American Society of Pediatric Otolaryngology Members' Experience With Recurrent Respiratory Papillomatosis and the Use of Adjuvant Therapy

OBJECTIVE

To evaluate how evolving treatment technologies have affected our management of recurrent respiratory papilloma (RRP) since the last comprehensive survey of pediatric otolaryngologists in 1998.

DESIGN

Web-based survey of all American Society of Pediatric Otolaryngology members residing in the United States, Canada, Europe, and Australia.

RESULTS

Evaluable survey results were tabulated from 74 practitioners in 62 separate practices managing 700 current children with RRP. A total of 150 (21%) of these patients presently receive adjuvant medical therapies with cidofovir and interferon, accounting for more than two thirds of the total. Sixty-one percent of patients treated with cidofovir have experienced a beneficial response. Distal spread of RRP has occurred in 94 (13%) of the 700 patients. Half of the practices surveyed have experienced a death from RRP, with 89% of deaths directly related to RRP. The laryngeal microdebrider (53%) has supplanted the carbon dioxide laser (42%) as the preferred means of surgically removing papilloma from the larynx in children. Spontaneous, apneic, and jet ventilation (88%) anesthesia techniques have replaced the use of laser-safe endotracheal tubes (10%) as the preferred anesthetic management. Routine human papillomavirus subtyping is practiced by 45% of respondents while 15% treat all their patients with antireflux medications. Half of respondents send lesions for histologic examination only if there is a change in growth pattern while one third send lesions with every surgery.

CONCLUSIONS

Recurrent respiratory papilloma continues to be a frustrating disease to treat and is associated with significant morbidity and mortality. There has been an evolution in the past decade toward the increased use of antiviral adjuvant therapy and the use of microdebrider techniques for surgical management.

Impact of Pneumococcal Polysaccharide Vaccine (Prevnar) on Middle Ear Fluid in Children Undergoing Tympanostomy Tube Insertion

OBJECTIVES

The purpose of this study was to describe the bacteriology of middle ear effusions in children who have received the pneumococcal polysaccharide vaccine (Prevnar) compared with unvaccinated children.

METHODS

A prospective review of medical records from July 2001 to July 2002 was conducted on children with middle ear effusion at time of tympanostomy tube insertion. Middle ear fluid was plated onto culture media immediately after acquisition, and antimicrobial resistance of cultured organisms along with serotyping of Streptococcus pneumoniae was examined. Vaccination status, demographics, and risk factors were determined from patients' medical records, parent interviews, or contact with their primary care physicians.

RESULTS

After adjusting for age and number of previous infections, children vaccinated with Prevnar are two times less likely to have non-S. pneumoniae pathogenic bacteria isolated than children not vaccinated. Of those with growth, vaccinated children were almost three times more likely than nonvaccinated children to have the presence of H. influenzae. Vaccinated children with H. influenzae were 7.5 times less likely to have beta-lactamase producing H. influenzae than nonvaccinated children with H. influenzae.

CONCLUSION

Because the incidence of S. pneumoniae was low, no inference could be made whether Prevnar decreased otitis media with effusion or recurrent acute otitis caused by the S. pneumoniae serotypes covered by the vaccine. However, vaccinated children did appear to have the unexpected benefit of having a certain level of protection to growth of typical acute otitis media pathogens.

Multicenter initiative seeking critical genes in respiratory papillomatosis

OBJECTIVES

To determine the host genes that govern susceptibility to recurrent respiratory papillomatosis (RRP). RRP is caused by human papillomavirus (HPV) 6 and 11. Millions of babies are exposed during the birthing process, but relatively few develop the disease and the aggressiveness of the course is highly variable. Genetically encoded host susceptibility is postulated. Determining the host genes that govern susceptibility will enhance our understanding not only of RRP but also of host-viral interaction in general.

STUDY DESIGN

A genome-wide association study on familial triads consisting of an RRP-affected child and his or her parents. Using the HapMap data from the human genome project, we will identify those alleles that are over-transmitted by the parents to their affected offspring as compared to those alleles that are under-transmitted.

METHODS

Approximately 400 patients and their parents will be recruited through a collaboration between the Center for Genomic Sciences and the RRP Task Force. DNA will be extracted from blood specimens and viral typing will be performed on biopsy specimens. Patients will be genotyped using single nucleotide polymorphism (SNP) markers and compared to their respective parents' genotype using the transmission disequilibrium test. Both a genome scan and a candidate gene approach will be utilized. RESULTS Institutional Review Board authorization has been obtained at three hospitals and the process is underway at 18 more. Patient and parent recruitment has begun. Specimens have been forwarded to Pittsburgh, Pennsylvania, where the DNA has been extracted and is being stored.

CONCLUSIONS

A novel approach combining a nationwide patient resource and the mapping power of the sub-centimorgan human haplotype map has been developed to elucidate the biological mechanisms of RRP by determining the genetically encoded susceptibilities of host-virus interaction.

Posttympanostomy tube otorrhea

This article will focus on some theories and recent advances to explain chronic post tympanostomy tube otorrhea, a step-wise approach to treatment and future research areas of interest.

Diagnosis and management of pulmonary metastasis from recurrent respiratory papillomatosis

OBJECTIVE

We sought to review the current and proposed management, as well as bring about discussion, of managing the patient with distal tracheal and pulmonary parenchymal involvement by recurrent respiratory papillomatosis (RRP).

DESIGN, SETTING, AND PATIENTS

We conducted a review of 6 patients with pulmonary metastasis from RRP at 3 academic tertiary care hospitals. Interventions included surgical and medical management with antiviral, chemotherapeutic, and/or immune-modulating agents.

RESULTS

Although treatment with alpha-2-beta interferon, isotretinoin, and methotrexate have not proved to eradicate pulmonary involvement by RRP, possible epithelial stabilization and slowing of disease progression are noted.

CONCLUSIONS

The rates of distal tracheal and pulmonary metastasis as seen in our cohort were higher than previously reported. Approximately 12% of our patients with RRP have distal tracheal spread and as many as 7% of all patients with RRP at our institutions have pulmonary dissemination. Also, high suspicion for malignant conversion to squamous carcinoma in the patient with pulmonary spread should be maintained. In addition, aggressive treatment, although not proved to eradicate the pulmonary disease, should be undertaken due to the high morbidity and mortality associated with pulmonary dissemination of RRP in our cohort.

Predictors of Remission in Juvenile-Onset Recurrent Respiratory Papillomatosis

OBJECTIVE

To determine factors associated with remission of juvenile-onset recurrent respiratory papillomatosis (JORRP).

DESIGN

Longitudinal study.

SETTING

Twenty-two tertiary care centers located across the United States.

STUDY PARTICIPANTS AND METHODS

The study included 165 patients diagnosed as having JORRP between January 1, 1997, and December 31, 2000. Kaplan-Meier curves and Cox proportional hazards models were used to determine associations between predictors and remission.

INTERVENTIONS

Surgical excision and drug therapy.

MAIN OUTCOME MEASURES

Remission of JORRP, defined as no surgical procedures for at least 1 year, as associated with age at diagnosis, drug therapy in the first year after diagnosis, number of surgical procedures in the first year after diagnosis, and number of anatomical sites of disease at diagnosis. Demographic factors (sex and race) and Medicaid status were also evaluated.

RESULTS

Older age at diagnosis was positively associated with remission of JORRP (hazards ratio for every increase of 1 year in age, 1.13; 95% confidence interval, 1.03-1.23).

CONCLUSIONS

Younger children were found to have persistent disease and often underwent an increased number of surgical procedures in the first year after diagnosis of JORRP. Sex and race were not important factors in determining remission.

Otitis media: concepts and controversies

PURPOSE OF REVIEW

Otitis media is the most common bacterial infection among children, accounting for as many as 30 million office visits annually. Proper treatment has become critical as offending pathogens become increasingly resistant to antibiotics and the cost of managing the disorder has exceeded 3 billion dollars per year. However, data suggest that many practitioners still struggle with the diagnosis of otitis media and often recommend medical and surgical intervention inappropriately. This article presents recent advances in the otitis media literature and an evidence-based approach to its management.

RECENT FINDINGS

Recent investigations have resulted in the following findings: (1) bacterial biofilms may account for the persistence of middle ear disease; (2) there is increasing evidence that heredity and reflux are risk factors for otitis media; (3) primary care providers may be receiving poor otitis media training, leading to inadequate diagnostic skills; (4) medical and surgical therapy are of limited utility in the management of acute and recurrent acute otitis media; (5) antibiotics and steroids are of limited value in the treatment of chronic middle ear effusion; (6) delayed management of effusion may not adversely affect development in children; (7) vaccination for pneumococcus may alter the serotypes responsible for otitis media; and (8) vaccine candidates for other middle ear pathogens are under investigation.

SUMMARY

Management of otitis media is constantly evolving, based on research from a variety of medical subspecialties. It is incumbent on the otolaryngologist and primary care providers treating otitis media to keep pace with and synthesize these findings into a rational approach to treatment.

National registry for juvenile-onset recurrent respiratory papillomatosis

BACKGROUND

Juvenile-onset recurrent respiratory papillomatosis (JORRP) is an infrequent but debilitating disease. Because JORRP is uncommon, it has proven difficult for studies at single institutions to accurately evaluate its natural history.

OBJECTIVE

To characterize the clinical spectrum of JORRP.

DESIGN

Standardized retrospective and prospective medical record abstraction.

SETTING

Twenty-two tertiary-care pediatric otolaryngology centers throughout the United States. Patients All patients with JORRP younger than 18 years seen between January 1, 1996, and March 31, 2002.

MAIN OUTCOME MEASURES

Demographics, age at diagnosis, anatomic sites of disease, longitudinal disease course, frequency of surgery, need for tracheotomy, and medication history.

RESULTS

The registry includes 603 children. The mean age at diagnosis was 4.0 years. The children underwent a mean of 5.1 surgeries annually. Current age, rather than age at diagnosis, was the primary determinant of surgical frequency. The larynx was involved at the time of diagnosis in 96.1% of children, and 87.4% had only 1 anatomic site involved. Children with 1 site involved were significantly older at diagnosis (mean age, 3.9 years) than those with 2 sites (mean age, 2.9 years). Most (74.2%) had stable disease over time, 5.8% showed progression of papillomas to new sites, and 17.9% had no evidence of disease for at least 1 year. Children with disease progression were diagnosed at a significantly younger age than those who remained stable or became disease-free. Children who required tracheotomy were significantly more likely to have progressive disease.

CONCLUSIONS

The registry has established the clinical course of JORRP in a large sample representative of the United States. Young age was the most important determinant of disease severity (frequency of surgery, extent of disease at diagnosis, and progression of disease). Addressing questions of pathogenesis and disease course will require a revised data collection instrument and molecular analysis of tissues.

Reliability of a staging assessment system for recurrent respiratory papillomatosis

INTRODUCTION

A staging system for the assessment of severity of disease and response to the therapy in recurrent respiratory papillomatosis (RRP) was proposed several years ago. It includes both a subjective functional assessment of clinical parameters and an anatomic assessment of disease distribution. The anatomic score can then be used in combination with the functional score to measure an individual patient's clinical course and response to the therapy over time. In using this system, it would be of benefit to know what level of variability can be expected from one surgeon to another in the assessment of an RRP patient and the assignment of a score.

DESIGN

Ten videotaped recordings of endoscopic assessments of patients with RRP were reviewed by 15 pediatric otolaryngologists and scored based on the criteria of the staging assessment system.

RESULTS

Analysis was conducted for 15 raters of scoring severity over 25 sites of 10 patients. The total score is the addition of scores over the 25 sites with a score equal to or greater than 20 representing high risk. For 8/10 (80%) of the subjects, there was a complete agreement about risk categorization (low risk) and agreement by 14/15 (93%) raters for categorization of one other patient. For 9/10 (90%) of subjects, the standard errors of the mean total scores were less than 1, meaning a low variance and subsequent high reliability of the total score.

CONCLUSIONS

This staging system was able to achieve agreement by 15 pediatric otolaryngologists on 9 of 10 subjects in terms of degree of severity of RRP.

Anesthetic complications of tympanostomy tube placement in children

OBJECTIVE

To determine the incidence of perioperative anesthesia complications during bilateral myringotomy with tympanostomy tube placement (BMTT).

SETTING

Tertiary care children's hospital where otolaryngology attending physicians and residents performed surgical procedures. Anesthesia providers included pediatric anesthesiologists, residents, nurse anesthetists, and students.

METHODS

Medical record review was performed for a consecutive series of 3198 children undergoing BMTT (1000 prospectively, 2198 retrospectively). For the prospectively studied patients, major adverse events, which included laryngospasm and stridor, and minor adverse events, including upper airway obstruction, prolonged recovery, emesis, and persistent postprocedural agitation, were noted. Also recorded were the patient's American Society of Anesthesiologists (ASA) physical class status, age, concurrent medical conditions, and type of anesthesia provider.

RESULTS

Fewer than 9% of prospectively studied pediatric patients experienced a minor adverse event, whereas a major event occurred in 1.9%. Eighty-one percent of the events experienced were attributable to agitation or prolonged recovery. Neither ASA status (P =.38), age (P =.15), nor type of anesthesia provider (P =.06) were significantly related to the occurrence of an adverse event. However, a child with an acute or chronic illness has 2.78 times the odds of experiencing an adverse event compared with a child with no illness (P<.001).

CONCLUSIONS

Anesthesia administered for placement of tympanostomy tubes by physicians who specialize in the care of children in a tertiary care children's hospital is safe. The most significant predictor of a minor anesthetic event during BMTT is the presence of a preexisting medical condition or concurrent acute illness.

Surfer's ear: external auditory exostoses are more prevalent in cold water surfers

OBJECTIVE

The study goal was to demonstrate the prevalence and severity of external auditory exostoses (EAEs) in a population of surfers and to examine the relationship between these lesions and the length of time surfed as well as water temperature in which the swimmers surfed. It was hypothesized that subjects who predominantly surfed in colder waters had more frequent and more severe exostoses.

METHODS

Two hundred two avid surfers (91% male and 9% female, median age 17 years) were included in the study. EAEs were graded based on the extent of external auditory canal patency; grades of normal (100% patency), mild (66% to 99% patency), and moderate-severe (<66% patency) were assigned. Otoscopic findings were correlated with data collected via questionnaires that detailed surfing habits.

RESULTS

There was a 38% overall prevalence of EAEs, with 69% of lesions graded as mild and 31% graded as moderate-severe. Professional surfers (odds ratio 3.8) and those subjects who surfed predominantly in colder waters (odds ratio 5.8) were found to be at a significantly increased risk for the development of EAEs. The number of years surfed was also found to be significant, increasing one's risk for developing an exostosis by 12% per year and for developing more severe lesions by 10% per year. Individuals who had moderate-severe EAEs were significantly more likely to be willing to surf in colder waters than were those who had mild EAEs (odds ratio 4.3).

CONCLUSIONS

EAEs are more prevalent in cold water surfers, and additional years surfing increase one's risk not only for developing an EAE but also for developing more severe lesions.

Simulated reflux and laryngotracheal reconstruction: a rabbit model

OBJECTIVES

(1) To test the feasibility of a rabbit model using a pharyngostomy tube to simulate gastroesophageal reflux and (2) to study the effects of gastroesophageal reflux on laryngotracheal reconstruction using a new rabbit model.

DESIGN

Prospective randomized trial.

SUBJECTS

Thirty-three New Zealand white rabbits.

INTERVENTIONS

Anterior cartilage laryngotracheoplasty and pharyngostomy tube placement into the pyriform sinus were performed in 33 rabbits, 22 of which are included in this analysis. Beginning postoperative day 1, hydrochloric acid at a pH of 1.5 with pepsin (n = 7) or at a pH of 4.0 with pepsin (n = 8) was irrigated twice daily through the pharyngostomy tube to simulate gastroesophageal reflux, and a control group received twice-daily isotonic sodium chloride solution irrigations (n = 7).

MAIN OUTCOME MEASURES

Specimens were scored by a pathologist masked to individual groups using a newly modified inflammation scoring system. In addition, cross-sectional areas of the cartilage grafts and subglottic airway lumina were compared.

RESULTS

Inflammation scores were significantly higher in rabbits receiving hydrochloric acid and pepsin irrigations at a pH of 4.0 (P =.04) but not in those in the pH 1.5 group. Cartilage necrosis was prominent in all groups, and airway sizes and cross-sectional areas of the grafts were not significantly different among the 3 groups.

CONCLUSIONS

Cartilage necrosis is prominent during the early stages after laryngotracheoplasty. Inflammation can be increased using hydrochloric acid and pepsin irrigations but is difficult to predict based on this study. Although we confirmed the feasibility of this model, further modifications of this study are proposed to improve animal survival and data collection.

Peritonsillar abscess in children: a 10-year review of diagnosis and management

OBJECTIVE

peritonsillar abscess is the most common deep neck infection in adults and children. However, pediatric patients with their smaller anatomy and often inability to cooperate with exam and treatment, provide a challenge. This study reviews the experience over the last 10 years at a children's hospital in the diagnosis and treatment of pediatric peritonsillar abscess.

METHODS

a retrospective chart review of 83 children diagnosed with a peritonsillar abscess by the Otolaryngology service over a 10-year period (March 1989-February 1999) were reviewed. Presenting signs and symptoms, physical findings, age, season of presentation, prior pharyngitis history, and prior treatment was collected from the charts. Additionally, diagnostic studies (if any), treatment performed, bacteriology, and outcome/complications were noted.

RESULTS

due to either an inability to cooperate fully for examination and treatment, or because of an earlier history of significant recurrent pharyngitis or obstructive tonsillar hypertrophy, half of the children required treatment in the operating room. Twenty-six out of 83 (31%) underwent a quinsy tonsillectomy. Length of stay was relatively short (0.9 days). There were no recurrent PTAs in our series, although four children initially treated with incision and drainage required tonsillectomy for persistent symptoms or residual abscess. Ten of those not treated with tonsillectomy (19%) required interval tonsillectomy for recurrent pharyngitis.

CONCLUSION

limited by the ability to cooperate with treatment, children often require different treatment plans. We offer a treatment algorithm for managing children with PTAs that takes into account their age, level of cooperativeness, co-morbidities and prior history of pharyngitis, PTA or obstructive sleep disorder.

Recurrent respiratory papillomatosis

Recurrent respiratory papillomatosis (RRP) is the most common benign neoplasm of the larynx in children. Despite its benign histology, RRP has potentially morbid consequences and is often difficult to treat because of its tendency to recur and spread throughout the respiratory tract. Long neglected from an epidemiological standpoint, recent initiatives to better understand this disease process have been launched through coordination between the Centers for Disease Control and Prevention and the American Society of Pediatric Otolaryngology. In this clinical review, I discuss what we currently know regarding the etiology, epidemiology, and transmission of this disease. Clinical features including pertinent aspects of the history, physical examination, airway endoscopy, and other considerations are highlighted. A detailed description of the surgical and anesthetic management of these challenging cases is presented. Adjuvant modalities of surgical and nonsurgical treatment and their indications are discussed. Ongoing research initiatives and the Practice Guidelines of the Recurrent Respiratory Papillomatosis Task Force are also included.

Recurrent respiratory papillomatosis of the larynx: current diagnosis and treatment

Treating children with recurrent respiratory papillomatosis can be very rewarding as more information is learned about human papillomavirus. The future goals are reducing the morbidity and mortality of this disease process. The establishment of the national recurrent respiratory papillomatosis patient registry and coordinated efforts between basic scientists involved in human papillomavirus research and clinicians involved in the treatment of recurrent respiratory papillomatosis should aid the endeavor.

Potpourri aspiration presenting as tension pneumothorax

Foreign body aspiration in children is a relatively common occurrence, with peanuts, seeds, or other food particles representing the most common items. Because radiological findings such as mediastinal shift, postobstructive emphysema, and pneumonia are notoriously inconsistent, diagnosis hinges on an accurate history, which may be correlated by physical examination and radiography. We present the case of a 2-year-old girl with delayed treatment of a bronchial foreign body who presented with tension pneumothorax before endoscopy. After chest tube removal, her pneumothorax recurred, thereby bringing about the question of bronchial erosion. Furthermore, an uncommonly reported aspirated object, household potpourri, was encountered.

Pediatric tracheotomies: changing indications and outcomes

OBJECTIVE/HYPOTHESIS

To study the outcomes and complications associated with pediatric tracheotomy, as well as the changing trend in indications and outcomes since 1970.

STUDY DESIGN

Retrospective chart review at a major tertiary care children's hospital.

METHODS

On children who underwent tracheotomy at Children's Hospital of the King's Daughters (Norfolk, VA) between 1988 and 1998, inpatient and outpatient records were reviewed. Of 218 tracheotomies, sufficient data were available on 204. Indications for tracheotomy were placed into the following six groups: craniofacial abnormalities (13%), upper airway obstruction (19%), prolonged intubation (26%), neurological impairment (27%), trauma (7%), and vocal fold paralysis (7%).

RESULTS

The average age at tracheotomy was 3.2 +/- 0.6 years. Although the prolonged intubation group was significantly younger than all others, the neurological impairment and trauma groups were significantly older. Decannulation was accomplished in 41%. Time to decannulation was significantly higher in the neurological impairment and prolonged intubation groups, but was significantly shorter in the craniofacial group. Complications occurred in 44%. Overall mortality was 19%, with a 3.6% tracheotomy-related death rate. Comparison of our series to other published series of pediatric tracheotomies since 1970 shows fewer being performed for airway infections and more for chronic diseases, with a corresponding increase in duration of tracheotomy and decreased decannulation rates.

CONCLUSIONS

Tracheotomy is a procedure performed with relative frequency at tertiary care children's hospitals. While children receiving a tracheotomy have a high overall mortality, deaths are usually related to the underlying disease, not the tracheotomy itself.

Impact of tympanostomy tubes on child quality of life

BACKGROUND

The objective benefits of tympanostomy tubes for otitis media are well established, but the subjective impact of surgery on child quality of life (QOL) has not been systematically studied.

OBJECTIVES

To determine the subjective impact of tympanostomy tubes on child QOL, and to compare the variability in QOL before surgery with that observed after surgery.

DESIGN

Prospective, observational, before-and-after trial.

SETTING

Fourteen referral-based pediatric otolaryngology practices in the United States.

PATIENTS

Consecutive (64%) and convenience (36%) sample of 248 children (median age, 1.4 years) with otitis media scheduled for bilateral tympanostomy tube placement as an isolated surgical procedure.

INTERVENTION

Tympanostomy tubes were inserted as part of routine clinical care. Validated measures of QOL (OM-6 survey), satisfaction with health care decision (Satisfaction With Decision Scale), and satisfaction with office visit; surveys were completed at baseline (visit 1), at surgery (visit 2), and after surgery (visit 3).

MAIN OUTCOME MEASURES

Short-term changes in QOL before surgery (visit 1 to visit 2) and after surgery (visit 2 to visit 3).

RESULTS

Changes in QOL before surgery were mostly trivial, and were smaller than changes observed after surgery (P<.001). Large, moderate, and small improvements in QOL occurred after surgery in 56%, 15%, and 8% of children, respectively. Physical symptoms, caregiver concerns, emotional distress, and hearing loss were most improved, but significant changes were also seen for activity limitations and speech impairment. Trivial changes occurred in 17% of children, and 4% had poorer QOL. Predictors of poorer QOL were otorrhea 3 or more days (10% of variance) and decreased satisfaction with surgical decision (3% of variance). Hearing status, child age, type of otitis media (recurrent vs chronic), and office visit satisfaction were unrelated to outcome.

CONCLUSIONS

Tympanostomy tubes produce large short-term improvements in QOL for most children. The best outcomes occur when postoperative otorrhea is absent or minimal, and when parents are satisfied with their initial decision to have surgery. Further research is needed to document the long-term impact of tubes on child QOL.