IAPO Interamerican Association of Pediatric Otorhinolaryngology

XII IAPO Manual of Pediatric Otorhinolaryngology

Editors TANIA SIH ALBERTO CHINSKI ROLAND EAVEY RICARDO GODINHO

Coordinator TANIA SIH Copyright © 2013 Interamerican Association of Pediatric Otorhinolaryngology (IAPO) This book contains information obtained from authentic and highly regarded sources. A wide variety of references or recommended readings are listed. The editors cannot assume responsibility for the validity of all materials or for the consequences of their use. No part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the editor/coordinator.

Tania Sih 306 Mato Grosso Street, suite 1510 São Paulo, SP 01239-040 Brazil Fax: (55-11) 2114-6512 E-mail: [email protected]

Alberto Chinski Charcas, 2777- 1A 1425 Buenos Aires Argentina Fax: (54-11) 4821-1272 E-mail: [email protected]

Roland D. Eavey Bill Wilkerson Center 1215, 21st Ave. South. Medical Center East South Tower, suite 6310 Nashville, TN 37232 FAX : (615) 936-0704 E-mail: [email protected]

Ricardo Godinho Rua Dr. Chassim, 208 Sete Lagoas, MG 35700-018 Brazil Fax: (55-31) 3772-2121 E-mail: [email protected]

THE DEPOSIT ESTABLISHED IN BRAZIL

Graphic Project: Larissa Zimbres De Carvalho

ISBN International Standard Book Number: 978-85-60209-03-3 (Hardcover)

Published in 2013 by Editora e Gráfica Vida & Consciência Rua Agostinho Gomes, 2312 São Paulo, SP, 04206-001, Brazil Phone: (55-11) 3577 3201 E-mail: [email protected] IAPO´s Board of Directors Ellen Friedman (USA) Officers 2012-2014 Elsa C. Marin (Cuba) Federico Murillo (Costa Rica) PRESIDENT Fred Kozak (Canada) Fernando Silva (Ecuador) Hugo Rodriguez (Argentina) PAST PRESIDENTS Jack Paradise (USA) Sylvan Stool (deceased) (USA) Jorge Astocondor (Peru) Alberto Chinski (Argentina) Liliana Palma (Uruguay) Tania Sih (Brazil) Moacyr Saffer (Brazil) Roland Eavey (USA) Oscar O. Terraza Calderon (Guatemala) Teolinda Morales (Venezuela) Peggy Kelley (USA) James Reilly (USA) Ricardo Godinho (Brazil) PRESIDENT ELECT Ricardo de Hoyos (Mexico) Margaretha Casselbrant (USA) Robert J. Ruben (USA) VICE PRESIDENT Robin Cotton (USA) Frida Sanabria (Colombia) Ximena Fonseca (Chile) SECRETARY Tania Sih (Brazil) INTERNET SERVICES ADJUNCT SECRETARY IAPO´s Web Site: www.iapo.org.br (for the Board) Ricardo Godinho (Brazil) Vera Santos (Brazil) E-mail: [email protected] TREASURER Marcelo Silber (Brazil) OFFICE OF THE SECRETARY DELEGATES Tania Sih Amarilis Meléndez (Panama) 306 Mato Grosso Street, suite 1510 Andrés Sibbald (Argentina) São Paulo, SP Augusto Peñaranda (Colombia) 01239-040 Brazil Cecilia Jové (Bolivia) Phones: (55-11) 2114-6510/2114-6511 Cesar Franco (Paraguay) Fax: (55-11) 2114-6512 Edgar Perdomo (San Salvador) E-mail: [email protected] Foreword

It gives me great pleasure to share one of my favorite books in pediatric otolaryngology with you. This 12th edition of the IAPO Manual of Pediatric Otolaryngology, like numbers 1 to 11, offers an overview of what is new and important to both clinicians and researchers in our specialty.

Dr. Tania Sih, with her incredible mix of dedication, charm, and intellect, has been a driving force and true leader in pediatric otolaryngology both nationally and internationally for more than two decades. For this book, she has tapped into her large network, and brought together contributions from experts from various disciplines from all over the world. With her team of co-editors Drs. Roland Eavey, Alberto Chinski and Ricardo Godinho she has put together this quality publication that is distributed free of charge worldwide in several languages. As such it provides a priceless educational service to pediatric otolaryngologists, and, most importantly, the families and children they serve.

Please enjoy the text and share the knowledge and inspiration it brings to you.

Anne G. M. Schilder, MD, PhD President, European Society of Pediatric ORL (ESPO) Professor of Pediatric Otorhinolaryngology University Medical Center Utrecht NIHR Research Professor and Director ENT Clinical Trials Programme University College London Introduction I

As President of the Interamerican Association of Pediatric Otolaryngology (IAPO), I have the honor and privilege of thanking you for your interest and support of IAPO’s mission to improve all of our children’s’ health and well being.

The Head & Neck region of every child possesses the unique facial features and beauty that creates their identity to parents, family members and friends. Equally important, all communication between parent and infant starts with the baby’s first cry and continues to expand their interactions by words from their mouth and listening attentively with their ears. Starting with a baby’s first breath, their young bodies can only grow if their nose and tracheal passages are without obstruction so that oxygen can easily enter their lungs.

All health care providers who are responsible for maintaining the integrity of the ears, nose, throat and respiratory tree are challenged to provide the best wisdom and interventions to safely guide the children under our care to maximize their potential for learning throughout their school years as they grow into adult life.

The 12th IAPO Manual is dedicated to assisting all of us to do what is best for all of the infants and children that are under our care. Dr. Tania Sih and her esteemed colleagues have led the path forward to provide this textbook to you since the inception of IAPO. The knowledge and information within this book is the summation of current diagnosis and treatment for virtually all ear, nose and throat disorders in children from many of the world wide leaders in this field.

Please read this text with interest and keep it near your clinical practice for quick reference. Share with interested students and colleagues. Go forward to help all of the children become healthy, trusting adults and lead our world to new and happy days. We have all dedicated our lives to help you provide the best of care in your practice.

Fernando Silva, MD President, IAPO 2012- 2014 Otolaryngologist Guayaquil, Ecuador Introduction II

The XIIth IAPO´s Manual on Pediatric ENT happens because I am lucky enough to have so many friends in the Pediatric ENT community around the globe. In 2012 and 2013, being a speaker in over 15 Medical meetings outside Brazil, in five continents, I have witnessed many excellent presentations. I invited the speakers to contribute to our Manual. Almost never I had a negative reply! Thanks to that, IAPO does a true “scientific community service”, due to the fact that the Manuals cannot be sold. They should be given (free of costs) to the members of our Organization - IAPO. Later on, they are displayed in our website (www.iapo.org.br), and our “virtual Pediatric ENT Library” in three languages (Spanish, English and Portuguese) is the most extensive of its kind! We have so may hits from all over the world! If someone related to medical care, reads our Manuals, for sure will help with updated subjects to treat better their children.

When someone says “a state of the art” it means excellence! I think that this particular Manual is a true commitment to give you, the reader, the most updated and broad knowledge in the area. Over 70 physicians from 18 countries contributed to this Manual. We always divide our Manuals in 5 Sections: a) General considerations; b) Mouth- Head & Neck) Nose & Sinus; d) Ear and e) Hearing & Communication disorders. So, other than specific subjects covering Pediatric ENT we consider that Section A (General Considerations) is also important to broaden the horizons outside ear, nose and throat, as Medical general culture. This is relevant for us to help us in a more holistic approach and management of our little patients. Not too much time left in our busy life, so it is easier and convenient to have new, updated and interesting informations in one book.

Enjoy the reading!

Tania Sih, MD, PhD IAPO´s General Secretary International Federation of ORL Societies (IFOS) Chair of the Standing Committee of Pediatrics Professor, Medical School, University of São Paulo São Paulo, Brazil List of Contributors

As they appear in the text

• Adriaan N Bosschaart, MD, Social Pediatrician, Dutch Asthmacentre, Davos, Switzerland. • Ann Hermansson, MD, Associate Professor, Department of ENT, University Hospital Lund, Sweden. • Thea van Zeben-van der A. MD, Social Pediatrician, Department of Pediatrics, Maastricht University MC, The Netherlands. • Deepa Bhargava, MD, MBBS, M.S, Department of Surgery ENT Division College of Medicine and Health Sciences, Sultan Qaboos University. Hospital, Muscat, Sultanate of Oman. • Kamlesh Bhargava, MD, MRCGP (INT), Department of Family and Community Medicine, College of Medicine and Health Sciences, Sultan Qaboos University Hospital, Sultanate of Oman. • Itzhak Brook, MD, MSc, Professor of Pediatrics Georgetown University School of Medicine, Washington DC, USA. • Wei-Chung Hsu, MD, PhD, Department of Otolaryngology, National Taiwan University Hospital, Sleep Center, National Taiwan University Hospital, Taipei, Taiwan. • Kun-Tai Kang, MD, Department of Otolaryngology, National Taiwan University Hospital, Sleep Center,. Department of Otolaryngology, Taipei Hospital, Department of Health, New Taipei City, Taiwan. • Pin-Lin Lee, MD. Sleep Center, National Taiwan University Hospital. Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan. • Wen-Chin Weng, MD, Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan. • Bryan Rolfes, MD, Department of Otolaryngology, Head and Neck Institute, Cleveland Clinic, Cleveland, OH, USA • Paul Krakovitz, MD, Vice Chairman, Surgical Operations, Section Head of Pediatric Otolaryngology, Head and Neck Institute, Assistant Professor of Surgery, Cleveland Clinic, Cleveland, OH, USA. • Julie Wei, MD, Professor of Pediatric Otolaryngology Nemours Children’s Hospital, Orlando, FL, USA. • Silvana Maria Coelho Pimentel, MD, Pediatric Otolaryngologist Albert Sabin Hospital, Fortaleza, Brazil. • Paola Marchisio, MD, Department of Pathophysiology and Transplantation, University of Milan, and Fondazione IRCCS Cà Granda Hospedale Maggiore Ploiclinico, Milan, Italy. • Elena Baggi, MD, Department of Pathophysiology and Transplantation, University of Milan, and Fondazione IRCCS Cà Granda Hospedale Maggiore Ploiclinico, Milan, Italy. • Sonia Bianchini, MD, Department of Pathophysiology and Transplantation, University of Milan, and Fondazione IRCCS Cà Granda Hospedale Maggiore Ploiclinico, Milan, Italy. • Erica Nazzari, MD, Department of Pathophysiology and Transplantation, University of Milan, and Fondazione IRCCS Cà Granda Hospedale Maggiore Ploiclinico, Milan, Italy. • Chiara Rosazza, MD, Department of Pathophysiology and Transplantation, University of Milan, and Fondazione IRCCS Cà Granda Hospedale Maggiore Ploiclinico, Milan, Italy. • Nicola Principi, MD, Department of Pathophysiology and Transplantation, University of Milan, and Fondazione IRCCS Cà Granda Hospedale Maggiore Ploiclinico, Milan, Italy. • Susanna Esposito, MD, Department of Pathophysiology and Transplantation, University of Milan, and Fondazione IRCCS Cà Granda Hospedale Maggiore Ploiclinico, Milan, Italy. • Anna Stjernquist-Desatnik, MD, PhD. Department of ENT, University Hospital, Lund, Sweden. • Syed Kamal Naqvi, MD, Associate Professor, Ditrector of Pediatric Sleep Medicine, Department of Pediatrics, UT Southwestern and Children’s Medical Center Dallas. Dallas, TX, USA. • Ron B. Mitchell, MD, Professor of Otolaryngology and Pediatrics, William Beckner Distinguished Chair in Otolaryngology, UT Southwestern and Children’s Medical Center Dallas. Dallas, TX, USA. • Syed Kamal Naqvi, MD, Associate Professor, Ditrector of Pediatric Sleep Medicine, Department of Pediatrics, UT Southwestern and Children’s Medical Center Dallas. Dallas, TX, USA. • Hugo Rodriguez, MD, Chief Respiratory Endoscopy, Pediatric Hospital Prof. Juan P. Garrahan. Buenos Aires, Argentina. • Giselle Cuestas, MD, Fellow Respiratory Endoscopy, Pediatric Hospital Prof. Juan P. Garrahan. Buenos Aires, Argentina. • Magdalena Roques Revol, MD. Fellow Respiratory Endoscopy, Pediatric Hospital Prof. Juan P. Garrahan. Buenos Aires, Argentina. • Juan Augustin Rodriguez D'Aquila, MD, Resident. Instituto Superior de Otorrinolaringología, Buenos Aires, Argentina. • Peter C. Revenaugh, MD, Department of Otolaryngology Head and Neck Institute, Cleveland Clinic, Cleveland, OH, USA. • Alyssa Hackett, MD, Department of Otolaryngology, University of Pittsburgh Pennsylvania, USA. • Deepak Mehta MD, Division of Pediatric Otolaryngology, Children's Hospital of Pittsburgh, Pennsylvania, USA. • Barry Schaitkin, MD, Division of Pediatric Otolaryngology, Children's Hospital of Pittsburgh, Pennsylvania, USA. • John Robert Newman, MD, Department of Surgery, Division of Otolaryngology Head and Neck Surgery, University of Alabama at Birmingham, Alabama, USA. • Paula Harmon, MD, Pediatric ENT Associates & Children’s Hospital of Alabama, Birmingham, Alabama, USA. • William Peyton Shirley, MD, Department of Surgery, Division of Otolaryngology Head and Neck Surgery, University of Alabama at Birmingham. .Pediatric ENT Associates & Children’s Hospital of Alabama, Birmingham, Alabama, USA. • Jimmy Scott Hill, MD, Department of Surgery, Division of Otolaryngology Head and Neck Surgery, University of Alabama at Birmingham. Pediatric ENT Associates & Children’s Hospital of Alabama, Birmingham, Alabama, USA. • Audie L. Wooley, MD, Department of Surgery, Division of Otolaryngology Head and Neck Surgery, University of Alabama at Birmingham. Pediatric ENT Associates & Children’s Hospital of Alabama, Birmingham, Alabama, USA. • Brian J. Wiatrak, MD, Department of Surgery, Division of Otolaryngology Head and Neck Surgery, University of Alabama at Birmingham. Pediatric ENT Associates & Children’s Hospital of Alabama, Birmingham, Alabama, USA • Karin P. Q. Oomen, MD, Fellow Pediatric Otolaryngology Department, Weill Cornell Medical College, New York, NY, USA. • Robert F. Ward, MD, Professor of Otolaryngology, Clinical Vice Chair of Otolaryngology, Chief, Division of Pediatric Otolaryngology, New York University (NYU). NYU Langone Medical Center, New York, NY, USA. • João Subtil, MD. Consultant Otolaryngologist, ENT Department, CUF Descobertas Hospital, Lisbon, Portugal. • Teresa Matos, MD, Consultant Otolaryngologist ENT Department, CUF Descobertas Hospital, Lisbon, Portugal. • José Saraiva, MD, Director ENT Department, CUF Descobertas Hospital, Lisbon, Portugal. • Rainer Haetinger, MD, PhD. Radiologist, Med Imagem Beneficiência Portuguesa Hospital, São Paulo, Brazil. • Maria T. Peña, MD, Division of Otolaryngology and the Center for Genetic Medicine Research, Children’s National Medical Center, Washington. D.C., USA. • Teolinda Mendoza de Morales, MD. Past President of the Venezuela ENT Society, Past President of IAPO, Past President of the Venezuelan Rhinology Society. Otorhinolaryngologist at the Instituto Cajigal de Otorrinolaringología, Caracas, Venezuela. • Myrian Adriana Perez, MD, ENT specialist at Hospital San Juan de Dios, Caracas. Laryngologist at MP Centro de Especialidades Médicas, Caracas, Venezuela. • Noboru Yamanaka, MD, PhD. Department of Otolaryngology-Head & Neck Surgery, Wakayama Medical University, Wakayama, Japan • Kelvin M. Kwong, MD, Department of Otolaryngology-Head & Neck Surgery, Wayne State University School of Medicine, Detroit, MI, USA. • James M. Coticchia, MD, FACS. Department of Otolaryngology-Head & Neck Surgery, Wayne State University School of Medicine, Detroit, MI, USA. • Nadejda Maria Ávila da Silva Varjinha, MD, Head of Otolaryngology Department, University Center Oswaldo Aranha Foundation, Volata Redonda, Brazil. • Isabela Ávila Varginha de Moraes e Silva, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil. • Vlad Postelnicu, MD, PhD. Department of Otolaryngology, Medlife Baneasa Hyperclinic, Bucharest, Romania. • Oana Iosif, MD. Department of Otolaryngology, Medlife Baneasa Hyperclinic, Bucharest, Romania. • Raluca Enache, MD, PhD. Sarafoleanu ENT Clinic, Bucharest, Romania. • Codrut Sarafoleanu, MD, PhD. Professor of Otolaryngology - Head & Neck Surgery, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania. • Mahmood F. Bhutta FRCS, PhD (DPhil), Research Fellow and Specialist Registar Nuffield Department of Surgical Sciences and Department of Otolaryngology Head and Neck Surgery, Oxford University Hospitals, Oxford, UK. • Leena Niittynen, MSc Nutritionist, Vihti, Finland. • Liisa Lehtoranta, PhD. Institute of Biomedicine, Pharmacology, Medical Nutrition Physiology, University of Helsinki, Helsinki, Finland. • Anne Pitkäranta, MD, PhD. Department of Otorhinolaryngology, Helsinki University Central Hospital, University of Helsinki, Medical Faculty, University of Helsinki, Finland. • Riitta Korpela, PhD, Institute of Biomedicine, Pharmacology, Medical Nutrition Physiology, University of Helsinki, University of Helsinki, Finland. • Shyan Vijayasekaran, FRACS, Princess Margaret Hospital for Children. School of Surgery, University of Western Australia. School of Paediatrics and Child Health, The University of Western Australia, Perth, Australia. • Harvey Coates, AO, FRACS, Princess Margaret Hospital for Children. School of Surgery, University of Western Australia. School of Paediatrics and Child Health, The University of Western Australia, Perth, Australia. • Ruth B. Thornton, PhD, School of Paediatrics and Child Health, The University of Western Australia. Telethon Institute for Child Health Research, Centre for Child Health Research, Perth, Australia. • Selma P. Wiertsema, PhD, School of Paediatrics and Child Health, The University of Western Australia. Telethon Institute for Child Health Research, Centre for Child Health Research, Perth, Australia. • Lea-Ann S. Kirkham, PhD, School of Paediatrics and Child Health, The University of Western Australia. Telethon Institute for Child Health Research, Centre for Child Health Research, Perth, Australia. • Sarra E. Jamieson, PhD, Telethon Institute for Child Health Research, Centre for Child Health Research, Perth, Australia. • Marie Rye, Telethon Institute for Child Health Research, Centre for Child Health Research, Perth, Australia. • Peter C. Richmond, FRACS, Princess Margaret Hospital for Children. School of Paediatrics and Child Health, The University of Western Australia. Telethon Institute for Child Health Research, Centre for Child Health Research, Perth, Australia. • Sarah C. Hugh, MD, Resident Physician, Department of Otolaryngology Head and Neck Surgery, University of Toronto, Toronto, Canada. • Sharon L. Cushing, MD, MSc. Department of Otolaryngology Head & Neck Surgery, Hospital for Sick Children, Toronto. Depart. of Otolaryngology Head & Neck Surgery, University of Toronto, Toronto, Canada. • Blake C. Papsin, MD, MSc, FRCSC, FAAP, FACS..Director of the Cochlear Implant Program, Staff Otolaryngologist Professor, Hospital for Sick Children, Toronto. Department of Otolaryngology Head and Neck Surgery, University of Toronto, Toronto, Canada. • Evan J. Propst, MD, MSc, FRCSC. Otolaryngologist, Hospital for Sick Children, Assistant Professor, Department of Otolaryngology Head and Neck Surgery, University of Toronto, Toronto, Canada. • Fergal O' Duffy, MD. Academic Department of Oto-Rhino-Laryngology, Galway University Hospitals, and National University of Ireland, Galway, Ireland. • Donald Mc Askill, MSc. Audiological Scientist, Community Audiology, Sea Road, Galway, Ireland. • Ivan J. Keogh, MD. Academic Department of Oto-Rhino-Laryngology, Galway University Hospitals, and National University of Ireland, Galway, Ireland. Content

IAPO: Board of Directors 5 Foreword 6 Introduction I 7 Introduction II 8 List of Contributors 9

General Considerations 19

1. Child Abuse and ENT 21 Adriaan N. Bosschaart, Ann Hermansson and Thea van Zeben-van der A 2. Evidence Based Complementary and Alternative Medicine. Do We 26 Need to Integrate it with Mainstream Pediatric Otolaryngology? Deepa Bhargava and Kamlesh Bhargava 3. A Physician's Personal Experience as a Cancer of the Neck Patient 31 Itzhak Brook 4. Obesity and Obstructive Sleep Apnea in Children 38 Wei-Chung Hsu, Kun-Tai Kang, Pin-Lin Lee and Wen-Chin Weng 5. Innovations and Technology in Pediatric Otolaryngology 44 Bryan Rolfes and Paul Krakovitz 6. How Diet and Dietary Habits Impact Pediatric Ear, Nose & 51 Throat Health Julie Wei 7. Piercing and Tatoos 65 Silvana Maria Coelho Pimentel 8. The Role of Vitamin D in Upper Respiratory Infections in Children 70 Paola Marchisio, Elena Baggi, Sonia Bianchini, Erica Nazzari, Chiara Rosazza, Nicola Principi and Susanna Esposito

Mouth, Head & Neck 77

1. Pharyngotonsillitis New Guidelines in Sweden 79 Ann Hermansson and Anna Stjernquist- Desatnik 2. Sleep Disordered Breathing in Children 83 Syed Kamal Naqvi and Ron B. Mitchell 3. Laryngeal Stridors 94 Hugo Rodriguez, Giselle Cuestas, Magdalena Roques Revol and Juan Augustín Rodríguez D'Aquila 4. Evaluation of Pediatric Neck Masses 127 Peter C. Revenaugh and Paul Krakovitz 5. Pediatric Sialendoscopy 136 Alyssa Hackett, Deepak Mehta and Barry Schaitkin

Nose and Sinus 143

1. Reflections on the Surgical Treatment of Choanal Atresia 145 John Robert Newman, Paula Harmon, William Peyton Shirley, Jimmy Scott Hill, Audie L. Woolley and Brian J. Wiatrak 2. Congenital Nasal Pyriform Aperture Stenosis 152 Karin P. Q. Oomen and Robert F. Ward 3. Complicated Sinusitis in the Newborn 156 João Subtil, Teresa Matos and José Saraiva 4. Indications and Contraindications in the Imaging Diagnosis 163 of Inflammatory Sinusopathy in Children Rainer G. Haetinger 5. Pediatric Orbital Complications of Acute Sinusitis: 170 Changing Trends in Bacteriology Maria T. Peña 6. Rhinoplasty in Pediatric Age 176 Teolinda Mendoza de Morales and Myrian Adriana Perez

Ear 183

1. Microbiology and Immulogy in Acute Otitis Media in Children 185 Noboru Yamanaka 2. Updates in Otitis Media in Preterm Infants 206 Kelvin M. Kwong and James M. Coticchia 3. Recurrent Acute Otitis Media - When Should 211 Immunodeficiency be Suspected? Nadejda Maria Ávila da Silva Varjinha and Isabela Ávila Varginha de Moraes e Silva 4. Efficacy of Ear Ventilation Tubes in Reducing the Total 218 Period of Conductive Hearing Loss in Children with Otitis Media with Effusion and Adenoid Hypertrophy Vlad Postelnicu, Oana Iosif, Raluca Enache and Codrut Sarafoleanu 5. Pathobiology of Otitis Media. Advances from Genetics 230 Mahmood Bhutta 6. Probiotics and Otitis Media in Children 237 Leena Niitynen, Liisa Lehtoranta, Anne Pitkäranta and Riitta Korpela 7. The Pathogenesis of Severe Otitis Media in Western Australian 246 Children: A Review Shyan Vijayasekaran, Harvey Coates, Ruth B. Thornton, Selma P. Wiertsema, Lea-Ann S. Kirkham, Sarra E. Jamieson, Marie Rye and Peter C. Richmond

Hearing and Communication Disorders in the XXI Century 253

1. Noise - Induced Hearing Loss: Are Infants and Children at Risk? 255 Sarah C. Hugh, Sharon L. Cushing, Blake C. Papsin and Evan J. Propst 2. Appreciating the Spectrum of Audiological Issues in 260 Children with Down Syndrome Fergal O' Duffy, Donald Mc Askill and Ivan J. Keogh 3. Peripheral Vestibular Dysfunction in Children with 565 Sensorineural Hearing Loss Sharon L. Cushing and Blake C. Papsin