Resolution of mucus plugging and atelectasis after intratracheal rhDNase therapy in a mechanically ventilated child with refractory status asthmaticus

OBJECTIVE

To report the dramatic resolution of unilateral mucus plugging and atelectasis in a mechanically ventilated child with refractory status asthmaticus after intratracheal recombinant human DNase (rhDNase) therapy.

DESIGN

Case report.

SETTING

Critical care unit.

PATIENT

A 7-yr-old boy with status asthmaticus, severe respiratory failure and barotrauma unresponsive to conventional therapy. Fiberoptic bronchoscopy confirmed widespread mucus impaction of the subsegmental bronchi of the left lung without response to bronchoscopic lavage.

INTERVENTIONS

Two 10-mg doses of intratracheal rhDNase were administered 8 hrs apart.

MAIN RESULTS

The left-sided atelectasis resolved 3 hrs after the first dose of rhDNase. Improvements in gas exchange and tidal volumes were sustained and particularly noticeable after the second dose. The patient was successfully extubated 26 hrs after receiving the rhDNase treatment without any adverse effects.

CONCLUSIONS

rhDNase should be considered as a potential therapy for refractory mucus plugging and atelectasis in intubated patients with status asthmaticus.

Advances in the management of major airway collapse: the use of airway stents

The management of major airway collapse in the pediatric age group has evolved and continues to evolve over time. Tracheobronchomalacia, either primary or secondary, is still the most frequent cause of major airway collapse. This article reviews tracheobronchomalacia and discusses several treatment options; from traditional aortopexy to the more recent introduction of tracheobronchial stenting. Various types of stents are discussed and the authors' preferences are included.

Comparison of thyroid, auricular, and costal cartilage donor sites for laryngotracheal reconstruction in an animal model

OBJECTIVE

To evaluate and compare the use of autogenous thyroid cartilage with that of auricular and costal cartilage in laryngotracheoplasty (LTP).

DESIGN

A blinded comparison of LTP techniques using anterior thyroid, auricular, or costal cartilage as graft material in a rabbit model. Histological and anatomical analyses were performed on the laryngeal specimens 1, 4, and 6 weeks after surgery. The following factors were analyzed in each specimen: graft viability, cartilage proliferation, perichondrial viability, degree of necrosis, inflammatory response, and degree of epithelialization.

SUBJECTS

Fifty-seven New Zealand adult male rabbits, aged 6 months, were divided into 3 study groups (19 animals in each group) initially and equally into the 3 time periods.

RESULTS

No episodes of respiratory compromise occurred in any of the animals in the 3 study groups. Gross inspection of the laryngotracheal complex in the thyroid cartilage group revealed no evidence of laryngeal structural compromise. There was no statistical difference between the 3 types of cartilage used for reconstruction for the variables of graft or perichondrial viability, degree of necrosis, or inflammatory response at 1, 4, or 6 weeks. Cartilage proliferation in the thyroid cartilage group was decreased compared with that in the other 2 groups at 1 week. The amount of proliferation increased in this group and was equal to the amount present in the other 2 groups 4 and 6 weeks after surgery. Complete epithelialization of the graft material was present in all 3 groups at 4 and 6 weeks after reconstruction.

CONCLUSIONS

The use of autogenous thyroid cartilage for LTP compares favorably with that of other methods of reconstruction that use either auricular or costal cartilage in the rabbit model. This technique is a viable alternative for single-stage LTP and has the added advantage of using a single incision.

Ewing's sarcoma of the head and neck in children

OBJECTIVE

The purpose of this paper was to review our experience with Ewing's sarcoma of the head and neck in children.

DESIGN

Retrospective chart review.

SETTING

The Hospital for Sick Children, Toronto, Ont., Canada.

METHODS

Between 1986 and 1996, 70 cases of Ewing's sarcoma were identified. The medical records, roentgenographic and pathology reports were reviewed retrospectively. The gender, age of presentation, location and clinical presentation of the tumor were noted in the cases involving the head and neck. The treatment and follow-up of these patients were recorded.

RESULTS

Of the 70 cases of Ewing's, five involved the head and neck (7.1%). The age of presentation ranged from 7.5 to 14 years. An enlarging mass in the mandible was the mode of presentation in three of the five children. Two patients had metastases at initial presentation. All patients received combination treatment regimens with chemotherapy initially, followed by adjuvant surgery and/or radiation. Follow-up ranged from 2 to 11 years. Three of five patients died of metastatic disease. Two are alive and well with no evidence of disease.

CONCLUSIONS

Ewing's sarcoma occurs infrequently in the head and neck in children. An enlarging mass in the mandible is the most frequent mode of presentation. This tumor is treated systemically with high dose chemotherapy and locally with surgical excision where possible. In lesions that are initially unresectable and/or show a poor response to chemotherapy, radiation is used for local control. A good prognosis can be expected if the disease has not metastasized.

Effect of harvesting autogenous laryngeal cartilage for laryngotracheal reconstruction on laryngeal growth and support

OBJECTIVE

Determine the effect of harvesting autogenous thyroid cartilage on subsequent laryngeal growth and stability in a kitten model.

STUDY DESIGN

Prospective controlled trial in animals.

METHODS

Seventeen kittens were divided into three groups. Group one (n = 5) included kittens that underwent a unilateral thyroid cartilage resection. Group two (n = 5) included kittens that underwent a bilateral cartilage resection. Group three (n = 7) comprised kittens that did not undergo any surgical procedure (controls). All animals underwent endoscopic examination followed by the surgical procedure designated for that group. Kittens were then assessed daily for 2.5 months. At the end of that period the now "adolescent" cats were examined endoscopically then euthanized. The larynx was removed for gross and histopathologic analysis.

RESULTS

All kittens tolerated the surgical procedure without airway compromise. Subsequent endoscopic examination 2.5 months after surgery revealed normal vocal cord function. Measurements of the true vocal cord and aryepiglottic and subglottic diameter did not differ significantly (one-way analysis of variance, P = .05) with respect to the side or the group. Histopathologic evaluation of the laryngeal sections indicated a patent airway, stable and viable thyroid cartilage, and no evidence of cartilaginous regrowth.

CONCLUSIONS

The removal of unilateral and bilateral superior thyroid alar cartilage can be performed in kittens without postoperative respiratory or wound problems. The harvesting of autogenous thyroid cartilage has no apparent effect on subsequent laryngeal growth and stability in a kitten model.

A novel approach to tracheostomal collapse: the use of an endoluminal Palmaz stent

There are a number of surgical treatments for tracheostomal collapse of the pediatric airway. The techniques include tracheoplasty with costal cartilage graft, the placement of a tracheostomy tube and partial tracheal resection and primary tracheal anastomosis to name a few. Since each child may possess unique medical and social factors in additional to the tracheal pathology, the surgical approach must be individualized. A case history of a 1-year-old Vietnamese child with a tracheostomal collapse is presented. In this case, an endoluminal Palmaz stent was placed endoscopically to support the collapsed tracheal segment for 3 months. After 3 months, the stent was removed, and the child has done well without any airway intervention for 2 years. The indications for this novel approach, the technique of insertion and removal of the stent are the focus of this paper.

The outcome after perinatal management of infants with potential airway obstruction

Masses in the head and neck are being detected prenatally with increasing frequency, necessitating the need for management of potential upper airway obstruction at delivery. Establishment of the airway at delivery and its maintenance thereafter are critical. This should optimally be performed with the baby still attached to the placental circulation. The importance of multidisciplinary team management, including a high risk obstetrician, neonatologist, pediatric otolaryngologist, pediatric thoracic surgeon, and an anesthetist, cannot be overemphasized. Endotracheal intubation is attempted first, if unsuccessful then is followed by insertion of a rigid bronchoscope. Tracheotomy should be reserved for airway obstructions, which are not amenable to endotracheal intubation or in babies in whom exchange from a bronchoscope to endotracheal tube cannot be safely performed. The management of six infants with prenatally diagnosed potential airway obstruction is presented. Morbidity and mortality still ultimately depend on the severity of the existent anomalies.

Lipomas of the head and neck in children

Head and neck lipomas in the pediatric population are rarely described in the literature. Two patients who presented to the Hospital for Sick Children with rapidly enlarging head and neck lipomas are presented. Radiographic imaging, including CT and MRI, as well as fine needle aspiration implicated a lipoma as the probable diagnosis. Both patients were treated by surgical excision. The clinical behavior, diagnostic work-up and treatment of these rare lesions are the focus of this study.

Tracheobronchial stenting for the treatment of airway obstruction

PURPOSE

The authors report a 5-year experience of inserting the Palmaz stent into infants and children who had a variety of major airway obstructions.

METHODS

From 1992 to 1997, 30 balloon expandable stents (Palmaz) were inserted in the trachea (n = 18) and bronchi (n = 12) of 16 infants, ages 1 week to 26 months (median, 9 months), suffering from three types of serious airway obstruction. In group 1, 10 stents were placed in eight children for tracheal or bronchomalacia. In group II, 11 stents were inserted in four infants for stricture at the site of surgical repair of stenosis. In group III, nine stents were placed to relieve airway compression from enlarged pulmonary arteries associated with severe congenital heart disease in three children and mediastinal lymphangioma in one. Tracheal stents were 30 mm long and were expanded to 8 to 10 mm at placement. Bronchial stents were 12 to 15 mm long and were expanded to 7 to 9 mm. The nonexpanded stents were placed on an inflatable balloon catheter and were inserted into the desired position in the airway through a bronchoscope or endotracheal tube using x-ray control. They were expanded and fixed in place by inflating the balloon to its rated diameter.

RESULTS

In group I, granulation tissue developed over the stents in five of eight cases. Obstructing granulations were removed by scraping or balloon compression in three and resulted in earlier than the planned removal in two. Stents have now been removed in six of eight cases. Major airway obstruction has not recurred. In group II, stents have been in place in all cases for 13 to 56 months after insertion, but in one child with three stents, two were removed for obstructive granulations 44 months after insertion. All are well. All group III patients could be extubated after stenting, but two with heart disease died after 3 and 12 months of palliation. During the course of follow-up, stents in the bronchi of two had migrated, and an additional stent was required. Autopsy in one showed full-thickness bronchial erosion but no perforation by the stent. A total 11 of 30 stents have been removed bronchoscopically in seven children without complications. Another child referred here for tracheal stent removal after laser resection of granulations died at attempted removal because the stent was "welded" into the tracheal wall by the inflammatory reaction. Manipulation of the stent completely occluded the airway.

CONCLUSIONS

Airway stents can be inserted easily and safely and left in-situ for prolonged periods to relieve major airway obstruction from a variety of causes. Tissue reaction may necessitate bronchoscopic manipulation and early stent removal, and adds to the difficulty of removal.

Foreign bodies of the hard palate

Foreign bodies of the hard palate are rare occurrences with only 11 reported cases in the literature. These patients can present to the Otolaryngologist in a variety of ways and often with confusing histories. We present seven cases of foreign bodies adherent to the hard palate. The age range was three to eighteen months and the most common referring diagnosis was a suspected tumor (five patients). The most common object removed was a nut shell. In six of the seven cases the foreign body could be removed in the ambulatory clinic without the need for sedation or anesthesia. The clinical presentation, incidence and management is reported and discussed with reference to the literature.

Prognostic factors in the treatment of lymphatic malformations

OBJECTIVE

To find factors that may influence the treatment outcomes of lymphatic malformations of the head and neck in children.

DESIGN

Charts of patients treated surgically for lymphatic malformations of the head and neck between 1988 and 1996 at our tertiary care children's hospital were reviewed retrospectively. Outcomes were correlated with age at presentation, associated symptoms, anatomical site (s) of involvement, extent of disease, length of time between first symptoms and surgery, completeness of removal, and histologic pattern.

PATIENTS

Of 85 children treated, 74 underwent primary surgical excision at our hospital. Follow-up ranged from 6 months to 8 years, with a mean of 3 years.

RESULTS

The overall recurrence rate, judged by functional or cosmetic deformity, was 22%. Two neonates died of the disease. Factors associated with a better prognosis were a single anatomical site of involvement; location in the neck, even if involving 2 sites; and the impression of completeness of resection at the time of surgery. Findings associated with a higher recurrence rate included younger age (especially neonates) and the presence of associated symptoms (ie, infection, dyspnea, dysphagia, and hemorrhage). The histologic pattern and the length of time from diagnosis to treatment were not significantly associated with the prognosis.

CONCLUSIONS

We recommend aggressive, timely surgical excision for lymphatic malformations of the head and neck. The timing of surgery should be based on the child's functional and cosmetic deformity at the time of presentation and on the likelihood of complete excision, weighed against the morbidity associated with surgical excision.

Extranasopharyngeal angiofibroma of the inferior turbinate

The first reported case of angiofibroma of an inferior turbinate is presented. The tumour occurred in a 9-year-old boy and was extirpated by subperiosteal dissection of the lateral nasal wall.

Experimental trial of balloon-expandable, metallic Palmaz stent in the trachea

OBJECTIVE

To determine the effect of the Palmaz stent, which has been successfully used to relieve airway obstruction in a small group of children, on the normal and operated on animal trachea.

DESIGN

In this experimental trial, stents were placed bronchoscopically in the thoracic tracheae of 4 groups of 50 anesthetized cats. The cats in group 1 (adults, n = 10) and group 2 (kittens, n = 10) had normal tracheae; the cats in group 3 (adults, n = 15) underwent horizontal tracheal incision and closure; and the cats in group 4 (adults, n = 15) underwent pericardial patch tracheoplasty. In group 3 and 4, the stents were inserted in 10 cats and 5 cats served as controls. Stents were inflated to a 15-mm diameter in group 1 and an 8-mm diameter in the other groups. Half of the animals with stents were killed 5 weeks after the procedure, and the others, 10 weeks after the procedure.

SETTING

The Hospital for Sick Children, Toronto, Ontario.

RESULTS

In group 1, 1 animal died of tracheal perforation. A mild cough was noted in 15 of the 39 cats with stents. In group 4, 3 cats had difficulty eating and lost weight. The results of esophagoscopy excluded esophageal inflammation or obstruction in these 3 animals. The results of bronchoscopy indicated a nonobstructing rim of granulation tissue at the end of the stent in 15 of 20 cats in groups 1 and 2 and 17 of 20 cats in groups 3 and 4 and at the repair site in all animals with stents from groups 3 and 4. The results of autopsy indicated the cross-sectional area at the site of the stent was greater than normal in group 1 (P < .003) and smaller than the normal trachea at the site of the tracheoplasty in group 4 controls without stents (P < .02); however, the cross-sectional area at the tracheoplasty site with the stent was not smaller (P < .13). The results of histologic examination indicated a mild inflammatory reaction, with granulation tissue in all animals with stents, but in group 1, with overexpanded stents, the reaction was more severe, with epithelial ulceration, fibrosis, and sealed-off perforations in most animals. In group 3, the tracheae with stents had significantly more inflammatory reaction, granulation tissue, and epithelial damage than the controls without stents.

CONCLUSIONS

The Palmaz stent provokes an inflammatory reaction in the normal trachea and the trachea recently operated on. With the exception of the group 1 animals with overexpanded stents, this reaction is clinically insignificant. The Palmaz stent is able to maintain a normal lumen size after pericardial tracheoplasty in cats.

A practical guide for the diagnosis and treatment of acute sinusitis

OBJECTIVE

To develop guidelines for the diagnosis and management of acute sinusitis.

OPTIONS

Diagnostic clinical criteria and imaging techniques, the role of antimicrobial therapy and duration of treatment, and the role of adjunct therapy, including decongestants, glucocorticosteroids and nasal irrigation.

OUTCOMES

Improved accuracy of clinical diagnosis, better utilization of imaging techniques and rational use of antimicrobial therapy.

EVIDENCE

A MEDLINE search for relevant articles published from 1980 to 1996 using the MeSH terms "sinusitis," "acute sinusitis," "respiratory infections," "upper respiratory infections," "sinusitis" and "diagnosis," "sinusitis" and "therapy," "sinusitis" and "etiology," and "antimicrobial resistance" and search for additional articles from the reference lists of retrieved articles. Papers referring to chronic sinusitis, sinusitis in compromised patients and documented nonbacterial sinusitis were excluded. The evidence was evaluated by participants at the Canadian Sinusitis Symposium, field in Toronto on April 26-27, 1996.

VALUES

A hierarchical evaluation of the strength of evidence modified from the methods of the Canadian Task Force on the Periodic Health Examination was used. Strategies were identified to deal with problems for which no adequate clinical data were available. Recommendations arrived at by consensus of the symposium participants were included.

BENEFITS, HARMS AND COSTS

Increased awareness of acute sinusitis, accurate diagnosis and prompt treatment should reduce costs related to unnecessary investigations, time lost from work and complications due to inappropriate treatment. As well, physicians will be better able to decide which patients will not require antimicrobial therapy, thus saving the patient the cost and potential side effects of treatment.

RECOMMENDATIONS

Clinical diagnosis can usually be made from the patient's history and findings on physical examination only. Five clinical findings comprising 3 symptoms (maxillary toothache, poor response to decongestants and a history of coloured nasal discharge) and 2 signs (purulent nasal secretion and abnormal transillumination result) are the best predictors of acute bacterial sinusitis (level I evidence). Transillumination is a useful technique in the hands of experienced personnel, but only negative findings are useful (level III evidence). Radiography is not warranted when the likelihood of acute sinusitis is high or low but is useful when the diagnosis is in doubt (level III evidence). First-line therapy should be a 10-day course of amoxicillin (trimethoprim-sulfamethoxazole should be given to patients allergic to penicillin) (level I evidence) and a decongestant (level III evidence). Patients allergic to amoxicillin and those not responding to first-line therapy should be switched to a second-line agent. As well, patients with recurrent episodes of acute sinusitis who have been assessed and found not to have anatomic anomalies may also benefit from second-line therapy (level III evidence).

VALIDATION

The recommendations are based on consensus of Canadian and American experts in infectious diseases, microbiology, otolaryngology and family medicine. The guidelines were reviewed independently for the advisory committee by 2 external experts. Previous guidelines did not exist in Canada.

Analysis of the recent cluster of invasive fungal sinusitis at the Toronto Hospital for Sick Children

OBJECTIVE

The aim of this study was to review the eight histopathologically proven cases of invasive fungal sinusitis that occurred at the Toronto Hospital for Sick Children between 1985 and 1995, seven of which that clustered between March 1990 and February 1992.

DESIGN

A retrospective review of the relevant cases and a review of the literature are presented.

METHOD

A clinical review of this rare, life-threatening entity, occurring almost exclusively in severely neutropenic patients is presented and compared to the relevant clinical findings from an analysis of this series, the largest reported to date and first to document a significant clustering (p < .01).

CONCLUSION

We conclude, based on epidemiologic evidence, that this clustering was directly related to the release of airborne fungal spores from dormant soil reservoirs disturbed during hospital construction. Therefore, we strongly advocate increased vigilance with respect to precautions against airborne pathogens wherever severely neutropenic hosts are treated.

Heterotopic brain in the parapharyngeal space

There have been numerous reports of various types of heterotopic tissue in the head and neck. Heterotopic cartilage, gastric tissue, thyroid, and salivary gland in such various locations as tongue, gingiva, palate, nasopharynx, parapharyngeal space, and neck have been frequently reported. Heterotopic brain in the parapharyngeal space causing airway obstruction in the neonate has been rarely described. These benign masses are capable of expansion and because of their location, can lead to significant airway and feeding difficulties. We describe 3 cases of heterotopic brain tissue in the parapharyngeal space causing feeding difficulties and airway obstruction in the neonatal period. Two were initially misdiagnosed as lymphatic malformations. In the third, a nine month delay in diagnosis occurred. The diagnostic features of heterotopic brain in this location and some management suggestions in treating such a lesion are discussed.

Unusual laryngeal cysts in the newborn

In the newborn, severe airway obstruction is a rare occurrence. The possible etiologies include a broad spectrum of diseases with laryngeal cysts an unusual cause. If diagnosed and properly managed, however, the prognosis for this entity is excellent. Three cases presenting with airway obstruction secondary to unusual laryngeal cysts are the material for this report. In all three, cases the laryngeal cystic structure extended through the cricothyroid membrane and in two, pathologically contained both mesodermal and endodermal elements suggesting a laryngotracheal duplication cyst anomaly, previously unreported. Laryngofissure can be safely employed for complete excision even in the neonatal period.

Congenital cystic adenomatoid malformation of the lung referred as 'airway foreign body'

Congenital cystic adenomatoid malformation of the lung is an uncommon anomaly. Two patients with this condition were recently referred to the Otolaryngology Service at The Hospital for Sick Children, Toronto, Ontario, for bronchoscopic evaluation of the airway to rule out a foreign body. Although history did not disclose a clear episode of aspiration in either case, chest radiographs showed unilateral lobar hyperinflation with mediastinal shift, consistent with foreign body obstruction. We report two cases to introduce congenital cystic adenomatoid malformation to the English otolaryngology literature and to increase awareness of it among otolaryngologists.

Ligation of the common carotid artery for the management of a mycotic pseudoaneurysm of an extracranial internal carotid artery. A case report and review of the literature

Although vascular involvement by deep neck space infections occurs very rarely today with the widespread use of antibiotics, they often pose a significant challenge to the modern otolaryngologist, who most likely will have had no previous experience with either the diagnosis or treatment of these potentially life-threatening infections. We describe the case of a young female presenting with fevers, dysphagia, and blood-tinged sputum, who was diagnosed by contrast-enhanced computerized tomography, to possess a mycotic pseudoaneurysm of her right extracranial internal carotid artery, for which ligation of her common carotid artery was required. We also discuss both the clinical findings which should lead one to suspect that a neck infection may be involving the extracranial carotid arteries, and the English literature, on the morbidity and mortality of ligating a common carotid artery.

The use of expandable metallic airway stents for tracheobronchial obstruction in children

Expandable metallic angioplasty stents (Palmaz stent) have been implanted in the trachea and/or bronchi of seven children. Three children had severe tracheal stenosis after tracheoplasty for congenital tracheal stenosis repair, and four had tracheomalacia or bronchomalacia with or without vascular compression. The mean age at stenting was 9.7 months (range, 2 to 15 months). Balloon expandable stents were inserted into the trachea or bronchus through a 3.5-mm bronchoscope under fluoroscopic control. Initially a single tracheal stent was used for all patients except for one with obstruction in the trachea and both bronchi, in whom three stents were implanted. Three children had recurrent airway obstruction 1 month later; one was cured with a second stent; one child died 1 year later; and the other is being treated for heart disease. The others have no serious respiratory problems. The stents in all have been in place for 1 to 25 (mean, 11) months. No immediate complications were noted. Early and late bronchoscopy showed incomplete epithelialization of the stent and patches of granulation tissue on it. Two stents were removed bronchoscopically, one at the completion of treatment for tracheomalacia and the other at the time of recurrent airway obstruction. This preliminary experience indicates that expandable metallic stents have a useful role in the treatment of selected lower airway obstructions.

Encephaloceles of the anterior cranial fossa

From a total of 114 encephaloceles treated surgically at The Hospital for Sick Children in the 15 years to 1994, the case records of 17 patients with sincipital and 5 patients with basal defects were reviewed retrospectively. The condition was evident at birth in 64% of patients, while the remainder presented with either cerebrospinal fluid (CSF) rhinorrhea, nasal obstruction, or feeding difficulty. Hypertelorism affected 73% of patients. All encephaloceles were repaired transcranially, at a mean age of 2 years, usually by means of an intradural pericranial graft. Five children with gross hypertelorism underwent orbital translocation at the time of encephalocele repair. Of those not corrected, primary and secondary hypertelorism regressed in most instances where the encephalocele was treated before the age of 2 years. There were no deaths. The only case of CSF rhinorrhea occurred in a patient with a basal defect, in whom intradural repair was not possible because of adherence of diencephalic structures to the sac wall. Hypertelorism recurred in 1 patient after orbital translocation, requiring recorrection 2 years later. One patient with untreated secondary hypertelorism failed to regress after the encephalocele was excised at the age of 4 months. Developmental outcome was normal in 59% of children, whilst 18% have mild mental or physical disability, and 23% are severely impaired. A child with a sincipital or basal defect and mild hypertelorism should have the encephalocele treated in early childhood to allow the facial skeleton to remodel with growth. When an encephalocele is accompanied by gross hypertelorism or a facial cleft, one-stage correction can be undertaken safely in early childhood with minimal mortality and acceptable morbidity.

[Prolonged respiratory support with extracorporeal membrane oxygenation in lung transplantation]

A 42 year-old woman with terminal chronic lung disease underwent to left lung transplantation. Extracorporeal membrane oxigenation (ECMO) was required because dysfunction of transplanted organ occurred and was non-responsive to conventional therapy. The time of assistance was 47 hours and after this, the dysfunction of the transplanted lung reversed and the patient was weaned from the oxigenator. During hospital stay, she developed sepsis and died. In conclusion, ECMO was decisive to the treatment of pulmonary dysfunction, allowing time to the resolution of lung lesion.

First brachial cleft sinuses: an analysis of current management strategies and treatment outcomes

First branchial cleft sinuses account for less than 1% of all branchial cleft anomalies. A thorough understanding of the embryology and developmental anatomy is essential for successful management. Nine cases of first branchial cleft sinuses treated at The Hospital for Sick Children by the Department of Otolaryngology between 1984 and 1990 were reviewed. A large proportion of these lesions were initially misdiagnosed despite significant symptomatology. This resulted in a high rate of infectious complications. Early diagnosis, prompt control of infection, and early surgical excision are recommended. Current methods of diagnosis and treatment are discussed along with techniques for facial nerve preservation.

Failed extubation in the neonatal intensive care unit

One of the roles of the pediatric otolaryngologist in the neonatal intensive care unit (NICU) is the assessment and management of the neonate who fails a trial of extubation. This paper reviews the recent 5-year institutional experience at The Hospital for Sick Children, Toronto, with neonates who failed extubation and who subsequently underwent diagnostic endoscopy. One hundred twenty-eight neonates from the NICU underwent diagnostic endoscopy. Of these, 58 neonates underwent diagnostic endoscopy for failure to extubate. Nine neonates were extubated after diagnostic endoscopy and retrial (16% of the series). Eleven neonates were extubated after additional endoscopic procedures (19% of the series). Twenty-four neonates underwent anterior cricoid split, of whom 20 or 83% (34% of the series) were eventually successfully extubated with no further airway intervention required during the study period (minimum 6 months' follow-up). Eleven neonates underwent tracheotomy (19% of the series). Four neonates underwent another external procedure to allow extubation (7% of the series). Three neonates died while still intubated (5% of the series). Our management of the neonate who fails a trial of extubation is discussed.

The balloon posterior tracheal split: a technique for managing tracheal stenosis in the premature infant

Congenital tracheal stenosis (CTS) in the premature infant almost invariably leads to death for lack of effective reconstructive techniques. We hypothesized that the complete or near complete cartilaginous rings of CTS have a weak point in the posterior portion. Aggressive balloon dilation would result in a posterior longitudinal disruption of the trachea, and an expanded tracheal wall would be created after an appropriate period of endotracheal stenting. Three premature infants with multiple anomalies and CTS were treated with endoscopic posterior tracheal splitting, dividing the trachea as predicted. Although two died of complications of congenital heart disease 2 weeks after the procedure, the third child is alive and well at 9 months of age without airway symptoms. The posterior tracheal wall also split when we performed the procedure in a fresh cadaveric CTS patient. We believe that balloon dilation may prove to be a valuable technique in the treatment of premature infants with congenital or acquired tracheal stenosis and/or in children with such complex diseases that major surgery is precluded.

Juvenile angiofibroma: a review of the literature and a case series report

Juvenile angiofibroma is a rare, histologically benign tumor which occurs almost exclusively in adolescent boys. The morbidity and mortality associated with this tumor are related to its prominent vascularity and its propensity for aggressive local growth. From 1974 through 1988, 21 male patients with a diagnosis of juvenile angiofibroma were managed at the Toronto General Hospital or the Hospital for Sick Children, Toronto. Preoperative computed tomography was performed on 20 patients, selective angiography on 21 patients, and preoperative embolization on 15 patients. Primary surgery was performed on 67% of these patients, with radiation therapy used for advanced stage II and stage III disease or in response to patient preference. Pterygopalatine fossa involvement was demonstrated in 90% of the patients; as a result, the lateral rhinotomy approach was most commonly used in the surgical cases. A successful outcome was achieved in 86% of patients treated with surgery alone. Two patients underwent radiotherapy for salvage following postoperative recurrence. There were no treatment-related deaths and no major surgical complications. The value of computed tomography is discussed, the authors' treatment protocol is outlined, and the case series results are presented.

Congenital mid-line cervical cleft

The mid-line cervical cleft is part of a broad spectrum of congenital mid-line branchiogenic syndromes. Two recent cases of this rare anomaly are presented, along with the clinical presentation, gross pathology and histopathology. The preferred operative technique of complete excision of the cervical cleft with Z-plasty is demonstrated. Embryologic origins and spectrum of severity of the mid-line branchiogenic syndromes is discussed.

Hairy polyp of the eustachian tube

The hairy polyp of the nasopharynx is a rare but potential cause of airway obstruction in the newborn. A case of hairy polyp arising off the Eustachian tube is reported. Only eight prior cases of Eustachian tube origin have been described in the literature. The terminology and embryology of these tumors are included in the discussion. The site of the tumor and histopathology of this case supports the embryologic origin of a congenital inclusion cyst.

Pressure, flow and resistance characteristics of the pediatric Storz-Hopkins bronchoscopes

Poiseuille's law describes the relationship between pressure and the flow of a gas or liquid of known viscosity through a conduit of known length and radius. In clinical bronchoscopy, resistance varies directly with changes in viscosity of the inspired gas and the length of the bronchoscope. According to Poiseuille's law, resistance varies inversely to the fourth power of the radius of the bronchoscope. Flow-pressure curves were generated for commonly used pediatric Storz-Hopkins bronchoscopes with and without telescopes and the resistance of each system was calculated. Extremely high resistance is encountered with the 2.5 x 20 cm bronchoscope with telescope in place, a fact that most pediatric endoscopists are well aware of. However, comparable resistance is encountered when the 3.5 x 30 cm bronchoscope is used with the telescope in place, a fact not well appreciated by most clinicians.

The management of otolaryngological problems in the mucopolysaccharidoses: a retrospective review

The mucopolysaccharidoses are rare, genetically transmitted metabolic disorders that affect children early in life. These potentially life-threatening diseases almost invariably involve the auditory apparatus and the upper respiratory tract. Thus, the otolaryngologist is frequently involved in the care of these patients. This paper presents a 10-year retrospective review of the management of these patients at the Hospital for Sick Children. Data concerning auditory and upper respiratory pathology are presented. Results indicate that persistent serous otitis, sensorineural hearing loss, and upper respiratory obstruction leading to sleep apnea, are frequent findings in these patients. Specific recommendations are made with regard to appropriate otolaryngologic intervention in children affected with these diseases.

Evaluation of neonatal subglottic stenosis: a 3-year prospective study

Subglottic stenosis is the most common cause of chronic airway obstruction. It results in prolonged tracheal cannulation of infants and children. Following the widespread adoption over the past 20 years of prolonged intubation for respiratory support in neonates, the incidence of acquired subglottic stenosis increased dramatically. On January 1, 1987, we began a 3-year prospective study to delineate potential etiologic factors involved in the development of subglottic stenosis in neonates. The present study analyzes data from 289 infants. Relationships between birth weight, gestational age, endotracheal tube size, duration of intubation and ventilation, number and difficulty of intubations, and the subsequent need for medical and surgical therapy are discussed. Whole organ larynges from autopsy specimens provide histological correlation.

Recurring giant-cell granuloma at the site of previous radiation therapy

A 15-year-old girl presented with an aggressive giant-cell granuloma (GCG) of the maxilla with local invasiveness and bony destruction. The tumor recurred twice and attained a diameter of 6 cm. Previously, this patient had had two hematologic malignancies for which she had received therapeutic doses of radiation to the site where the GCG occurred. It is therefore possible that this tumor was radiation induced.

Nose/mouth distribution of respiratory airflow in 'mouth breathing' children

Oro-nasal distribution of respiratory airflow was determined in 120 'mouth breathing' children by a minimally invasive computer-assisted method that employed a modified CPAP nasal mask/pneumotach and a head-out body plethysmograph. Resulting measurements were reproducible but clinical assessments correlated poorly with these values. Airflow distribution was almost identical in inspiration and expiration. 100% nasal breathing was found over a wide range of nasal resistances, many subjects with lips apart. Overall, the nasal fraction was negatively correlated with resistance and it was increased by topical decongestant. Decreasing nasal resistance with increasing age was confirmed, but corresponding changes in airflow distribution were not demonstrated. Quantitative assessment is advocated in clinical management of 'mouth breathers'.

Malignant nasopharyngeal tumors in children

From 1964 to 1984, 25 children with malignant tumors of the nasopharynx were seen, and their progress was followed at The Hospital for Sick Children in Toronto. Two types of malignancies: rhabdomyosarcoma and lymphoepithelioma were most prevalent with eight cases apiece. The presenting signs and symptoms were related to local and/or regional manifestations of disease. No child presented with signs or symptoms related to distant metastatic disease. The diagnosis and treatment of this series of patients are described briefly. The advent of combined treatment modalities in the past decade has improved the prognosis for nasopharyngeal tumors, especially for the rhabdomyosarcomas; in general, however, survival rates are still poor, approximating 50%.

Maxillary myxoma in children

Myxoma of the maxilla is a rare, slowly growing, benign mesenchymal tumor. Pathologically, it may be difficult to differentiate from other tumors with myxoid stroma and is occasionally misinterpreted as malignant. This tumor is particularly uncommon in children; in a search of the literature, we were able to document only 17 cases of myxomas in the maxilla in patients aged 14 years or less. This report on two children with myxoma of the maxilla emphasizes the importance of including myxoma in the differential diagnosis of children with maxillofacial tumors, and underlines the difficulties in making a correct diagnosis.

Sistrunk revisited: a 10-year review of revision thyroglossal duct surgery at Toronto's Hospital for Sick Children

The definitive surgical management of thyroglossal duct cysts (TGDC) was elucidated by Sistrunk in 1920. However, the procedure is often poorly performed. We reviewed the charts of 143 patients managed for TGDC at the Hospital for Sick Children. Toronto, between 1978-1988. These patients underwent 214 surgical procedures at HSC and elsewhere for cure. One hundred and five patients needed only one procedure. Thirty-eight patients had recurrent disease. These needed 109 procedures for cure. Inadequate surgery was the direct cause of recurrence. Areas of surgical failure included misdiagnosis, inadequate hyoid bone resection and persistent infra or suprahyoid tract remnants. Representative case samples are outlined with clinical, surgical and pathologic correlation. We recommend performing the complete, classic Sistrunk procedure for all cases of TGDC.

Objective tinnitus associated with abnormal mastoid emissary vein

Tinnitus may be defined as the perception of sound in the absence of environmental input. It can be subjective. Objective tinnitus may be caused by clearly definable mechanical or vascular abnormalities, and as such may be amenable to specific management. We report a case of objective tinnitus associated with an abnormal mastoid emissary vein. A review of the literature identified only one other report of objective tinnitus associated with an emissary vein. That report involved a posterior condylar emissary vein. The venous drainage of the sigmoid sinus was studied on 50 human skulls demonstrating three possible emissary veins of each sigmoid sinus. The postauricular region was dopplered on 30 asymptomatic human subjects. None was found to have dopplered emissary vein flow.

Surgical management of nasal airway obstruction in children

Common causes of nasal airway obstruction in children include adenoid hypertrophy, septal deviation, inferior turbinate hypertrophy, nasal polypi and choanal atresia. A management philosophy for each of these is presented.

The evaluation of intranasal topical beclomethasone spray in the treatment of children with non-purulent rhinitis using rhinometric, cytologic and symptomatologic assessment

The diagnosis and treatment of non-purulent rhinitis in the pediatric population poses a challenge to the clinician. In this randomized double blind study, the authors conclude that rhinometry is more effective than cytologic or symptomologic assessment in children with non-purulent rhinitis treated with either intranasal beclomethasone or placebo spray. Intranasal beclomethasone spray produced significant reductions in nasal airflow resistance values compared to the placebo-treated group.

Maximal cardiorespiratory responses to one- and two-legged cycling during acute and long-term exposure to 4300 meters altitude

During exposure to altitudes greater than about 2200 m, maximal oxygen uptake (VO2max) is immediately diminished in proportion to the reduction in the partial pressure of oxygen in the inspired air. If the exposure lasts longer than a couple of days, an increase in arterial oxygen content (CaO2), due to a hemoconcentration and an increase in arterial oxygen saturation, occurs. However, there is also a reduction in maximal cardiac output (Qmax) at altitude which offsets the increase in CaO2 and, therefore, VO2max does not improve. The purpose of this investigation was to study the contribution of the increase in CaO2 to the working muscles without the potentially confounding problem of a reduced Qmax. The approach used was to have seven male subjects (aged 17 to 24 years) perform one- and two-legged VO2max tests on a cycle ergometer at sea level (SL, PIO2 = 159 Torr), after 1 h at 4300 m simulated altitude (SA, PIO2 = 94 Torr) and during two weeks of residence on the summit of Pikes Peak, CO. (PP, 4300 m, PIO2 = 94 Torr). Cardiac output limits maximal performance during two-legged cycling but does not limit performance during one-legged cycling. During the study, CaO2 changed from 189 +/- 3 (mean +/- SE) at SL to 161 +/- 4 ml.L-1 during SA (SL vs. SA, p less than 0.01) and to 200 +/- 6 ml.L-1 at PP (SL vs. PP, p less than 0.05; SA vs. PP, p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Acquired bronchial injury in neonates

The increasing success of modern neonatology has been associated with the use of prolonged intubation, ventilation and respiratory support. Inappropriate management of the endotrachial tubes or excessive and improper use of suction catheters may result in significant tracheobronchial injury. These injuries range from readily reversible abrasions through to obstructing granulomas, polyps and even bronchial stenosis and acquired bronchial atresia. These lesions are for the most part preventable with appropriate patient care. Examples of these lesions are presented.

Objective assessment of upper airway resistance in the tracheotomized patient

A test has been devised for measuring upper airway resistance to respiratory airflow in the tracheotomized patient. The test is simple and noninvasive; it utilizes either a body plethysmograph or an oral pneumotach to measure airflow. Pressure is measured through the tracheostomy tube of the stoma below the partial obstruction of the upper airway. The test has many important clinical applications. Its technique, rationale for use, and some clinical applications are briefly discussed in this paper, together with basic concepts of flow dynamics.

Posterior tracheal wall disruption: a rare complication of pediatric tracheotomy and bronchoscopy

Disruption of the posterior tracheal wall is an uncommon complication of tracheotomy, bronchoscopy, or even endotracheal intubation. With disruption of the posterior tracheal wall, air tracking may present as surgical emphysema, pneumomediastinum, or pneumothoraces, and may be associated with respiratory distress. Six children with posterior tracheal wall disruptions are presented: three associated with tracheotomy, one bronchoscopy, and another during endotracheal intubation. Early recognition and appropriate management of tracheal disruption will minimize air tracking and the associated morbidity. Tracheal disruption may be avoided by utilizing appropriate surgical, endoscopic, and intubation techniques.

Expansion of myocutaneous flaps

The controlled expansion of myocutaneous flaps offers a potential means of increasing their size. The pectoralis major flap was successfully expanded in pigs, giving mean percentage increases in the axial lengths of 32% and widths of 51% over nonexpanded controls. Angiographic and histomorphologic studies of the expanded flaps demonstrated the vascular and histologic changes that resulted. This new surgical technique should prove valuable in extending the field of head and neck reconstruction in man.