Dare to be Deaf!

Vertigo in Children

Vertigo in children is uncommon.The attacks of vertigo in children may be less dramatic than adults,however they cause severe anxiety if a diagnosis is not reached and appropriately explained.

The clinical diagnosis involves accurate history which many adults are not capable of giving.The reason I say so is that the terms "Vertigo" "Dizziness""Giddiness" and "Imbalance" are very commonly used without proper understanding by adult patients,let alone poor child!
When a child presents with vertigo, we also need to keep in mind their distractibility,coordination capabilities and behavioral problems.Also the compliance in pediatric population to perform otoneurological examinations is limited

Let us go through various terms commonly used by patients or parents.
Dizziness can be used to explain different sensations like lightheadedness, Fainting or Syncope, Giddiness (when engaging in activities like spinning) or Vertigo.

Vertigo is a sensation of spinning (either we feel spinning or the surrounding is spinning).It can be associated with nausea,jerky eye movements,headache,sweating and ringing in the ears or hearing loss.

Vertigo is an uncommon complaint in children and adolescents.Despite the most significant technological achievements in the development of diagnostic tools like scans and audiology, diagnosis is still based mainly upon the patient’s history and physical examination.There could be history of migraine or vertigo in the family.

The child's pediatrician may refer to Pediatric ENT for further otologic and audiologic evaluation.If required, the child may be seen by neurologist for evaluation.

There have been various scientific studies about the etiologies or causes of vertigo in children.The common causes of vertigo or the differential diagnosis includes Migraine associated vertigo or variants,Benign Paroxysmal Vertigo, Otitis Media and rarely other inner ear pathologies.

It is worth mentioning about "Motion Sickness" here.
It is a clinical phenomenon provoked by passive locomotion or movement of the visual environment only.It consists of pallor,tiredness,weakness,hypersalivation,nausea and emesis.

Diagnosis should be followed by adequate symptomatic treatment and management of underlying etiologies.The success of treatment of vertigo lies in regular follow up.

Noisy breathing in infants and children

 A newborn breathes more rapidly than an adult. This is due to the fact that lung capacity of a baby is less than adult. So to hold oxygen they need to breath in and out more often.This is the reason why babies and young children have higher respiratory rate than adults.  

Some children present with abnormal sound during breathing. There are two common types of noisy breathing -Snoring and Stridor.

Snoring in children is a sound due to upper airway obstruction. The commonest cause of snoring in children is enlargement of adenoids and tonsils referred to as Adenotonsillar Hypertrophy.

The degree of adenotonsillar hypertrophy is assessed with clinical examination. In some children this can lead to disturbed sleep and daytime hyperactivity. This is referred to as Obstructive Sleep Apnoea. Your child’s paediatrician will send to an ENT surgeon to confirm the diagnosis. Adenotonsillectomy surgery is the solution for obstructive sleep apnoea in children.

Stridor is a sound produced by turbulent airflow through a partially obstructed airway. There can be various types of stridor depending on the location and severity of airway narrowing. There can be acute causes of stridor like airway inflammation or infections. These are medically managed by Paediatricians.

The most common non acute cause of stridor in infants and children is Laryngomalacia. 

In laryngomalacia, cartilages of upper larynx collapse inwards during taking breath in.This leads to obstruction.

Laryngomalacia is the commonest congenital laryngeal anomaly followed by vocal cord paralysis and subglottic stenosis. This is generally a self-limiting disease but when severe it may cause airway obstruction, feeding difficulty and failure to thrive.

In most cases of noisy breathers, your child’s Pediatrician will decide whether an ENT opinion is required. A visit to ENT clinic will consist of consultation with otolaryngologist who will decide whether direct visualisation of your child’s airway is required.

Flexible fiber-optic laryngoscopy examination is performed as an out patient procedure in most of the children. It allows excellent visualisation of upper airway structures.

 

Baby swallowing button battery: Flexi Bronchoscopy, ENT: Dr. Sheelu Srinivas: Fortis Hospitals Bangalore...

Pediatric Airway:Who should visit a Pediatric ENT Specialist?

Pediatric Airway Program

Airway Clinic : A multidisciplinary approach with the team including ENT Surgeon specializing in Pediatric airway, Pediatric Pulmonologist and equipped with outpatient endoscopic setup to complete ICU back up for open airway surgeries.

Tracheostomy Program

Swallowing Evaluation and FEES (Functional Endoscopic Evaluation of Swallowing)

Whom to refer?

1.       Noisy Breathers especially babies with failure to thrive

2.       Infants and children with stridor

3.       Babies with recurrent croup

4.       Children with recurrent pneumonias

5.       Wheeze or asthma not responding to regular treatment to look for associated airway pathologies

6.       NICU Babies or kids with increased respiratory effort post extubation

7.       Swallowing and Feeding difficulty in babies

8.       Infants and children with congenital malformations of head and neck

What happens when babies come to hospital?

First they will have an outpatient consultation with ENT surgeon. We perform outpatient flexible nasolaryngoscopy and swallowing assessment. Referral to other specialties including pulmonology, speech therapy will be done as required.

Flexible Nasolaryngoscopy

If further assessments of lower airways are required, then micro laryngoscopy and Bronchoscopy under anesthesia will be planned.

Depending on final diagnosis, management including conservative, endoscopic procedure or open airway surgery will be planned.

Doctor Patient Encounter : Paternalistic versus Mutualistic

A doctor patient encounter in out patients is the consultation.A consultation has to be used as a means to understand patients ideas,concerns and expectations about their illness.This is called Concordance.Concordance is the quality of consultation.

The old fashioned paternalistic approach is no more accepted by many patients. The free availability of information about medical conditions on the internet means patients can now arrive at a consultation with sheaves of paper to challenge the doctors authoritative knowledge.
Mutualistic Approach is the way forward.

Unlike the words Compliance or Adherence we use for the patients.Better concordance leads to compliance and adherence to treatment.

If we do not involve them in this way,there are bound to be misunderstanding and dissatisfaction.

Usually any doctor spends time in a consultation to reach a diagnosis after listening to patient symptoms and clinical examination.
However once in a while you meet a patient who believes that the doctor has not spent enough time with them.What causes this confusion or misunderstanding?

How do we decide with whom to spent how much time?
It appears that the time of interaction is decided by presenting symptom OR rather how quickly the patient comes to the main complains.
Simple example is that if someone has an acute infection,it's a simple and short consultation within allotted 15-20 minutes.(with an average consultation time of 8 minutes)
Versus if someone has a chronic illness or a disability,then doctor needs to spend more time.

We come across patients who are having simpler diagnosis complaining about spending less time with them ( well precisely that's whats its going to be) I understand the patients perspective that for him/her illness is illness or grave for some.

As a doctor I feel that they can make a list of questions or concerns before visiting the doctor(especially since internet gives a lot of info) and get them answer promptly.Rather than quoting internet or what they have read or other specialists have told them.

Mutualistic Approach brings benefits to both patients and doctors....

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