The midfacial degloving approach to sinonasal tumours in children

The midfacial degloving approach was originally described by Denker and Kahler in 1926 but has been little used in the paediatric population. The procedure allows access to benign and malignant lesions of the sinonasal region with the avoidance of an external scar. The advantages and application of this technique are presented in 9 paediatric patients, ranging from 3 months to 15 years of age with a mean follow-up of 7 months. Eight children had benign pathology. There were two juvenile angiofibromas, two nasal gliomas, one ossifying fibroma, one fibroma, one fibrous dysplasia and one benign myofibroblastic proliferation. One child had malignant disease in the form of recurrent embryonal rhabdomyosarcoma. All had excellent cosmetic results and no complications were encountered during follow-up.

Optimization of diarylamines as non-nucleoside inhibitors of HIV-1 reverse transcriptase

Following computational analyses, potential non-nucleoside inhibitors of HIV-1 reverse transcriptase have been pursued through synthesis and assaying for anti-viral activity. The general class Het-NH-Ph-U has been considered, where Het is an aromatic heterocycle and U is an unsaturated, hydrophobic group. Results for compounds with Het=2-thiazoyl and 2-pyrimidinyl are the focus of this report.

How we do it: BAHA positioning in patients with microtia requiring auricular reconstruction

Keypoints * Bilateral microtia is a challenging problem as these patients require both reconstruction of the auricle and rehabilitation of hearing. * Our aim was to find the optimal position for bone-anchored hearing aids (BAHA) in patients requiring reconstruction of the auricle on the same side. * From an analysis of five such operated patients, it was found that siting a BAHA 6.5-7.0 cm from the position of the external auditory meatus is probably the correct distance to facilitate optimal auricular reconstruction. * Using these criteria, a group of another five patients with BAHA awaiting auricular reconstruction were reviewed. Of these only three (60%) have been satisfactorily sited.

Bioinformatics, genomics and evolution of non-flagellar type-III secretion systems: a Darwinian perpective

We review the biology of non-flagellar type-III secretion systems from a Darwinian perspective, highlighting the themes of evolution, conservation, variation and decay. The presence of these systems in environmental organisms such as Myxococcus, Desulfovibrio and Verrucomicrobium hints at roles beyond virulence. We review newly discovered sequence homologies (e.g., YopN/TyeA and SepL). We discuss synapomorphies that might be useful in formulating a taxonomy of type-III secretion. The problem of information overload is likely to be ameliorated by launch of a web site devoted to the comparative biology of type-III secretion ().

Bioinformatics analysis of the locus for enterocyte effacement provides novel insights into type-III secretion

Background

Like many other pathogens, enterohaemorrhagic and enteropathogenic strains of Escherichia coli employ a type-III secretion system to translocate bacterial effector proteins into host cells, where they then disrupt a range of cellular functions. This system is encoded by the locus for enterocyte effacement. Many of the genes within this locus have been assigned names and functions through homology with the better characterised Ysc-Yop system from Yersinia spp. However, the functions and homologies of many LEE genes remain obscure.

Results

We have performed a fresh bioinformatics analysis of the LEE. Using PSI-BLAST we have been able to identify several novel homologies between LEE-encoded and Ysc-Yop-associated proteins: Orf2/YscE, Orf5/YscL, rORF8/EscI, SepQ/YscQ, SepL/YopN-TyeA, CesD2/LcrR. In addition, we highlight homology between EspA and flagellin, and report many new homologues of the chaperone CesT.

Conclusion

We conclude that the vast majority of LEE-encoded proteins do indeed possess homologues and that homology data can be used in combination with experimental data to make fresh functional predictions.

Laryngeal ultrasound to assess vocal fold paralysis in children

The purpose of this study was to assess the practicality and validity of laryngeal ultrasound to establish vocal fold movement in children with suspected vocal fold palsy. Fifty-five consecutive patients (age range three days to 12 years) with suspected vocal fold palsy underwent both laryngoscopy and laryngeal ultrasound. Ultrasonographic findings correlated with endoscopic findings in 81.2 per cent of cases. This, however, rose to a concordance rate of 89.5 per cent in patients aged over 12 months. Laryngeal ultrasound is well-tolerated, safe and non-invasive and the authors feel that it is a useful adjunct to endoscopy in the diagnosis of vocal fold palsy.

An update on choanal atresia surgery at Great Ormond Street Hospital for Children: preliminary results with Mitomycin C and the KTP laser

We present the results of transnasal choanal atresia correction in 46 children, as an update to the published Great Ormond Street Hospital series. Females outnumbered males 2-1, and half the cases in our series were bilateral. Eight of the children with bilateral atresia had the CHARGE association. The median number of procedures required was three over a period of up to 3 years. Eighty-two percent of children with unilateral atresia and 78% of those with bilateral atresia were asymptomatic at the time of their last follow up. Four deaths occurred, all but one in children with CHARGE association. We were not able to demonstrate any benefit from the use of Mitomycin C, the KTP laser, betamethasone nasal drops or (in unilateral cases) stents.

The ETT2 gene cluster, encoding a second type III secretion system from Escherichia coli, is present in the majority of strains but has undergone widespread mutational attrition

ETT2 is a second cryptic type III secretion system in Escherichia coli which was first discovered through the analysis of genome sequences of enterohemorrhagic E. coli O157:H7. Comparative analyses of Escherichia and Shigella genome sequences revealed that the ETT2 gene cluster is larger than was previously thought, encompassing homologues of genes from the Spi-1, Spi-2, and Spi-3 Salmonella pathogenicity islands. ETT2-associated genes, including regulators and chaperones, were found at the same chromosomal location in the majority of genome-sequenced strains, including the laboratory strain K-12. Using a PCR-based approach, we constructed a complete tiling path through the ETT2 gene cluster for 79 strains, including the well-characterized E. coli reference collection supplemented with additional pathotypes. The ETT2 gene cluster was found to be present in whole or in part in the majority of E. coli strains, whether pathogenic or commensal, with patterns of distribution and deletion mirroring the known phylogenetic structure of the species. In almost all strains, including enterohemorrhagic E. coli O157:H7, ETT2 has been subjected to varying degrees of mutational attrition that render it unable to encode a functioning secretion system. A second type III secretion system-associated locus that likely encodes the ETT2 translocation apparatus was found in some E. coli strains. Intact versions of both ETT2-related clusters are apparently present in enteroaggregative E. coli strain O42.

Defining a molecular mechanism of synergy between nucleoside and nonnucleoside AIDS drugs

Combination therapies treating human immunodeficiency virus type 1 (HIV-1) infection delay the emergence of drug-resistant virus and exhibit synergistic inhibition. This synergy is observed within the two classes of inhibitors that target the essential viral reverse transcriptase (RT): the chain-terminating nucleoside analogs (NRTIs) and the allosteric nonnucleosides (NNRTIs) that bind in a pocket distinct from the active site. A general mechanism to define the molecular basis for synergy between these two classes remains to be elucidated. Previous mechanistic studies from our laboratory (Spence, R. A., Kati, W. M., Anderson, K. S., and Johnson, K. A. (1995) Science 267, 988-993) have shown that the natural deoxynucleoside triphosphate and the NNRTI can simultaneously bind to their respective sites. This work also suggests communication between the two sites, since the inhibition of RT by NNRTIs is manifested through a remote effect on the chemical step. This interplay between the two sites offers a plausible hypothesis for understanding synergy in which binding of NNRTIs modulates the chain termination by NRTIs. The present study supports this hypothesis by illustrating that the clinically approved NNRTIs, nevirapine and efavirenz, inhibit the ATP-mediated removal of AZTMP, d4TMP, ddCMP, (-)3TCMP, (-)FTCMP, and (+)3TCMP, thereby prolonging the effectiveness of chain termination. This inhibition is mediated through an effect on both the rate of the chemical step and binding of ATP, resulting in an overall decrease in efficiency of removal. This work substantiates communication between the two binding pockets, the sustained use of combination therapy to treat HIV infection, and a molecular basis for understanding synergy.

Type IV laryngotracheoesophageal clefts -- recent 5 year experience at Great Ormond Street Hospital for Children

This article summarises a 5 year experience of type IV laryngotracheoesophageal clefts from Great Ormond Street Hospital for Children, London. We present six infants who had type IV clefts, two of whom are long-term survivors, and we review the literature. The recognition of specific complicating issues may lead to a standardised approach, which can result in successful repair and long-term survival. Increased awareness of the condition and early diagnosis combined with aggressive, planned surgical intervention in centres of paediatric expertise should result in a significant reduction of current mortality.

Aryepiglottoplasty for laryngomalacia: 100 consecutive cases

A retrospective review of the notes of 100 consecutive patients who had undergone aryepiglottoplasty for laryngomalacia, at Great Ormond Street Hospital for Children, was undertaken. Fifty-six were male, 44 female and 47 were under three months of age. Indications for surgery were oxygen desaturation below 92 per cent and feeding difficulties causing failure to thrive. Forty-seven patients had other pathology contributing to their airway compromise or feeding problems. Improvement in stridor after one month was achieved in 86/91 (94.5 per cent) being abolished completely in 50/91 (55 per cent). Of the 25 per cent of patients whose symptoms took more than one week to resolve, 16/22 (63.6 per cent) were later found to have a serious neurological condition. Feeding was improved in 42 of 58 patients (72.4 per cent) who had a pre-operative feeding difficulty. The complication rate was low, with only five out of 86 (10 per cent) experiencing initial worsening of the airway and six per cent having aspiration of early feeds before improvement occurred. Endoscopic aryepiglottoplasty remains the operation of choice for patients with severe laryngomalacia, however, in the presence of neurological disease surgery is less likely to be successful.

Management and outcome of choanal atresia correction

OBJECTIVES

Outcome analyses of factors that may either maximize success or predict a better outcome following choanal atresia correction.

METHODS

A retrospective review of children undergoing choanal atresia correction at Great Ormond Street Hospital for Children, London between January 1990 and April 1998. Children with unilateral or bilateral choanal atresia were studied. In all cases, correction was by a transnasal approach under endoscopic control. A 120 degrees Hopkins rod telescope was used to visualize the atretic plate from the nasopharynx. Straight urethral sounds were used to perforate the plate followed by use of an air drill to remove the bony component. Portex endotracheal tubes were subsequently inserted as nasal stents.

RESULTS

Sixty-five children (19 M, 46 F: age range 1 day to 17 years) presented with choanal atresia and the outcomes for 46 were included in the study. Twenty-six patients (40%) had other major anomalies. In children with unilateral atresia neither duration of stenting nor presence of facial anomalies had an impact on outcome. Of those children with bilateral choanal atresia and associated facial anomalies (n=9), 56% were asymptomatic following correction. In children with isolated bilateral choanal atresia (n=19), 74% were asymptomatic following correction; 29% (n2.3 kg (n3. 5 mm (n=6) had an 83% chance of a good outcome. Those patients stented with a tube </=3.5 mm (n=22) had only a 64% success rate. None of the patients who were stented for at least 12 weeks remained symptomatic.

CONCLUSIONS

Neonates with bilateral choanal atresia who were stented for at least 12 weeks with the largest Portex tube that comfortably passed through the anterior nares had the best outcome. If they had either associated anomalies or low weight at surgery, they were less likely to become asymptomatic. For patients with unilateral choanal atresia, neither the presence of facial anomalies nor stent duration had an impact on outcome.

Investigation and treatment of thyroglossal cysts in children

Thyroglossal cysts are the commonest midline neck masses in children. To evaluate current practice questionnaires were sent to all ear, nose and throat (ENT) and paediatric surgeons in the UK and 72% responded. The commonest investigation requested was an ultrasound scan (54%) and the commonest operation was a variant of Sistrunk's procedure (78%). Paediatric surgeons did fewer investigations than ENT surgeons and tended to excise more of the thyroglossal tract. Review of the published work suggests that ultrasound scanning and Sistrunk's procedure are the best management policy. The scan can avoid inadvertent excision of an ectopic thyroid gland. Extensive thyroglossal tract excisions give lower recurrence rates.

Laparostomy for severe intra-abdominal infection complicating colorectal disease

PURPOSE

The aim of this study was to evaluate the use of laparostomy in the management of patients with severe intra-abdominal infection resulting from colorectal disease.

METHODS

Seven patients, four with inflammatory bowel disease, two with colorectal carcinoma, and one with diverticular perforation, underwent laparostomy during a six-year period for postoperative, severe, intra-abdominal infection.

RESULTS

The median age was 42 years, the mean Acute Physiology and Chronic Health Evaluation II score was 22.7, and the observed mortality was 28.6 percent (2/7 patients). In one patient the laparostomy was closed at 11 days; in all the others the wound was left to heal by granulation and contraction, and two of these later required reconstructive surgery. The median follow-up was three years and seven months.

CONCLUSION

Laparostomy is an effective and practical method of managing patients with severe intra-abdominal infection as a result of colorectal disease.

Pediatric vocal fold paralysis: a long-term retrospective study

OBJECTIVE

To review our experience of pediatric vocal fold paralysis (VFP), with particular emphasis on etiological factors, associated airway pathologic conditions, and treatment and prognostic outcomes.

DESIGN

Retrospective case review of a cohort of patients presenting with VFP.

SETTING

Tertiary referral center.

PATIENTS

A consecutive sample of 102 patients presenting with VFP to Great Ormond Street Hospital for Children, London, England, over a 14-year period from 1980 to 1994.

RESULTS

There was an almost equal distribution of unilateral (52% [n = 53]) and bilateral (48% [n = 49]) VFP. Iatrogenic causes (43% [n = 44]) formed the largest group, followed by idiopathic VFP (35% [n = 36]), neurological causes (16% [n = 16]), and finally birth trauma (5% [n = 5]). Associated upper airway pathologic conditions were noted in 66% (n = 23) of patients who underwent tracheotomy. Tracheotomy was necessary in only 57% (n = 28) of children with bilateral VFP. Prognosis was variable depending upon the cause, with neurological VFP having the highest rate of recovery (71% [5/7]) and iatrogenic VFP the lowest rate (46% [12/26]).

CONCLUSION

Recovery after an interval of up to 11 years was seen in idiopathic bilateral VFP; this has significant implications when considering lateralization procedures in these patients.

An inquiry-based teaching tool for understanding arterial blood pressure regulation and cardiovascular function

Educators are placing a greater emphasis on the development of cooperative laboratory experiences that supplement the traditional lecture format. The new laboratory materials should encourage active learning, problem-solving, and inquiry-based approaches. To address these goals, we developed a laboratory exercise designed to introduce students to the hemodynamic variables (heart rate, stroke volume, total peripheral resistance, and compliance) that alter arterial pressure. For this experience, students are presented with "unknown" chart recordings illustrating pulsatile arterial pressure before and in response to several interventions. Students must analyze and interpret these unknown recordings and match each recording with the appropriate intervention. These active learning procedures help students understand and apply basic science concepts in a challenging and interactive format. Furthermore, laboratory experiences may enhance the students' level of understanding and ability to synthesize and apply information. In conducting this exercise, students are introduced to the joys and excitement of inquiry-based learning through experimentation.

Late Cenozoic Reverse Faulting in the Fall Zone, Southeastern Virginia

A set of en-echelon reverse faults cut Paleozoic metamorphosed igneous rocks of the Piedmont and overlying late Cenozoic sediments at the Old Hickory Heavy Mineral Deposit in the Fall Zone of southeastern Virginia. Diorite of the eastern Slate Belt was faulted over nearshore to shore-face deposits of the Pliocene Yorktown Formation. These NW-SE-striking faults experienced oblique dip-slip movement with a maximum displacement of up to 6 m on individual faults. Faults tip out along strike and are overlain by distinct cobble beds, suggesting that sediment deposition and faulting were contemporaneous. Deformation at Old Hickory may have been formed by reactivation of existing Paleozoic structures under a regionally extensive compressional stress field parallel to the modern one.

Prenatal care for low-income women enrolled in a managed-care organization

OBJECTIVE

To determine barriers to prenatal care among managed-care enrollees who receive Medicaid.

METHODS

In-person interviews were conducted with women 13-45 years old who were members of the Prudential HealthCare Community Plan in Memphis, Tennessee. Interview data were linked to medical chart reviews for 200 women who were currently pregnant or had delivered a baby since enrollment in Prudential. Factors related to untimely entry to prenatal care and inadequate prenatal visits were examined.

RESULTS

More than half of the respondents had either untimely entry to or inadequate prenatal care. Overall, 89% of respondents had favorable attitudes about prenatal care. Several system and personal factors were associated with receipt of early or adequate prenatal care. Multivariate analysis showed that one system and two personal factors remained significantly related to entry to prenatal care. Women who entered Prudential during pregnancy were 2.4 times more likely (95% CI 1.1, 5.0) to receive late care than women who enrolled before pregnancy. Women who felt too tired to go for care were 2.2 times more likely (95% CI 1.0, 4.9) to receive late care. Women who experienced physical violence during pregnancy were 3.5 times more likely (95% CI 1.0, 12.0) to receive late care. Multivariate analysis with adequacy of prenatal care as the outcome showed several personal factors that increased odds of receiving inadequate prenatal care; however, only help from the infant's father was significantly related to adequacy of prenatal care. Women who did not have much help from the infant's father were 1.9 times more likely not to have adequate care (95% CI 1.0, 3.6).

CONCLUSION

Even when affordable care was available, many low-income women did not avail themselves of it. Although women knew the importance of prenatal care, there was a gap between attitudes and actually seeking appropriate care. System and personal factors need to be addressed to overcome barriers to prenatal care.

Educational puzzles for understanding gastrointestinal physiology

We developed four innovative, creative, and fun educational tools to promote active learning, enhance problem-solving skills, and encourage small group discussion. Furthermore, the tools encourage deductive reasoning and critical thinking rather than passive memorization of material. The tools include crossword puzzles, hidden messages, word scrambles, and word searches. These tools were developed using two computer programs: the Crossword Construction Kit and The New Puzzle Factory. Instructors are encouraged to optimize the value of the tools by using the additional options presented at the end of each of the puzzles. The additional options encourage students to become active learners by creating their own tools. Although the principles of these four tools can be adapted to many disciplines, these specific games focused on gastrointestinal physiology. Our goal was to create tools that can be used either inside or outside the classroom to complement and enhance the lecture.

"Virtual rat": a tool for understanding hormonal regulation of gastrointestinal function

This manuscript describes a "dry laboratory" using the "virtual rat" to help students understand the hormonal regulation of gastrointestinal function. The laboratory was modeled after a recent exercise that used the virtual rat to teach basic endocrine physiology. The virtual rat concept avoids the many obstacles associated with animal experimentation (for example, lack of adequate animal facilities, expense, equipment, and limited teacher experience). Our goal was to create a fun and educational experience while avoiding the complications associated with laboratory experimentation. No additional materials are required to complete this exercise. After finishing this laboratory, the students should have a greater understanding and appreciation for experimental design and the collection, analysis, and interpretation of data.

Plummer-Vinson syndrome--a rare presentation in a child

Plummer-Vinson (Paterson, Brown-Kelly) syndrome refers to the association of iron-deficiency anaemia with dysphagia secondary to a post-cricoid web. Only seven cases of Plummer-Vinson syndrome in children and adolescents between the ages of 14 and 19 have been reported in the world literature. We report a case of the syndrome occurring in a child of 14 years and provide a short review of the present knowledge concerning the symptom complex.

Long-term follow-up of submandibular duct rerouting for the treatment of sialorrhea in the pediatric population

OBJECTIVE

To determine the long-term control of sialorrhea in children who underwent submandibular duct rerouting (SMDR) and to identify potential preoperative predictors of outcome.

DESIGN

Retrospective chart review of children who underwent SMDR; information updated by discussion with the permanent caregiver.

SETTING

Tertiary care center.

PATIENTS

Children who had significant sialorrhea resulting from a variety of neuromuscular disabilities between January 1980 and December 1995.

OUTCOME

We report the outcome on 59 patients who underwent SMDR for the treatment of sialorrhea. Patients were ascribed a preoperative sialorrhea and global neurologic deficit score. Postoperative outcome was scored as marked, moderate, no improvement, or worse. Twenty-eight of 59 (47.4%), 28 of 59 (47.4%), and 3 of 59 (5.1%) of the patients had preoperative sialorrhea scores of 3 (profuse), 2 (moderate), and 1 (mild), respectively. Twenty of 59 (33.9%), 29 of 59 (49.2%), and 10 of 59 (16.9%) had preoperative scores of 3 (severe), 2 (moderate), and 1 (mild) neurologic impairment, respectively. Mean time to follow-up of the 59 patients was 5.46 years. Postoperative improvement scores were as follows: 50.8% had marked, 28.8% had moderate, and 20% had no to minimal improvement in their sialorrhea. Two patients were transiently worse. A complication rate of 11.3% (9 of 79) was demonstrated: 7 ranulae, 1 transient swelling of the floor of the mouth, and 1 submandibular gland infection. The preoperative global neurologic deficit score was found to be more predictive of surgical outcome than sialorrhea score.

Update on paediatric tracheostomy tubes

In the recent past there has been a significant expansion in the range of paediatric tracheostomy tubes available. This has mainly been in response to clinicians' requests. This article reviews those now available and the situations in which they are useful. A sizing chart is included for easy reference.

Laryngeal paraganglioma in a five-year-old child--the youngest case ever recorded

A paraganglioma is a neuroendocrine neoplasm that originates from the paraganglion cells of the parasympathetic system. The average age of presentation is in the fifth decade. We report a case of laryngeal paraganglioma in a five-year-old child, the youngest case ever recorded. The features of paraganglioma which differentiate it from other tumours are also discussed.

Labyrinthine involvement in Langerhans' cell histiocytosis

BACKGROUND

Langerhans' cell histiocytosis, a rare condition caused by the proliferation of abnormal Langerhans' cells ('LCH cells') and an accompanying granulomatous infiltrate, can affect several organs including the ear. External and middle ear involvement are common with a reported incidence as high as 61%. The bony labyrinth is resistant to erosion by the granulation tissue, thereby protecting the cochlea and vestibular structures. Probably for this reason, involvement of the inner ear is rare, with few case reports in the literature.

PATIENTS

We report two girls, one with bilateral and the other with unilateral mastoid involvement, in whom there was invasion of the labyrinth. The first girl had 'single system' LCH affecting only bone and developed an acute hearing loss due to invasion of the cochlea, while the second had both bone and skin involvement and labyrinthine involvement was diagnosed on imaging prior to the onset of labyrinthine symptoms.

CONCLUSION

Inner ear involvement can lead to permanent deafness, which may be prevented by early institution of treatment. Threatened inner ear involvement requires urgent systemic medical therapy with steroids, possibly combined with chemotherapy.

Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization. A randomized, controlled trial

BACKGROUND

Control of hyperglycemia delays or prevents complications of diabetes, but many persons with diabetes do not achieve optimal control.

OBJECTIVE

To compare diabetes control in patients receiving nurse case management and patients receiving usual care.

DESIGN

Randomized, controlled trial.

SETTING

Primary care clinics in a group-model health maintenance organization (HMO).

PATIENTS

17 patients with type 1 diabetes mellitus and 121 patients with type 2 diabetes mellitus.

INTERVENTION

The nurse case manager followed written management algorithms under the direction of a family physician and an endocrinologist. Changes in therapy were communicated to primary care physicians. All patients received ongoing care through their primary care physicians.

MEASUREMENTS

The primary outcome, hemoglobin A1c (HbA1c) value, was measured at baseline and at 12 months. Fasting blood glucose levels, medication type and dose, body weight, blood pressure, lipid levels, patient-perceived health status, episodes of severe hypoglycemia, and emergency department and hospital admissions were also assessed.

RESULTS

72% of patients completed follow-up. Patients in the nurse case management group had mean decreases of 1.7 percentage points in HbA1c values and 43 mg/dL (2.38 mmol/L) in fasting glucose levels; patients in the usual care group had decreases of 0.6 percentage points in HbA1c values and 15 mg/dL (0.83 mmol/L) in fasting glucose levels (P < 0.01). Self-reported health status improved in the nurse case management group (P = 0.02). The nurse case management intervention was not associated with statistically significant changes in medication type or dose, body weight, blood pressure, or lipids or with adverse events.

CONCLUSIONS

A nurse case manager with considerable management responsibility can, in association with primary care physicians and an endocrinologist, help improve glycemic control in diabetic patients in a group-model HMO.

Management of subglottic haemangioma

Two contrasting methods of treatment for paediatric subglottic haemangioma are presented. Dr Hoeve describes his results using intralesional steroids and short-term intubation, and Dr Froehlich discusses his outcomes with open surgical excision. Mr Bailey then reviews the currently available therapeutic options with special reference to each of the above techniques, and suggests an optimum plan of management given our current state of knowledge. The conclusion is that very small haemangiomas may not require treatment, or may be amenable to CO2 laser vaporization. Medium-sized lesions seem suitable for intra-lesional steroids and intubation, but large ones are probably best managed by primary submucous resection. Very large haemangiomas, and especially those which are circumferential or in which magnetic resonance imaging (MRI) shows extension down into the trachea and/or through the tracheal wall into the surrounding tissues, may be more safely dealt with by performing a tracheostomy and awaiting spontaneous involution.

Otologic and laryngologic manifestations of mucopolysaccharidoses after bone marrow transplantation

INTRODUCTION

Children with mucopolysaccharidosis have significant functional impairment of a number of systems because of deposition of glycosaminoglycans. The otolaryngologic system is affected, resulting in conductive and sensorineural hearing loss and voice abnormality.

METHOD

Eleven children who had undergone bone marrow transplantation had their hearing and voices assessed. Unmatched data from patients who had not undergone transplantation were collected for nonstatistical comparison.

RESULTS

The hearing loss in children who had undergone bone marrow transplantation was variable but on average was less severe than in the younger children who had not undergone transplantation. The incidence of otitis media with effusion was diminished in the transplanted group. Approximately half had normal voices.

DISCUSSION

Diminution of the progression of hearing loss and voice abnormality probably occurs in patients after treatment by bone marrow transplantation.

Measuring pediatric immunization status in a managed care organization: agreement between medical charts and parent telephone interviews

OBJECTIVE

To measure the agreement between pediatric immunization data obtained from medical charts and data provided by parents during telephone interviews and to assess the reliability of immunization information provided during parent telephone interviews.

DESIGN

Medical charts reviews and telephone interviews with parents.

SETTING

Prudential HealthCare.

PARTICIPANTS

Children sampled for the 1993 HEDIS study and the parents of those children (n = 356).

MAIN OUTCOME MEASURE

Overall agreement between immunization data obtained from medical charts and data provided by parents during telephone interviews.

RESULTS

Agreement between immunization data obtained from medical charts and data provided in parent telephone interviews varies from poor to good if the parent refers to a shot record during the interview. Agreement between the two data sources is better with single dose vaccines (i.e., 1 MMR) than multiple dose vaccines (i.e., 4 DTP). Although parents tend to report fewer immunizations than are indicated in the child's medical chart, the medical charts in this study contained too many vaccine omissions to be considered reliable "gold standards" of vaccine receipt. Parents who refer to a shot record when providing information about pediatric immunizations provide reliable data (r = .8807-1.0).

CONCLUSION

When measuring completion of the immunization series, especially among parents who do not have access to a shot record, medical chart reviews remain the better approach in the managed care setting.

Surgical experience with bone-anchored hearing aids in children

Titanium osseointegrated implants for bone-anchored hearing aids (BAHAs) have been in use since 1977. A series of 32 children who received implantation since 1990 is reported. The report focuses on the surgical aspects of BAHAs, predisposing factors, and prevention of complications in an unusual pediatric population. The records of 32 children who had undergone two-stage implantation of a BAHA were retrospectively reviewed. The majority of the patients had craniofacial abnormalities. Of the 32 implantees, 29 use their BAHA at present. Five children failed to achieve osseointegration, and eight patients have had revision surgery for lost abutments, trauma, or chronic skin problems. There were no differences between preimplantation and postimplantation bone or air conduction thresholds. The pediatric BAHA carries with it a unique set of challenges and problems but can be successfully implanted and maintained.

Maternity experiences in a managed care organization

We conducted a telephone survey of female managed care enrollees who recently had a normal vaginal delivery to examine the relationship between hospital length-of-stay and maternal characteristics, pregnancy factors, length-of-stay preferences, and postdischarge experiences. Results indicated that length-of-stay varied by maternal characteristics and pregnancy factors. Length-of-stay and maternal or newborn readmissions were not statistically associated. Most respondents reported that they would be willing to go home within twenty-four hours after future deliveries if additional services were provided. Emphasis should be placed on which services can be provided to prepare and assist mothers through the perinatal period.

The Great Ormond Street protocol for ward decannulation of children with tracheostomy: increasing safety and decreasing cost

Ward decannulation is the eventual endpoint for the majority of the 40 children managed by tracheostomy at Great Ormond Street Hospital each year. Our previous protocol dictated a 10 day stay in hospital for the 25 children decannulated annually. The aim of this retrospective study was to determine the minimum safe duration for this inpatient stay. In addition, we hoped to identify any factors which might distinguish potentially successful candidates from those likely to fail decannulation. Of 104 patients decannulated between January 1991 and January 1996, complete nursing and medical records were retrieved for 84 children. These notes were retrospectively reviewed and in this group of patients there were 101 attempted decannulations. Information about the initial pathology, interim course and details of the decannulation were collected. Summary statistics were generated. There was no relation between initial pathology or duration of tracheostomy and eventual success or failure of decannulation. Observations by the nursing staff of restlessness, anxiety and recession appeared more frequently in children who eventually failed decannulation. All failures occurred within 48 h of the 24 h trial of tracheostomy blocking. Our results suggest that a safe decannulation protocol can allow discharge after day five.

Surgical aspects of paediatric cochlear implantation

Cochlear implantation in the paediatric population is now an accepted method of rehabilitating profoundly or totally deaf children. The problems of cochlear implantation in children with other significant medical problems are examined. A retrospective review of the records of the first 45 children implanted at our centre was carried out. The review focused on surgical factors and outcome in addition to variations in technique which have occurred since the programme began. Congenital hearing loss was the most common indication for implantation. Fifteen children (33 per cent) had other medical problems. Three cases of flap breakdown (two occurring after direct trauma to the package bed) and one case of a misplaced electrode requiring re-implantation accounted for the only major complications to date. Minor complications included hypertrophic scar formation and post-operative wound infection. All children were using their implants at the time of this review, but two have subsequently been explanted. Cochlear implantation of children with multiple medical problems requires acceptance of a slightly higher risk of complications.

Otitis media with effusion in paediatric cochlear implantees: the role of peri-implant grommet insertion

INTRODUCTION

Otitis media with effusion (OME) is a common disease coincident with the need for cochlear implantation in 44% of the 45 children (mean = 4.8 years) currently implanted at our centre. Our suspicion that peri-implant effusion contributed to complications generated our interest in studying this issue.

METHOD

Retrospective review of patient records was carried out with the focus on clinical and audiological evidence of OME before, during and after implantation. Operative records were reviewed to determine any effect OME had on the procedure and postoperative complications.

RESULTS

Of our 45 implanted patients, 10 males and 10 female had OME prior to or after implantation. Pre-implant, 19 children had OME diagnosed and 11 received grommets (6 had multiple sets). Peri-implantation, 11 children had OME. These children with peri-implant effusions had 2 of 3 major, 2 of 2 intermediate and 1 of 2 minor complications. Children with peri-implant effusions also accounted for 3 of 4 cases in which there were bothersome middle ear effusions or granulation tissue at operation. The 6 children in whom grommets were placed within two months of cochlear implantation accounted for only one case of effusion at implantation and their courses were complicated only by a keloid in one child and a late flap disruption in another.

SUMMARY

Insertion of grommets prior to cochlear implantation in children with peri-implant OME may provide some protection against intra-operative and some post-operative complications. Our management policy in patients with OME now aims at placing grommets such that they are in and patent at the time of implantation.

Pediatric tracheal homograft reconstruction: a novel approach to complex tracheal stenoses in children

PURPOSE

Tracheal stenosis can be a life-threatening problem in children. Long-segment tracheal stenosis and recurrent tracheal stenosis are especially problematic. Tracheal homograft reconstruction represents a novel therapeutic modality for these patients.

METHODS

Cadaveric trachea is harvested, fixed in formalin, washed in thimerosal (Methiolate), and stored in acetone. The stenosed tracheal segment is opened to widely patent segments proximally and distally. The anterior cartilage is excised and the posterior trachealis muscle or tracheal wall remains. A temporary silicone rubber intraluminal stent is placed and absorbable sutures secure the homograft. Regular postoperative bronchoscopic treatment clears granulation tissue. The stent is removed endoscopically after epithelialization over the homograft. Twenty-four children with severe tracheal stenosis (age 5 months to 18 years, mean +/- standard error of the mean = 8.18 +/- 1.21 years) underwent tracheal homograft reconstruction. All but one had had previous unsuccessful reconstructive attempts. Ten lesions were congenital, nine were posttraumatic, and five were due to prolonged intubation.

RESULTS

Follow-up ranged from 5 months to 10 years (3.79 +/- 0.70 years). Twenty patients survive (20/24 = 83%), 16 without any airway problems. Four patients are still undergoing treatment. One patient requiring emergency extracorporeal membrane oxygenator support before the operation died 10 days after tracheal homograft reconstruction. Another patient with severe preoperative mediastinal sepsis died 3.5 months after tracheal homograft reconstruction. Two patients with functional airways died late of unrelated problems.

CONCLUSIONS

Tracheal homograft reconstruction demonstrates encouraging short-term to medium-term results for children with severe recurrent tracheal stenosis. Postoperative bronchoscopic and histologic studies provide evidence of epithelialization and support the expectation of good long-term results.

Successful complete tracheal resection in a three-month-old infant

We report an infant with severe long-segment tracheal stenosis in whom the posterior trachea was formed by complete cartilage rings and the anterior trachea was almost totally formed by a solid cartilage plate. The child was successfully treated initially by complete resection of the trachea and primary end-to-end repair and subsequently with tracheal homograft transplantation for secondary stenosis.

Craniometaphyseal and craniodiaphyseal dysplasia, head and neck manifestations and management

Craniometaphyseal and craniodiaphyseal dysplasia are rare genetic disorders of bone due to modelling errors of long bones and skull bones. These syndromes present with multiple ENT symptomatology from an early age. The diagnostic distinction can now be made radiologically by serial skeletal survey which is important for prognosis. We review the clinical, radiological, computed tomography (CT) scan, otological, audiological and histopathological findings in two cases with craniodiaphyseal, and two cases with craniometaphyseal dysplasia, and report our experiences of medical and surgical treatment to date. In the craniodiaphyseal dysplasia, the hearing abnormality progressed from an initial conductive to a mixed loss on serial audiometric follow up. Temporal bone CT scans showed narrowing of the middle ear cavity, internal auditory meatus, and facial nerve canal at the geniculate ganglion. Benefits from choanal stenosis surgery, craniofacial remodelling and dacrocystorhinostomy were shortlived. Calcitriol therapy with a low calcium diet did not alter the clinical course of progression in our cases. The underlying defect, causing net bone formation in these phenotypically similar syndromes, appears to be different when based on the differing biochemical responses to calcitriol and bone biopsy findings. Increased numbers of osteoblasts were found in bone biopsies from both cases with craniodiaphyseal dysplasia. Early recognition is crucial in these conditions as therapy directed at the underlying bony defect has the best chance of success if initiated in infancy.

Nasal lipomas presenting as part of a syndromic diagnosis

An important part of the initial assessment of children presenting with congenital nasal masses is to exclude an intracranial extension using either magnetic resonance imaging (MRI) or computed tomography (CT) imaging. We present three patients with such lesions in which unusual radiological findings were noted as part of the investigations.

The ENT manifestations of HIV infection in children

This study identified the ENT symptoms of 66 HIV infected children over an 8 year period (1986-1993) at Great Ormond Street Hospital for Children. The incidence, nature and age of onset of ENT symptoms were investigated; 91% of the children had ENT symptoms, the most common being cervical lymphadenopathy, oro-oesophageal candidiasis and otitis media. The HIV infected children suffered from the common ENT diseases of childhood. They also presented with specific conditions such as diffuse parotid swelling. Therefore, their clinical features differed from HIV infected adults as well as non-infected children. An increasing incidence of paediatric HIV infection was demonstrated by the study. Most were due to vertical transmission. ENT surgeons are likely to see more HIV infected children in future, either with the usual ENT diseases of childhood (to which they seem more susceptible) or with HIV-specific conditions. Although the diagnosis of HIV may be known, the ENT condition could be the initial presentation suggestive of immunodeficiency.

Tracheal reconstruction in children using cadaveric homograft trachea

OBJECTIVE

We report the use of cadaveric human tracheal homograft in the treatment of severe long segment congenital tracheal stenosis in children.

METHODS

Five children (aged 5 months-8 years) with severe life-threatening airway obstruction due to long segment congenital tracheal stenosis had failed conventional management. All were ventilator dependent or rapidly deteriorating at the time of surgery, two were on extracorporeal membrane oxygenation, and no alternative therapy was available. The stenosed trachea was removed and the posterior trachealis muscle left in situ when possible. Surgical technique involved the use of cardiopulmonary bypass in four of five cases. Stored cadaveric tracheal homograft tissue was shaped and inserted over a silastic intra-luminal stent which was kept in place for up to 3 months. Regular bronchoscopy was necessary postoperatively to clear granulation tissue, which resolved on removal of the stent.

RESULTS

Four patients are all now without stents, intubation or tracheostomy. Three are without airway problems 16, 14, and 9 months after surgery and one attends for occasional dilatation of a distal tracheal stenosis, but is now at home despite other severe multiple congenital problems. One patient presented with complete disruption of the trachea and mediastinal sepsis and was supported on extracorporeal membrane oxygenation prior to surgery; this patient eventually died of airway failure and sepsis.

CONCLUSIONS

The application of cadaveric human tracheal homograft to congenital tracheal stenosis is novel. Its use in five children who would otherwise have died has provided an extra therapy in an extremely difficult group of patients.

Management of posterior laryngeal and laryngotracheoesophageal clefts

OBJECTIVE

To review the clinical features, associated congenital abnormalities, management, and morbidity of infants presenting with posterior laryngeal and laryngotracheal clefts.

DESIGN

Case series.

SETTING

Great Ormond Street Hospital for Sick Children NHS Trust, London, England.

PATIENTS

Consecutive sample of 44 patients presenting with posterior laryngeal and laryngotracheal clefts between December 10, 1979, and January 30, 1992.

MAIN OUTCOME MEASURES

Clinical features, incidence of surgery, and associated morbidity and mortality related to different types of airway cleft.

RESULTS

The main presenting features were stridor and aspiration, which were more evident with the more extensive clefts. Twenty-five patients (56%) had associated congenital abnormalities. Fourteen patients (32%) were treated conservatively. Sixteen patients (36%) underwent primary endoscopic surgical repair. Eight patients (18%) underwent primary repair via an anterior laryngofissure; and six patients (14%) underwent primary repair via a lateral pharyngotomy. Eight patients (18%) required revision surgery, two (4%) of them on more than one occasion. Ten patients (23%) required fundoplication to control gastroesophageal reflux. Six patients (14%) died.

CONCLUSIONS

The identification of an airway cleft requires a high index of suspicion. Morbidity and mortality are reduced by securing the airway, controlling gastroesophageal reflux, and using a multidisciplinary pediatric team. We recommend the anterior laryngofissure because of the ease of surgical access.

Pharyngeal trauma in children--accidental and otherwise

Pharyngeal perforation is an uncommon injury in children. Most reported cases to date have been secondary to instrumentation or penetrating wounds. Laceration to the pharyngeal wall may introduce air, secretions and bacteria into the parapharyngeal space and mediastinum and consequently has potentially life-threatening sequelae. The management of these injuries is controversial. We present a series of four children who suffered pharyngeal trauma, accidentally and otherwise, and discuss their management. We recommend a high index of suspicion of pharyngeal injury in all cases of oropharyngeal trauma and overnight admission to hospital for observation until an accurate diagnosis has been established. Non-accidental injury of the child must be seriously considered in all cases.

Recurrent respiratory papillomatosis in the larynx: re-emergence of clinical disease following surgery

The treatment and aetiology of recurrent respiratory papillomatosis remains unclear. We report a case of laryngeal papillomatosis where repeated suction diathermy and later laser treatment led to the formation of a substantial glottic web, but a clinically papilloma-free state of the upper aerodigestive system. Division of the web led to widespread recurrence of the papillomas, which eventually resolved after the larynx had healed with the reformation of a limited anterior web. The role of surgical trauma and its effect on re-emergence of papillomas is discussed.

Parotid haemangiomas in childhood: a case for MRI

Seven infants with unilateral parotid haemangiomas seen at one centre are presented. Their case notes and special investigations are reviewed. Magnetic resonance imaging (MRI) is revealed as the investigation of choice because of picture quality, definition of soft tissues and lack of exposure to ionizing radiation. MRI allows a definite diagnosis to be made without any invasive procedure being required. A future study following up these infants may be of interest because of controversy regarding the spontaneous resolution of these lesions.

Posterior glottic stenosis in children

The management of posterior glottic stenosis resulting from impaired crico-arytenoid joint (CAJ) mobility in infants and children presents a perplexing and frequently unrewarding surgical dilemma; any improvement in the airway is almost invariably at the expense of the voice. Progress in this area has been hampered not only by the rarity of cases, but also by the technical difficulty of achieving an accurate diagnosis at endoscopy. In order to address this problem we have undertaken a retrospective analysis of 35 infants and children, treated at Great Ormond Street between 1980 and 1991, with endoscopically confirmed impairment of CAJ mobility. Five cases of mild posterior glottic stenosis were successfully treated either conservatively or by laser scar division. Thirty cases of moderate or severe stenosis were identified, and 19 of these have undergone corrective surgery. Of these 19, 17 had a prior tracheostomy, and 12 have been decannulated. No problems with aspiration were encountered but five (i.e. 25%) of those treated surgically suffered a deterioration of voice quality.

Surgical decannulation of children with tracheostomy

Over a five-year period during which 99 children underwent successful ward decannulation, 14 other children were deemed unsuitable and underwent surgical decannulation. The technique of surgical decannulation involves excision of the tracheostomy tract with any granuloma and splinting of the anterior tracheal wall by the use of an indwelling nasotracheal tube for 48 hours post-operatively. It is indicated in carefully selected patients whose tracheostomies are complicated by large suprastomal granulomas, anterior tracheal wall collapse or previous anterior rib graft collapse into the airway. Nine of the 14 decannulations were successful. Success is dependent upon accurate prior endoscopic assessment and satisfactory previous reconstruction surgery in cases of subglottic stenosis. The five failures (4.42 per cent of all decannulations) represent some of the most demanding airway problems encountered.

Neonatal vocal cord paralysis

The consultants agree that surgery is a common cause of unilateral vocal cord paralysis in neonates. In the absence of a history of surgery, they would evaluate a neonate for cardiovascular or central nervous system anomalies. None believes a relationship between laryngomalacia and vocal cord paralysis exists. But there is disagreement regarding the additional steps required to evaluate this child. The recommendations include endoscopy under general anesthesia with assessment of cricoarytenoid mobility, evaluation for other congenital anomalies, and observation of laryngeal dynamics (Dr. Benjamin), neurologic examination (Dr. Bailey), and no further testing (Dr. Gray). Laryngeal EMG in an infant is not an established technique and none of the consultants routinely performs this test. However, EMGs are part of the research protocol for one physician (Dr. Gray). The consensus is that aspiration is unlikely to be a problem in this case. However, if aspiration does occur, all would recommend conservative treatment. Feedings should be thickened and anti-reflux precautions taken. None was convinced that severe aspiration would be a problem. However, given the need for more aggressive treatment, the considerations would include collagen or Teflon injections or a tracheotomy (Dr. Gray) or a Nissen fundoplication, nasogastric tube feedings, or a gastrostomy (Dr. Bailey). Only one consultant would defer further treatment (Dr. Benjamin). The prognosis is generally good. Two consultants (Drs. Benjamin and Bailey) would follow a child with vocal cord paralysis by periodically repeating a laryngoscopic examination. A reinnervation procedure would be considered by one consultant at the age of 3 if the voice remains weak (Dr. Gray).