return to: Pediatric Airway

Pediatric Otolaryngology Call

* Schedule at https://uihc.org/otolaryngology-clinic. On the schedule "C" = first call, "B" = backup.* On weekend days when the fellow is not on call - All pediatric patient calls, admits and consults will be staffed by the staff on general call by the senior resident

• EXCEPTIONS:
  • Pediatric foreign bodies: always goes directly to pediatric oto fellow or staff immediately
  • Specific pediatric patients as defined below:
    • PICU consults
    • NICU consults
    • Laryngeal/tracheal injury under age 12
    • Abscesses requiring drainage in OR under age 12
    • Heme/Onc consults under age 12
• ALL pediatric issues are otherwise handled by the team whose staff is on call including otitis media with complications, PE tubes, sinusitis, post-tonsil bleeds by outside physicians, PTAs, etc.

Staff-specific recommendations

Richard Smith

• He does not want to staff patients with you the night before cases. He knows what he wants to do in the OR and expects you to have a plan. 
• Follow ups:
  • Mx&T: 6 months
  • T&A: parents to call triage nurse in 2 weeks, if doing ok, no need to f/u 

Deborah Kacmarynski

• Follow ups:
  • Mx&T: 1 month and one year thereafter, ear gtt (ofloxacin) paper Rx with 11 refills; 3 drops, TID
  • T&A: no post op abx, f/u one month and then PRN 

Jose Manaligod

• follow ups generally 3-4 weeks post-op.

Call

• When on call, senior resident should call for any admission at that time. Any cases that may need to go to OR should also be staffed at that time. For night float resident any patients that will need to be seen should be staffed prior to OR - around 530 am. 
• Residents should feel free to call her or the Peds fellow about any issues with the cleft/craniofacial kids even if she is not on call. She may or may not be available but it is OK to try first before going to whoever is on call. She knows most of the kids pretty well and may be able to head off problems or triage stuff better because he has known them for so long.
• After hours, before paging, please try calling at home first and then cell+*. This also applies to staffing cases because he does not generally wear his pager around the house at night.

General Kacmarynski guidlelines

• Check H/H pre-op for most cases
• Know weight-based dosing for all medications to be used, and allowable blood loss for very small kids
• All patients should be added to the peds team list every evening and if there are any problems they should be directed to the peds fellow or Dr Kacmarynski. All patients get Unasyn (30 mg/kg)max 3 grams or Clindamycin (20-40 mg/kg per day divided by 3)max 900mg and Decadron (0.25 mg/kg)max 4 mg, a one time dose---all patients should receive at least 3 doses of the antibiotics and kept on it while in house
• All patients should go home on oral antibiotics (ie. amoxicillin or equivalent) and ibuprofen/tylenol. Continue ear drops begun in the OR

Cleft lip

• Consent for possible possible myringotomy and tubes bilaterally
• Use EPIC cleft lip post-op smartset
• Diet: child may take the bottle
• Lip is covered with dermabond so don’t need any topical ointment, may cover prn. No straws, spoons or sharp implements to be given to the child
• Wears arm splints for 3 weeks at all times
• If nasal bolsters are placed during the procedure. then only prescribe 3-5 days of antibiotics with f/u in 1 week. Nasal bolsters are removed in 1 week and 2 weeks of antibiotics and f/u in 2 weeks. Must apply bacitracin to the bolsters daily.
• Can usually be discharged on POD #1 and everything should be ready to go in the AM
• In general patients who had surgery on their skin (ie. lips) need to be seen in one week if bolsters in place then 10-14 day return. 
• Patients s/p surgery on their mouth need to be seen in three weeks

Cleft Palate

• Consent for possible possible myringotomy and tubes bilaterally
• Use EPIC cleft palate post-op smartset
• Diet: may have a cup diet (anything they can drink from a cup) sippee cups may be used if their spouts are cut off (first years are best)
• All patients need an O2 monitor and arm restraints
• May be discharged whenever taking adequate po, they should have everything written and ready on POD #1, but some may stay until day #2

Pharyngeal Flaps

• Diet: cup diet
• Need to make sure on abx, O2 monitor, Stents must stay in place for 2 days, they require saline irrigation (2-3 cc tid/qid) to keep them from building up boogers, etc.  Don’t try to replace if falls out
• The stents may be removed during rounds on POD#1/2 and patients can be prepared for d/c. These patients don’t wear arm restraints if over age 4 years. Home on 1 week abx
• Phrase for testing VPI: “I went to the zoo. There are bears there. I petted one”.

Alveolar Bone Grafts

• Diet: cup diet
• No need for arm restraints
• Need to make sure on abx, O2 monitor, Peridex rinses (15 cc swish spit tid/after meals)
• They also should brush after meals. Begin brushing lower teeth only day after surgery and gently start brushing upper teeth the week after surgery, stop if starts bleeding or hurting badly
• The hip graft area needs a compression bandage placed in the OR and may be removed on POD #1 and they can ambulate
• Home on 2 weeks abx

Cranioplasty

• Let neurosurgery manage all issues, we just need to drop a note on the chart every day. They usually go home in 4-6 days after they have their helmet fitted. Dr. Menezes will decide on d/c date so we do not suggest to family when this might be. 
• Antibiotics per neurosurgery, usually nafcillin

Procedure-specific Pearls

• Laryngoscopy – Prior to the child receiving any anesthetic, check to make sure that the appropriately sized bronchoscope is set up and the lights work. If the patient needs to be debrided, make sure the equipment (microdebrider, CO2 laser) is set up and ready to go. For children, have 1% preservative free lidocaine in a Luer lock syringe ready to spray the cords. Make sure anesthesia has ET tubes (several sizes) open with the peds stylet ready so that you can intubate if necessary. When you place the laryngoscope in the suspension arm, do NOT tighten the screw, so that you remove the scope from the arm quickly. Familiarize yourself with the equipment on the Storz cart before the case so that you can ask for or get the equipment you need. See appendix for Cotton-Myer Grading / ETT sizes
• OK432 – Diane Burke is the nurse for the OK432 study so she usually attends all of the OR cases. If you see someone with a lymphatic malformation, be sure to let Diane know. 
• Peds decannulation protocol – based on a paper that Richard Smith published in Laryngoscope 107:868-871, 1997