Common Clinical Diagnoses and Conditions

1.16 HEAD AND NECK DISORDERS neck (including plain radiographs, fluoroscopy, ultrasonog- raphy, computed tomography, magnetic resonance imag- Introduction ing, and direct laryngoscopy) and discuss the risks, benefits, Disorders of the head and neck, including infectious processes and indications for each. and anatomic abnormalities, are some of the most common • Discuss the indications, contraindications, and mechanisms encountered by pediatric hospitalists. Upper respiratory tract of action of pharmacological agents used to treat various infections (URIs) are the most common reason for acute pedi- disorders of the head and neck, such as antibiotics, nebu- atric medical care. Children under age six years of age aver- lized epinephrine, glucocorticoids, proton pump inhibitors, age six to eight URIs per year. Acute illness with an infectious histamine 2 blockers, and others. process often exacerbates underlying anatomic abnormalities, • Compare and contrast the benefits and limitations of var- such as , tracheomalacia, subglottic stenosis, ious modalities of airway stabilization and respiratory sup- and others, but these abnormalities alone can require acute port (including heated humidified high flow nasal cannula, intervention and lead to hospitalization. Bacterial infections non-invasive positive pressure support, and intubation with have the potential to invade other structures or compromise mechanical ventilation) in patients with varying degrees of the airway, rapidly resulting in both immediate and long-term upper airway obstruction. sequelae if not appropriately treated. Pediatric hospitalists • Discuss the changes in clinical status that indicate need frequently encounter patients with disorders of the head and for escalation of care, such as worsening or work of neck and should be able to recognize their signs and symp- , decreased air entry, , altered mental sta- toms and provide evidence-based and efficient care. In partic- tus, and others. ular, pediatric hospitalists must be able to identify impending • Describe the patient characteristics that indicate the need airway obstruction, provide immediate care, and arrange for for higher level of care and/or transfer to a referral center the appropriate subsequent level of care. in cases requiring pediatric-specific services not available at the local facility. Knowledge • Describe criteria, including specific measures of clinical sta- Pediatric hospitalists should be able to: bility, that must be met before discharging patients with • Compare and contrast the head and neck anatomy of chil- head and neck disorders, including oxygenation, hydration, dren at different chronological ages, including how abnor- and patient/family education. malities of airflow in different locations may alter the clinical presentation at different ages. Skills • Discuss the symptoms of various anatomic abnormalities Pediatric hospitalists should be able to: (such as laryngomalacia, tracheomalacia, subglottic steno- • Perform an appropriately focused medical history, attending sis, and others), including the acute infectious processes to symptoms of potential airway obstruction. which may exacerbate their clinical presentation. • Conduct a thorough physical examination directed by signs • Discuss the pathophysiology, presenting features, and com- and symptoms that may indicate the location, etiology, or mon pathogens associated with bacterial infections of the severity of the disorder. head and neck (such as otitis media, otitis externa, retropha- • Identify patients with comorbidities or underlying anatomic ryngeal abscess, orbital cellulitis, dental infections, mastoid- abnormalities that impact the management plan and order itis, peritonsillar abscess, and others). appropriate testing, correctly interpreting results. • Describe the differential diagnosis of common presenting • Order appropriate monitoring and correctly interpret mon- symptoms of head and neck disorders, such as shortness of itor data. breath, stridor, , nasal discharge, neck swelling/pain, • Adhere consistently to infection control practices. dysphagia/drooling, facial swelling, and others. • Identify complications and respond with appropriate ac- • Describe the features of upper airway obstruction, such as tions. stertor, stridor, tripod positioning, dysphagia, drooling, tris- • Perform an evidence-based, cost-effective diagnostic evalu- mus, and others. ation and treatment plan, avoiding unnecessary testing. • Discuss alternate diagnoses that may mimic the presenta- • Perform careful reassessments daily and as needed, note tion of acute upper respiratory infection such as allergic re- changes in clinical status, and respond with appropriate ac- action, toxic inhalant exposure, and others. tions and escalation of care as appropriate. • List the indications for hospital admission, explain the utility • Stabilize the airway and provide appropriate respiratory sup- of various monitoring options, and review the indications for port for patients with impending or actual airway obstruction emergent and non-emergent subspecialist consultation. or respiratory failure, including head tilt/chin lift, nasal trum- • Describe the of obstructive sleep ap- pet, and intubation, or arrange for the appropriate personnel nea (OSA) including , respiratory pauses, and hypox- to perform the procedure in an effective and efficient manner. ia, and discuss appropriate evaluation, referral, and man- • Engage consultants (such as otolaryngologists, pulmonol- agement. ogists, surgeons, speech and feeding specialists, dentists, • Explain the types of studies available to assess the head and and others) efficiently and effectively when needed.

An Official Publication of the Society of Hospital Medicine Journal of Hospital Medicine® Vol 15 | No S1 | April 2020 47 Common Clinical Diagnoses and Conditions

Attitudes • Lead, coordinate, or participate in the development, im- Pediatric hospitalists should be able to: plementation, and improvement of cost-effective, safe, ev- • Role model and advocate for strict adherence to infection idence-based care within a multidisciplinary team for hospi- control practices. talized children with head and neck disorders. • Realize responsibility for effective communication with pa- • Collaborate with hospital administration and community tients and the family/caregivers regarding the diagnosis, partners to develop and sustain referral networks between management plan, and follow-up needs. local facilities and tertiary referral centers for hospitalized • Recognize the value of collaboration with the primary care patients with head and neck disorders. provider, subspecialists, nursing, the hospital staff, and oth- er outpatient providers to ensure coordinated longitudinal References care at the time of discharge. 1. Geddes G, Butterly MM, Patel SM, Marra S. Pediatric neck masses. Pediatr Rev. 2013 Mar;34(3):115-124; quiz 125. https://doi.org/10.1542/pir.34-3-115. Systems Organization and Improvement 2. Virbalas J, Smith L. Upper airway obstruction. Pediatr Rev. 2015;36(2):62-72. https://doi.org/10.1542/pir.36-2-62. In order to improve efficiency and quality within their organiza- 3. Murray AD. Deep Neck Infections. Medscape. https://emedicine.medscape. tions, pediatric hospitalists should: com/article/837048-overview. Updated Apr 12, 2018. Accessed August 28, 2019.

48 Journal of Hospital Medicine® Vol 15 | No S1 | April 2020 An Official Publication of the Society of Hospital Medicine