Pro Golfer with History of Leukemia and ENT Emergencies

The New York Times published a story about pro golfer Laura Kueny who was diagnosed with acute lymphocytic leukemia at 3 years of age and the harrowing experiences she had to go through to beat the cancer.

It certainly brought back memories when I was a resident at Duke University and was filled with dread whenever I got consulted to evaluate a sick child with leukemia undergoing treatment.

It is breathtaking just how sick such children are... what in a normal child is not considered an ENT emergency like strep throat, tonsillitis, sinusitis, and ear infections, are now considered an emergency. Such common childhood infections can literally kill a child undergoing chemotherapy and/or bone marrow transplant. With cancer treatment, these kids have no immune system and significantly reduced ability to clot due to platelet loss.

Being poked and prodded is a given... but there's also the ENT endoscopies and surgeries that often need to be performed to either save a life or to just figure out what germ is causing an infection so the appropriate powerful antibiotic can be given.

Making a hole in the eardrum as well as nasal endoscopies are routinely performed in order to culture the pus present.

Tonsillectomy surgery can be a particularly harrowing experience for an ENT surgeon as it can be literally life-saving and life-ending all at the same time. A bad tonsillitis can overwhelm what little immune system these children have in spite of antibiotics and emergency tonsillectomy may need to be performed to help the child recover from a potentially lethal infection... BUT... performing this type of surgery when platelet counts may be non-existent can also result in life-threatening blood loss. In the end, the child remains intubated after surgery while getting IV platelet infusions, and the entire oral cavity packed with gauze to provide direct pressure to manually stop bleeding for a few days. Once the gauze packing is removed and no bleeding is seen, extubation can proceed.

Sinus surgery for persistent sinusitis can also result in a nosebleed that just will not stop bleeding thereby requiring prolonged nasal packing.

And is it worth it in the end?

Yes... for what used to be a death sentence has now become one of the more curable cancers.

Source:
Golfer Leaves Hospital as a Survivor, Returns as a Winner. New York Times 6/22/13

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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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