8/22/2012

1

Deena B. Hollingsworth MSN,FNP-BC, CORLN

Wendy Mackey APRN-BC, CORLN

Disclosure

� Speaker Alcon Labs Inc Ciprodex webinar

Objectives� Discuss the pharmacokinetics and potential adverse events

of corticosteroids

� Discuss appropriate delivery and dosage regimens for common adult ORL pathology

� Discuss pediatric considerations with the use of corticosteroids

� Participate in an interactive discussion of the use of steroids in ORL patients

Definitions

Anabolic steroids

Man-made substances related to sex hormones

Corticosteroids

Similar to adrenal hormones produced in response to stress associated with illness or injury. Include cortisone, hydrocortisone and prednisone.

How do corticosteroids work?

� Mimic the effects of natural adrenal hormones

� Higher doses suppress inflammation and the immune response

� Produces multiple glucocorticoid and mineralocorticoid effects

� Metabolized in the liver ( CYP450)

� Excreted in urine ( half-life 18-36 h)

Administration Routes� Topical

� Divided by potency classes I-IV

� Used on skin, eye, ear, and mucous membranes

� Inhaled� Used to treat nasal mucosa, sinuses, bronchi and lungs

� Oral

� Parenteral

8/22/2012

2

Common Corticosteroids� Betamethasone

� Budesonide

� Dexamethasone

� Fluticasonepropionate

� Flunisolide

� Hydrocortisone

� Methylprednisolone

� Prednisone

� Triamcinolone

Betamethasone� Route: topical Class II-IV

� Dosage: variable

� Side effects: acne, burning, itching, dry skin, changes in skin color

� Systemic absorption varies with application site, area, occlusion and patient specific factors

Nasal Steroids Budesonide� Route: nasal

� Dosage: 32 mcg/spray 1-4 sprays / nostril daily

� Indications: nasal polyposis , allergic rhinitis, turbinate hypertrophy

� Adverse reactions: septal perforation , nasal oral

candidiasis, epistaxis, pharyngitis, cough

� Category B for use in pregnancy

Fluticasone propionate� Route: nasal spray

� Dosage: 50 mcg/spray 2 sprays/nostril daily

� Indications: allergic rhinitis , non-allergic rhinitis, polyposis, turbinate hypertrophy

� Adverse reactions: septal perforation, nasal ulcer, glaucoma, cataracts, epistaxis, headache, nasal burning

� Category C

Mometasone� Route: Nasal Spray

� Dosage: 2 sprays/nostril daily to bid

� Indications: allergic rhinitis , nasal polyps, non-allergic rhinitis, turbinate hypertrophy

� Adverse reactions: IOP increase, glaucoma, nasal ulcer, epistaxis, URI symptoms

� Category C

8/22/2012

3

Prednisone� Route: oral

� Dosage: Variable with condition

� Indications: acute sinusitis, sudden sensorineural hearing loss, polyposis, Herpes Zoster, Bell’s Palsy

� Category C

Adverse Reactions

adrenal insufficiency

immunosuppression

diabetes

steroid psychosis

GI ulceration/perforation

osteoporosis/osteopenia

seizures

tendon rupture

glaucoma

anaphylaxis

headache

vertigo

nervousness

mood swings

elevated BP

elevated BS

muscle weakness

increased appetite

Cushing’s syndrome

WithdrawalHigh dose steroids for > 1 week produce adrenal suppression

5 days or lesscan be abruptly stoppedrecovery takes 1 week

6-10 daysreduce to replacement dose taper over 4 or more daysrecovery takes 2-4 weeks

11-30 daysreduce to 2x replacement dosetaper 25% every 4 daysrecovery takes 1-3 months

Any patient who has received more than 20 mg of prednisone daily (or an equivalent dose of other glucocorticoids) for more than five days in the previous year is at risk for HPA axis suppression

Any steroid dose given at bedtime—even physiologic doses—is more likely to suppress the HPA axis than a similar dose given in the morning

Med Clin North Am. 2001 Sep;85(5):1311-1317.

Patients receiving doses equivalent to 5 mg of prednisone in the morning for any length of time are not associated with HPA axis suppression

Endocrinol Metab Clin North Am. 2003;32:367-383

Sudden Sensorineural Hearing Loss� Definition

� A loss of 30 dB

� over three contiguous frequencies

� occurs over 72 hours or less

� Usually unilateral

� Accompanied by tinnitus and/or vertigo

� Incidence 5-20 /100,000

� Men = Women

(Mattox,1977)

Oral Steroid Therapy� Give immediately , better if within 2 weeks

� Prednisone 1 mg /kg ( max 60 mg/d)

� Full dose for 7-14 d then taper( do not divide)

� Repeat audiogram at 1 week and completion of course

� Monitor potential side effects

8/22/2012

4

Intratympanic Steroids� Can be given immediately or as salvage therapy

� Dexamethasone 10 mg/ml (stock)

� Methylprednisolone 40 mg/ml

� Inject 0.4 - 0.8ml into middle ear space every 3-7 days for total of 3-4 sessions

� Anterosuperior myringotomy, small gauge needle

� Maintain otologic position for 15-20 minutes

� Audiogram before each injection and at completion

� Inspect TM for healing

Oral prednisone 40 mg daily for 2 weeks

Acute Sinusitis� infection that occurs if obstruction or congestion

leads to bacterial growth in the paranasal sinuses

� swelling, and inflammation create further blockage, which may cause the sinuses to close up completely

� primary objectives for treatment of sinusitis are reduction of swelling, eradication of infection, draining of the sinuses, and ensuring that the sinuses remain open.

• Support treatment with only saline nasal irrigation, decongestants, antihistamines, and expectorants are appropriate for a minimum of 7 - 10 days for patients with mild-to-moderate symptoms, and may be used for longer.

• Antibiotics are not helpful for patients with mild-to-moderate symptoms, so they should not be prescribed for at least the first 7 days.

• Nasal spray corticosteroids are important for reducing the inflammatory response in the nasal passages and airways.

• Severe cases may require a burst of oral steroids

Nasal Polyposis� An inflammatory condition of unknown etiology

� Most common tumors of the nasal cavity

� Approximately 30% of patients with nasal polyps test positive for environmental allergies

� Increased prevalence in adults with aspirin sensitivity and children with cystic fibrosis

� Primary problems are decreased sense of smell and nasal congestion Rhinology. Dec 2011;49(5):525-32

Classic Ramsey Hunt Syndrome� Vesicular rash of ear /mouth

� Facial paresis or paralysis

� Vertigo and ipsilateral hearing loss

� Tinnitus

� Otalgia

� Headaches

� Dysarthria

� Gait ataxia

� Fever

� Cervical adenopathy

8/22/2012

5

Treatment Goals

�Limit the severity and duration of the pain

�Shorten the duration of the shingles episode

�Reduce complications

Corticosteroids� Decreases inflammation

� Give larger dose acutely then taper

� Interacts with multiple medications

� Contraindicated in severe infections, peptic ulcer disease, hepatic dysfunction

Bell’s Palsy� Unilateral facial muscle weakness

� Can occur at any age

� Associated with viral exposure

� Usually temporary but can be permanent

� Symptoms improve in a few weeks with complete recovery in 6 months

� Can recur

� Treat with oral steroids(40mg/day with slow wean)

Discuss pediatric considerations with the

use of corticosteroids

� Disorders commonly treated with Steroids in Pediatric Otolaryngology

� Complications specific to pediatrics

� Proceed with caution

Disorders commonly treated with Steroids in

Pediatric Otolaryngology

� Granulation Tissue

� Nasal obstruction

� Otitis externa

� Otitis media with tubes/TM perforation

� Tonsillectomy

� Tonsil hypertrophy

� Airway Disorders- croup, extubation, stenosis

� Hemangioma

8/22/2012

6

Tracheostomy Tube Granuloma� Granulation can occur anywhere on the

body where there is disruption of the skin/mucosa

� Commonly seen around trachs due to excessive movement, irritation, infection, predisposition

� Commonly treated with triamcinolone cream applied to granuloma bid for up to 10 days

� Suprastomal granuloma also common

� Off label use of ciprofloxicin/dex gtts

Tympanostomy Tube Granulation

� Presents as bloody or recurrent otorrhea

� Treatment- topical steroid +/- abx

� ciprofloxicin/dexamethasone gtts- 4 drops bid for 7-14 days

� Ofloxicin and dexamethamethasone opthalmic drops 2 gtts of each bid

� Always recheck to see ensure ear is healthy

Acute Otitis Externa� Definition: infection and/or

inflammation of EAC

� Etiology-moisture in ear canal, trauma, cerumen impaction, purulent secretions, dermatologic disorders

� Presentation- severe pain/throbbing, itching, aural fullness, otorrhea

� Diagnosis- movement of pinna, otoscope (meatus inflamed, cellulitis, furuncle, otorrhea)

Treatment: Acute Otitis Externa

� Extensive cleaning of EAC

� antibiotic/corticosteroid otic drops

� Otic wick

� Acetic acid drops

� keep the ear dry

� analgesia

Treatment: Acute Otitis Media with

Tympanostomy Tubes or TM perforation

� Presents as painless otorrhea

� Antibiotic/corticosteroid otic drops

� Dosing- 4 gtts bid x 7d

� Technique

� Advantages-Increased MIC

� Reduced antibiotic resistance and tx failure

� Precautions- overuse can lead to fungal infection

� Extensive cleaning of EAC

� Water precautions

� No systemic antibiotics required

Nasal Obstruction from

Turbinate Hypertrophy

� Symptoms may include mouth breathing, sleep disordered breathing, ETD, post nasal drip, alteration in smell and taste

� Treatment with Nasal steroids� Most are FDA-approved for children >6 yrs� Fluticasone and mometasone in childen > 2y � Minimal side effects (no systemic SE)

� irritation and nose bleeds � Possible transient vertical growth affect� some increased risk for cataracts and

glaucoma particularly in children with family history or predisposition who are otherwise prone to them� Routine annual optho exam recommended

8/22/2012

7

Allergic Rhinitis: Mucosal Abnormalities

� Common problem in older children/adults

� Symptoms:

� Watery rhinorrhea and nasal obstruction

� History of seasonal sneezing, itching

� Typical findings on PE:

� Edema of nasal mucosa and blue boggy turbinates

� Treatment (based on s&s/severity/pattern)

� antihistamines, nasal steroids/sprays

Proper Technique for Nasal Steroid Administration

� Clear nasal mucus � Tilt head down toward the

floor � Use opposite hand to

administer into nostril aiming outward toward turbs

� Pump the nasal spray while sniffing gently

Neonates are Obligate Nose BreathersNasal Obstruction: Mucosal AbnormalitiesRhinitis, Infection, Trauma & Tubes

� Swelling of nasal mucosa

� Respiratory distress of infant

� Discourage use of blue bulb

� Clear nasal passages

� Decadron opthalmic drops

Tonsillectomy and Adenoidectomy� AAO-HNS Tonsillectomy Guidelines 2011

Statement 7- Intraoperative Steroids � Clinicians should administer a single,

intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy.� Dose- 0.5mg/kg (lower doses effective)

� Strong recommendation based on randomized controlled trials and systematic reviews of randomized controlled trials with a preponderance of benefit over harm

� Benefits: � Decreased incidence of PONV up to 24 hrs

postop

� decreased times to first oral intake� decreased pain as measured by lower pain

scores and longer latency times to analgesic administration

Tonsillectomy/AdenoidectomyPostoperative Recovery

� Difficult recovery� Pain, irritability, otalgia, poor oral

intake, stridor/sterdor

� Irritation of nerve endings

� Inflammation

� Pharyngeal muscle spasm

� Consider dose or two of oral steroids

8/22/2012

8

Severe Tonsil Hypertrophy� Severe symptoms: respiratory

distress, dysphagia, drooling, trismus

� Mononucleosis

� Treatment:

� Vary based on diagnosis

� Steroids have significant impact on symptoms

Respiratory Distress: Airway Considerations

� Anatomic Considerations

� Smaller and narrower

� Airway stenosis

� Croup

� Extubation

Pouseuille’s Law: Tubular Fluid Dynamics

� Flow within the system is related to the radius of the tube to the fourth power

� Resistance is related to the inverse of the radius to the fourth power

� Triangular aperture of the normal infant larynx is approx 7mm x 4 mm (A=14 mm2)

� 1 mm of edema =cross-sectional area reduced to 5 mm2

� 35% of normal

EDEMA RESISTANCE CROSS-SECTIONAL

AREA ADULT 1mm Double 30% TEEN 1mm Triple 44%

NEONATE 1mm Increase x16 75%

Respiratory Signs and SymptomsCroup and Subglottic Stenosis

� Severity of symptoms based on degree of obstruction

� Respiratory symptoms� Biphasic stridor, croupy cough, retractions, cyanosis and nasal flaring

� Feeding difficulties

� FTT

� Voice disturbance if VC involved

� Mild to moderate may be asymptomatic until inflammatory process (mirrors croup)

� May be identified with difficulty with intubation/extubation

CroupCroup-- LaryngotracheobronchitisLaryngotracheobronchitis

� An obstructive disease of the airway that generally follows an upper respiratory tract infection

� Occurs primarily in children 1-3 yrs � Characterized by subglottic edema� Symptoms include: fever,

inspiratory stridor, hoarseness and a barking cough, restlessness, retractions

� “steeple sign”

Fiberoptic view of larynxFiberoptic view of larynx

AP Neck FilmAP Neck Film

Croup Management

� Most cases are treated as outpt

� maintaining adequate hydration

� cold humidification

� rest and reassurance

� Steroids

� Need for airway intervention is rare

8/22/2012

9

Subglottic Stenosis� Narrowing of the subglottic airway

� Third most common congenital anomaly of the airway

� Signs and Symptoms- dependent on staging (Cotton-Meyer)

� Medical Management

� Multifactorial, varies dramatically

� Supportive (grades I – II)

� Medications- supportive

� steroids (oral, IV, inhaled)

� Racemic epinephrine

� Supplemental O2

� Anti-reflux medications

Myer-Cotton Classification of SGSGrade I- 0-50% obstruction of lumen Grade II- 51-70% obstruction of lumen Grade III- 71-99% obstruction of lumen Grade IV - 100% obstruction of lumen

Hemangiomas� Benign vascular tumors

composed of endothelial cells

� Most common tumor of childhood(incidence 10% in infants)

� Growth phases� Proliferative phase- usually lasts 6-9

months (individualized)

� Involutive phase- may last up to 10 years

� Treatment is individualized� observation, laser, drug therapy,

surgery

Treatment with Steroids

� Until recently, prednisolone - first line medical treatment

� Administered typically orally, also IV topically or Intra-lesional

� Most effective in treating hemangioma when initiated during proliferative phase (first 6m)

� Dose: 2.0mg/kg/d - 4.0mg/kg/d qd or bid. � Response typically seen in 2-4 weeks, in

about 85% of patients� Once growth of the hemangioma has

slowed or stopped the medication is often slowly tapered

� If taper is done too quickly there can be new growth

Treatment with Propranolol

� Propranolol (non selective beta blocker) is now mainstay treatment

� induces early involution in hemangiomas even during the proliferative phase (Leaute-Labreze, 2008)

� Multiple studies verify rapid, successful treatment

� small risk of bradycardia, hypotension, bronchospasm and hypoglycemia

� Treatment failures

“I have to tell you...I worked with a

pediatrician once that said that

steroids were the ‘nector of the

gods’...and he is so right..it makes

EVERYTHING better” (Melissa—August 16, 2012)

8/22/2012

10

Hypothalamic-pituitary-adrenal

(HPA) suppression

� More pronounced in young children and pts receiving high doses for prolonged periods

� Acute adrenal insufficiency (adrenal crisis)

� Avoid abrupt withdrawal� Stress dosing prior to surgery,

with illness of times of unusual stress

� Tapering schedules

Immunosuppression with Corticosteroid Use

� May increase susceptibility to infections- reduce exposure

� Prolonged use may increase incidence of secondary infection

� May mask acute infection

� Immunizations

� May limit response to vaccines

� NO Live Virus immunizations should be given while using steroid medications and until the patient has been off the steroid for at least 1 month

� Avoid exposure to Chicken-pox

� Do not use in patients with ocular herpes simplex, viral hepatitis, cerebral malaria, latent TB, chickenpox, measles

Impact of Bones� Inhibition of bone growth

� Systemic

� Inhaled

� Osteoporosis

� Fractures

� Increased risk with >4 courses of corticosteroids

Emotional Disturbances� Mood swings

� Personality changes

� Increased appetite

� Psychiatric disturbances including depression, euphoria, insomnia

� Pre-existing psych conditions may be exacerbated

� Increase in adverse neurodevelopment outcomes (including CP) in preemies treated with high dose dex for BPD prevention(>0.5mg/kg/day)

� No clinical benefit over lower doses (Watterberg, 2010)

Cardiomyopathy

� Case reports of steroid-induced obstructive cardiomyopathy� Case report in child with subglottic stenosis (Balys et al, 2005,

IJPO)

� Multiple reports in premature infants (Shuster et al(1991), Finer et al

(2000))

� Signs and Symptoms

� tachycardia, new cardiac murmur, increased oxygen requirements, decreased UO, decreased peripheral perfusion

Proceed with Caution� Impact of steroids on white count

� Rebound effect

� Many drug interactions

� Antacids, antidiabetic agents, amphotericin, loop diuretics, quinolones, NSAIDS

� Food interactions- systemic use

� May require diet increase in potassium, vitamins A, B6, C, D, folate, calcium, zinc and phosphorus

� Decrease sodium

� Diabetics- monitor glucose levels closely

8/22/2012

11

Questions?

ReferencesAh-Tye, C., Paradise et al. Otorrhea in young children after tympanostomy tube placement for persitent middle ear effusion: prevalence, incidence and duration. Pediatrics. 2001; 107:1251-1258 Avila, L., Gutierrez, J., Diaz, M. et al. 2003. Severe complications in the treatment of vascular anomalies. Pediatrics 16: 169-174.AAP Subcommittee on Management of Sinusitis and Committee on Quality Improvement. 2001. Clinical Practice Guideline: Management of Sinusitis. Pediatrics 108(3): 798-807. Baugh, R., Sanford, A. et al. 2011. Clinical Practice Guidelines: Pediatric Tonsillectomy. Otolaryngology -- Head and Neck Surgery 2011 144: S1Becker, W., Naumann, H.H., Pfaltz, C. 1989. Ear Nose and Throat Diseases. Thieme Medical Publishers, Inc. Boat, Thomas F., Green, Thomas P. 2007. Chronic or Recurrent Respiratory Symptoms. In Nelson Textbook of Pediatrics, 18th ed., Chapter 381. Philadelphia: Saunders.Boyd, N. & Gottschall, J. Assessing the efficacy of tragal pumping: a randomized controlled trial. Otolaryngology-Head and Neck Surgery. 2001: June.Brook, Itzhak, Gooch W. Manford, Jenkins, Stephen G., Pichichero, Michael E., Reiner, Seth A., Sher, Lawrence, Yamauchi, Terry. 2000. Medical Management of Acute Bacterial Sinusitis

Recommendations Of A Clinical Advisory Committee On Pediatric And Adult Sinusitis. Ann Otol Rhinol Laryngol 109: 2-20. Brown, O. 2000. “Structure and function of the upper airway.” In Pediatric Otolaryngology: Principles and Practice Pathways, edited by Ralph Wetmore, Harlan Muntz, Trevor McGill, William Potsic,

Gerald Healy, Rodney Lusk, pp. 679-688. Thieme Publishers.Bruckner, A., Frieden, I. 2006. Infantile hemangioma. Journal of the American Academy of Dermatology 55:671-682 Canadas, K., Baum E. et al. 2010. Case report: treatment failure using propanolol for treatment of focal subglottic hemangioma. International Journal of Pediatric Otorhinolaryngology 74:956-958.Chan, Yvonne. 2010. Nasal and Sinus Infections, Pain, Pressure. In Health Care Reform Through Practical Clinical Guidelines Ear Nose Throat, pp. 201-207. San Diego: Plural Publishing Inc.Cotton, R., Willging, J.P. 1999. “Subglottic Stenosis in the Pediatric Patient.” In II Manual of Pediatric Otorhinolaryngology of the IAPO, edited by Alberto Chinski, Roland Eavy, pp. 143-154.Dohar JE, Garner ET, Nielsen RW, et al. Topical ofloxacin treatment of otorrhea in children with tympanostomy tubes. Arch Otolaryngol Head Neck Surg. 1999;125:537-545.Dohar, J., et al. Topical ciprofloxacino/dexamethasone superior to oral amoxicillin/cluvalanic acid in acute otitis media with otorrhea through tympanostomy tubes. Pediatrics, 2006; 118: 561-569.Dykewicz, Mark S. 2003. Rhinitis and Sinusitis. Journal of Clinical Immunology 111(2): S520-S529.Economides, Athena, Kaliner, Michael A. 2002. Allergic Rhinitis. In Current Review of Rhinitis, edited by Kaliner, Michael A., pp. 35-51. Philadelphia: Current Medicine, Inc.Fireman, Philip, Schreiber Rachel. 2003. Allergic Rhinitis. In Pediatric Otolaryngology, 4th edition, vol.2, pp. 1065-1081. Geelhoed, GC, Macdonald, WB. 1995. Oral dexamethasone in the treatment of croup: 0.15mg/kg versus 0.3mg/kg versus 0.6mg/kg: Pediatr Pulmonol 20:362-8. Abstract.Lenore L. Harris. Mary B. Huntoon.2008. Core Curriculum For Otorhinolaryngology and Head and Neck Nurses, 2nd ed.New Smyrna Beach, Florida SOHN, Inc.Goldblatt, E., et al. Topical ofloxacin versus systemic amoxicillin/clanulanate in purulent otorrhea in children with tympanostomy tubes. Intl Jour of Pedi Otorhinolaryngology. 1998: 46: 91-101.Goldstein, N. Mandel. E. Kurs-Lasky, M., Rockette, H., Casselbrant, M. Water precautions and tympanostomy tubes: a randomized, controlled trial. Laryngoscope. 2005; 115: 324-330.Granath, A., Rynnel-Dagoo, B., Backheden, M. & Lindberg, K. Tube associated otorrhea in children with recurrent acute otitis media; results of a prospective randomized study on bacteriology and topical

treatment with or without systemic antibiotics. International Journal of Pediatric Otolaryngology. 2008; 72: 1225-1233.Hannley MT, Denneny JC, Sedory Holzer, S. Consensus Report – Use of ototopical antibiotics in treating 3 common ear diseases. Otolaryngology – Head and Neck Surgery. 2000;122(6):934-940.Hartnick C.J., Brigger M.T., Willging J.P., et al. 2003. Surgery for pediatric vocal cord paralysis: a retrospective review. Ann Otol Rhinol Laryngol 112(1):1-6.AbstractHealy, G. 2000. “Introduction to Disorders of the Upper Airway.” In Pediatric Otolaryngology: Principles and Practice Pathways, edited by Ralph Wetmore et al., pp. 763-774. Thieme Publishers.Healy, G. 1989. Subglottic stenosis. The Otolaryngology Clinics of North America 22(3):599-606. Hellstrom, S., Groth, A., Jorgensen, F., Pettersson, A., Ryding, M., Uhlen, I. Ventilation Tube Treatment: A Systematic Review of the Literature.Heslop, A., Lildholdt, T., Gammelgaard, N. & Ovesen, T. Topical ciproflacin is superior to topical saline and systemic antibiotics in the treatment of tympanostomy tube otorrhea in children: The results

of a randomized clinical trial. Laryngoscope. 2010; DecemberKlassen, TP.. et al. 1998. Nebulized budesonide and oral dexamethasone for treatment of croup: a randomized controlled trial. JAMA 279:1629-32. Abstract.Robert Kliegman. 2007. Nelson Textbook of Pediatrics, 18th edition. Philadelphia, Saunders Section 382.1Knutson, D. Aring, A. 2004. Viral croup. American Family Physicians 69(3):535-40.Lasley, Mary V. 2000. Allergic and Nonallergic Rhinitides. In Allergy in Primary Care, edited by Altman, Leonard C., Becker, Jonathan W., Williams, Paul V., pp. 109-119. Phil: W.B. Saunders Leaute-Labreze, C., de la Roque, E., Hubiche, T., Boralevi, F. 2008. Propranolol for severe hemangiomas of infancy. New England Journal of Medicine358:2649-2651.Leung, Roxanne S., Katial, Rohit. 2008. The Diagnosis and Management of Acute and Chronic Sinusitis. Primary Care: Clinics in Office Practice, 35(1): 1-10. Lusk, Rodney P. 2010. Pediatric Chronic Sinusitis. In Cummings Otolaryngology: Head & Neck Surgery, 5th ed. Chapter 195. Philadelphia: Mosby.Miller, R., Gray, S., Cotton, R., Myer, C., Netterville, J. 1990. Subglottic stenosis and Down Syndrome. American Journal of Otolaryngology- Head and Neck Medicine and Surgery 11:274-277.Myer CM, O’Connor DM, Cotton RT. 1994. Proposed grading system for subglottic stenosis based on endotracheal tube sizes. Annals of Otol Rhinol Laryngology 103:319O-Lee, T., Messner, A. 2008. Subglottic hemangioma. Otolaryngology Clinics of North America 41: 903-911.Parker, G., Tami. T., Maddox, M. & Wilson, J. The effect of water exposure after tympanostomy tube insertion. Amer Journal of otolaryngology. 1994; 15: 193-196.Rittichier, KK. Ledwith,CA. 2000. Outpatient treatment of moderate croup with dexamehasone: intramuscular versus oral dosing. Pediatrics 106:1344-8. Abstract.Sobol, S., Zapata, S. 2008. Epiglottitis and croup. OtolaryngologicClinics of North America 41(3):551-66.Weber, Richard, W. 2008. Allergic Rhinitis. Primary Care: Clinics in Office Practice35: 1-10. Zipfel TE, Wood WE, Street DF, et al. The effect of topical ciprofloxacin on postoperative otorrhea after tympanostomy tube insertion. Am J Otol. 1999;20:416-420.