the risk sounds "high," the overall risk is still relatively small and CT scans should still be performed if medically warranted.

Phrased another way, the risk corresponds to one additional case of leukemia in the 10 years after the first scan for every 10,000 patients younger than 10 who were scanned or an extra case of brain cancer for every 30,000 children scanned.

Even so, the study does illustrate that CT scans should not be ordered unless there's a very good reason to do so, especially in children given they are more radiosensitive compared to adults.

In the ENT world, the most common reason to order a CT scan is to evaluate for sinusitis.

My own personal preference is to obtain one in children if and only if all other sinusitis interventions have already been performed.

Such "sinusitis" interventions include:

• Allergy intervention (steroid and/or anti-histamine nasal sprays)
• Failure to respond to antibiotics
• Adenoidectomy (if large adenoids present which can be determined on endoscopy)
• Turbinate Reduction (if turbinates are enlarged)
• Check for cystic fibrosis and primary ciliary dyskinesia

If above interventions have been performed, only than would I consider a CT scan of the sinuses.

Some (other ENTs) may argue that CT scan of the sinuses should be performed early as a more directed intervention can than be performed.

My argument against that is, EVEN if the CT sinus comes back abnormal, I STILL would perform the above interventions first because often the above interventions will clear up and sinus abnormality seen on a CT scan.

Only when everything else has been tried would I consider sinus surgery in a child and only than would a CT sinus be justified in my mind.

However, there are certain other situations I may consider getting a CT scan relatively quickly...

• If I find a sino-nasal mass on exam concerning for tumor or nasal polyps
• Congenital hearing loss
• Cholesteatoma (tumor of the ear)
• "Significant" Facial Trauma (ie, not just for a simple broken nose)


Reference:
Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. The Lancet. 7 June 2012. doi:10.1016/S0140-6736(12)60815-0

Source:
Children's CT Scans Pose Cancer Risk. Wall Street Journal 6/6/12

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Dental X-rays Linked to Brain Tumors

In a study spanning over decades, researchers have found an association between dental x-rays and increased risk of a non-malignant type of brain tumor called meningioma.

Of the four types of dental x-rays, only the full-mouth series was associated with this increased risk. More specifically, the risk was elevated with the aggregate number of full-mouth series in 10-year periods from approximately 15–40 years before diagnosis, with significant elevations in the 10-year periods beginning 22–30 years before diagnosis. The risks in these analyses were even greater when only women were considered.

One needs to be aware that radiation exposure from full-mouth series was much greater in the past than it is now and as such, this risk may be nominal (though not zero) with current dental x-ray technology.

However, it also should be a reminder that x-rays should not be routinely performed unless there is a very good reason to obtain especially in children who are more susceptible to radiation injury... and that applies to not only x-rays, but any kind of testing involving ionizing radiation including CT scans.

Some x-rays should NEVER be performed including sinus x-rays for sinus problems given a nearly 50% error rate in diagnosing the presence OR absence of sinus problems.

X-rays for nasal fractures is not recommended given x-rays rarely change how such fractures are managed.

Soft-tissue lateral x-rays to look for large adenoids should also be discouraged as nasal endoscopy can provide similar if not better information without any radiation exposure.

To know what the cancer risk is with different types of x-rays, check out this website!

Source:
Dental X-rays and the risk of intracranial meningioma. Cancer. Volume 100, Issue 5, pages 1026–1034, 1 March 2004

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Magic Ears Club Founded by Fauquier ENT Hosts Halloween Party

The Magic Ears Club kicked off its existence with a first ever Halloween Party on October 29, 2011 where over 15 kids from elementary to high school ages who wear hearing aids co-mingled and played games while their parents talked amongst each other their experiences. Prizes and free hearing aid goodies were also distributed.

Dr. Catie Chalmers, audiologist with Fauquier ENT who founded the Magic Ears Club, stated that the purpose of the club is to help parents, as well as their hard-of-hearing children, connect, share, and provide support for each other.

Being a member of this unique club means being able to participate in practice-sponsored parties as well as meeting new friends who also have "magic ears" (aka, hearing aids).

Furthermore, members can participate over the internet in either open or closed forums hosted by Fauquier ENT where members can ask questions or provide other meaningful support to each other wherever and whenever they wish.

The open forum is through Facebook which is open to all who support our goals whereas the closed forum is hosted through Yahoo Groups and limited to ONLY those individuals who are patients of Fauquier ENT.

For more information, go to http://www.MagicEarsClub.com

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Sedated Anesthesia for Kids Under 2 Years May Cause Learning Disability

There is mounting evidence in animals and in humans that general anesthesia might damage developing young brains.

Researchers at Mayo Clinic compared the learning skills of 350 kids who underwent 1 or more general anesthesia before age 2 to 700 kids who have never been under sedated (general) anesthesia. What they found was that before the age of 19 (after statistical normalization):

No significant difference in learning disability between kids who have been under anesthesia once (23 out of 100) with kids who have never been under anesthesia (21 out of 100).  

However, those kids who have been under anesthesia 2 or more times had increased rate of learning disability (36 out of 100). 

Based on animal studies, anesthetics are known to cause accelerated loss of brain cells during development which leads to learning and behavior problems later in life. Whether that's also true for humans has not been studied.

However, further study is required as the results were obtained based on observation and did not account for other variables (type of surgery for example).

This information, though not definitive, does warrant extra circumspection by parents and surgeons when deciding to pursue surgery in kids under age 2 years, no matter how minor the surgery including ear tubes, tonsillectomy, adenoidectomy, and turbinate reduction.

IF surgery pursued, one should perform as much as required to minimize need for a 2nd procedure at a later date. That means multiple procedures under one anesthesia would be preferable than multiple procedures at different times.

Of course, surgery should only be done if the benefits outweigh the risks including anesthetic risks.

Read the MSNBC report here.

Reference:
Cognitive and Behavioral Outcomes After Early Exposure to Anesthesia and Surgery. Published online in Pediatrics October 3, 2011. doi: 10.1542/peds.2011-0351

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