Standardising reporting of cervical lymphadenopathy in paediatric neck ultrasound: a pilot study using an evidence-based reporting protocol

OBJECTIVES

Cervical lymphadenopathy is common in children and can arise from a wide range of aetiologies. Ultrasound can be a useful imaging tool for initial investigation but is known to be operator dependent. We aimed to compare the content of ultrasound reporting in this clinical scenario before and after the introduction of an evidence-based reporting protocol.

METHODS

We performed a prospective 8-month pilot study assessing the content of ultrasound reports generated from scans to investigate suspected cervical lymphadenopathy in children referred to our tertiary referral otolaryngology service. We found wide variation in report content and inconsistent reporting of certain radiological features. In response to this we performed a literature search to identify key, clinically relevant ultrasonographic features for cervical lymphadenopathy and then in consultation with our radiology colleagues, devised a protocol to facilitate the reporting of these key features. Content of reports was then prospectively re-audited over a further 8-month period.

RESULTS

23 reports were assessed before and 26 after introduction of the reporting protocol. Fisher's exact test was used to analyse the data. We found a statistically significant (p < 0.05) improvement in the frequency of reporting of various key features such as nodal distribution, shape, echogenicity, calcification, necrosis and vascular pattern.

CONCLUSIONS

The introduction of a standardised protocol has helped to streamline the reporting of ultrasounds to investigate cervical lymphadenopathy within our department. In the absence of any national guidelines on the reporting of paediatric neck ultrasound in this scenario, we propose that our protocol could be used by other departments to improve standardisation and as a teaching aid.

Subglottic stenosis and socio-economic deprivation: a 6-year review of the Scottish National Service for Paediatric Complex Airway Reconstruction

OBJECTIVE

Subglottic stenosis is the third most common cause of stridor in children, and severe cases may need surgical reconstruction. Babies born to parents in high-deprivation areas are at increased risk of prematurity and low birth weight. This may require intensive care admission with prolonged intubation, hence, putting them at increased risk of subglottic stenosis. We aimed to review cases of subglottic stenosis requiring surgical intervention in the Scottish population and its association with socio-economic deprivation.

METHODS

We collected retrospective data on all children who underwent open reconstructive surgery for subglottic stenosis between January 2005 and January 2011 at the Royal Hospital for Sick Children, Yorkhill, which provides the national complex airway reconstruction service for Scotland. The Scottish Index of Multiple Deprivation (SIMD) was used to categorise deprivation based on the child's home postal code. Incidence figures were calculated based on the total number of births in each deprivation category over the time period.

RESULTS

There were a total of 53 cases of subglottic stenosis undergoing surgery in Scotland over the last 6 years, of which 31 were acquired and 22 were congenital. The most common procedure performed was laryngotracheal reconstruction with cartilage grafts (46 cases). No association was found between deprivation and the incidence of acquired or congenital subglottic stenosis.

CONCLUSION

Our data is the first attempt to review the incidence of subglottic stenosis in the Scottish population and its association with deprivation. Perhaps surprisingly, we found no association.

Development of a screening service for neonatal ear deformity using neonatal hearing screeners and an information leaflet

OBJECTIVES

Early splinting of neonatal ear deformities has been proven to be successful but the opportunity to splint is frequently missed due to lack of awareness amongst healthcare personnel. We aimed to develop a regional screening service using neonatal hearing screeners and an information leaflet to allow for the early detection and treatment of such children.

METHODS

We created an information leaflet that was distributed by hearing screeners to all parents in Greater Glasgow at the time of the child's neonatal hearing assessment, with a contact number allowing parents to self refer. All neonates referred were seen at a dedicated clinic within a week and suitability for splints determined. We aimed to assess acceptability of the service, splinting result as rated by parents and otolaryngologist and also costs involved.

RESULTS

Over a 15 month period, 13,403 leaflets were distributed. 88 babies were referred (0.7%) and 54 were found suitable for splinting. 78% of parents rated the efficacy of splints as either excellent or very good and 96% said they would recommend the service to a friend. Median age at first review was 4 days. We found a weak but statistically significant correlation between age at first review and the surgeon rated outcome from splinting (Spearman's rho=-0.321, p=0.038), with those babies commencing treatment early generally having a better splinting result. We also found that age at first review correlated with duration of splinting required (Spearman's rho=0.357, p=0.008), with younger babies generally requiring shorter splinting times. Cost analysis revealed a saving of £482.76 per child when comparing splint treatment to potential later corrective ear surgery costs.

CONCLUSIONS

Our screening service is both acceptable to parents and efficient in allowing for early correction of ear deformity in the majority of cases. By detecting treatable children early, we propose that the introduction of routine screening and splinting on a wider basis will avoid the psychological burden of ear deformity in childhood and also avoid the need for later corrective surgery.

Impact and workload implications on service provision with establishment of a neonatal complex airway service in Scotland

The objective of this study was to assess if any changes have occurred in the utilization of neonatal services with referral for neonatal airway assessment and how this is related to the establishment of a National Complex Airway Service. A retrospective case-note review was performed for neonates referred for airway assessment from 2004-2010 inclusive. Seventy-nine neonates were referred from throughout Scotland; 10 in 2004-2006, 24 in 2007-2008 and 45 in 2009-2010. The mean gestational age was 35 weeks; 39% were preterm. Stridor was the most common reason for referral (46%). The most common diagnosis was airway malacia (38%). Fifty-three procedures were performed on the ward. In total, 64 microlaryngobronchoscopies were performed; 45 diagnostic and 19 interventional. The most common intervention was supraglottoplasty for airway malacia. Thirty-five separate airway procedures were undertaken. Additional investigations were frequently requested and co-morbidities were common. Since the establishment of the Scottish National Complex Airway Service in 2006, referrals for neonatal airway assessment have increased significantly. The reasons for this include a greater awareness of the service, improved treatment options and increased preterm survival. These neonates frequently have associated co-morbidities and require a repertoire of specialist input. This increase has significant implications for further service provision.

Coblation adenotonsillectomy in children

OBJECTIVE

To determine re-admission rate for post-tonsillectomy pain; the primary and secondary post-tonsillectomy bleeding rate; the percentage requiring control of post-tonsillectomy bleeding in children undergoing coblation tonsillectomy.

STUDY DESIGN

A descriptive study.

PLACE AND DURATION OF STUDY

Royal Hospital for Sick Children (Yorkhill Hospital) between 2004 and 2006.

METHODOLOGY

All patients who underwent tonsillectomy with or without adenoidectomy by coblation technique. Patients were identified from operation theatre log book and electronic data base of theatre activity. The hospital case notes were reviewed retrospectively to collect data, regarding demographics, indication and type of surgery, grade of operating surgeon, duration of hospital stay, re-attendance and re-admission, and management of complications.

RESULTS

A total of 106 children; males (n = 53, 50%), females (n = 53, 50%) with a mean age 6.3 years underwent surgery using coblation technique. Thirty-one percent had a tonsillectomy while 69% underwent an adenotonsillectomy. Of these, 48% had history of recurrent tonsillitis, 43% had obstructive sleep apnoea and 9% suffered predominantly from obstructive symptoms. Eighty-two percent of patients were discharged on the first postoperative day. Only one patient had primary bleeding requiring re-operation. After discharge, 7 patients (6.7%) were re-admitted with secondary bleeding, 3 (2.8%) of whom were taken back to theatre to control the bleeding under general anaesthesia.

CONCLUSION

Coblation tonsillectomy is a useful technique in having a low primary and secondary bleeding rates in children undergoing tonsillectomy and adenotonsillectomy.

Cricoid split for acute subglottic injury in the older child

OBJECTIVES

To describe our experience of cricoid split in the older child for acquired subglottic stenosis secondary to chemical or thermal burns.

METHODS

A retrospective case series.

RESULTS

We describe two patients, both two years old, who benefitted from the procedure and had a return to a normal-sized airway. Neither child required a tracheostomy or further airway intervention after the cricoid split.

CONCLUSIONS

Laryngotracheal reconstruction (LTR) is the standard treatment for subglottic injuries with associated subglottic stenosis in children, infants and (where possible) neonates. We have found the cricoid split a useful technique in carefully selected older children with acute subglottic injury and associated early subglottic stenosis, where LTR or ballooning is not feasible, where there is limited experience of ballooning, and/or ballooning has failed in the early stages of treatment. Cricoid split is a technique that is part of the airway surgeon's open operative repertoire and therefore should be remembered as a management option.

Retrospective review of three antiemetic regimens versus no therapy in the prevention of postoperative and vomiting following adenotonsillar surgery

OBJECTIVE

To study the effect of intraoperative ondansetron and dexamethasone on postoperative vomiting in children undergoing tonsillectomy, adenotonsillectomy, or adenoidectomy.

STUDY DESIGN

Retrospective chart review.

SETTING

Academic tertiary care referral centre in the west of Scotland.

SUBJECTS AND METHODS

A retrospective chart review was conducted on 432 children admitted to our institute between 2004 and 2006. Of these, 285 (66%) patients underwent a tonsillectomy, 50 (11.6%) an adenotonsillectomy, and 97 (22.4%) an adenoidectomy. There was an equal gender distribution, with a mean age of 7.4 years (interquartile range 4.6-10.0). Patients were divided into four groups: group 1 received ondansetron plus dexamethasone (n  =  64, 14.7%), group 2 received ondansetron only (n  =  189, 43.6%), group 3 received dexamethasone only (n  =  17, 3.9%), and group 4 did not receive ondansetron or dexamethasone (n  =  162, 37.4%).

RESULTS

Overall, 98 (22.7%) patients experienced postoperative vomiting (5 at the time of recovery and 93 on the ward). Patients in group 1 had a significantly lower incidence of postoperative vomiting than those in group 2 (10.9% vs 22.8%, p  =  .04) and group 4 (10.9% vs 27.2%, p < .01). The incidence of postoperative vomiting was also lower in group 1 than in group 3, but this did not reach statistical significance (10.9% vs 23.5%, p  =  .18).

CONCLUSION

The combined intraoperative use of ondansetron and dexamethasone appears to be superior to no antiemetic or ondansetron alone in reducing the incidence of vomiting in children undergoing adenotonsillar surgery.

Development of a minimum protocol for assessment in the paediatric voice clinic. Part 1: evaluating vocal function

The European Laryngological Society (ELS) recommend that functional assessment of voice disorder in adults requires evaluation of a number of different parameters. The current paper presents a discussion of four of the five parameters highlighted in the ELS protocol: perceptual evaluation of voice, videostroboscopic examination, evaluation of aerodynamic performance in voice, and acoustic analysis. Subjective rating of voice in children is explored in a companion paper. These parameters have been extensively evaluated in adults, and a review of the literature pertaining to the paediatric population is presented.

The management of laryngeal clefts

OBJECTIVE

To review the clinical presentation and management of all infants and children presenting with laryngeal clefts to a tertiary pediatric ENT centre and to identify changes in practice over time.

PATIENTS AND METHODS

A retrospective case note review of the management of all infants and children with a diagnosis of a laryngeal cleft identified in our Department between 01/11/2003 and 31/12/2010.

RESULTS

Twelve children with laryngeal clefts were identified. Six clefts were grade 1, five grade 2 and one grade 3b. All grade 1 clefts were managed conservatively. Of the grade 2 clefts, four required surgery with one being managed conservatively. Two were repaired using an open technique and two using an endoscopic technique. The grade 3b cleft was repaired endoscopically. Two cleft repairs broke down post-operatively requiring further surgery.

CONCLUSIONS

Conservative management remains the management of choice for lower grade clefts. Where a laryngeal cleft requires repair there has been a trend towards the endoscopic over open technique, even of more extensive clefts.

Tonsillectomy: a cost-effective option for childhood sore throat? Further analysis of a randomized controlled trial

OBJECTIVE

To compare the estimated cost-effectiveness of childhood (adeno)tonsillectomy vs medical therapy for recurrent sore throats from the intention-to-treat (ITT) analysis of a randomized controlled trial (RCT) with that modeled on the recorded timing of surgical interventions as observed in all participants irrespective of their original group allocation.

STUDY DESIGN

A pragmatic RCT (trial) with a parallel nonrandomized patient preference group (cohort) of (adeno)tonsillectomy vs medical therapy.

SETTING

Five secondary care UK otolaryngology departments.

SUBJECTS AND METHODS

Eligible children, aged 4 to 15 years, were enrolled to the trial (268) or cohort (461) groups. Outcomes included sore throat diaries, quality of life, and general practice consultations. The RCT protocol ITT analysis was compared with an as-treated analysis incorporating the cohort group, modeled to reflect the timing of tonsillectomy and the differential switch rates among the original groups.

RESULTS

In the RCT ITT analysis, tonsillectomy saved 3.5 sore throats, whereas the as-treated model suggested an average reduction of more than 8 sore throats in 2 years for surgery within 10 weeks of consultation, falling to only 3.5 twelve months later due to the spontaneous improvement in the medical therapy group.

CONCLUSION

In eligible UK school-age children, tonsillectomy can save up to 8 sore throats at a reasonable cost, if performed promptly. Further prospective data collection, accounting for baseline and per-trial preferences and choice, is urgently needed.

The pathology of visible blood vessels on the nasal septum in children with epistaxis

OBJECTIVE

Epistaxis is common in children, but its cause remains unknown. About half the children who present with epistaxis have prominent vessels on the nasal septum. The aim of this study was to determine the pathological nature of the prominent septal vessels in children with recurrent epistaxis.

METHODS

4mm punch biopsies of the nasal septal mucosa were taken from 5 children undergoing nasal cautery under general anaesthesia.

RESULTS

Histology showed that the prominent vessels were thin-walled arterioles and capillaries with a surrounding inflammatory infiltrate. There was no evidence of venous varicosities or arterial microaneurysms.

CONCLUSION

We postulate a mechanism for septal neovascularisation due to chronic low-grade inflammation as a cause for recurrent epistaxis in children.

The prevalence of ear, nose and throat disorders in preschool children with Down's syndrome in Glasgow

Guidelines suggest that all children with Down's syndrome have hearing testing on a regular basis. Since 2004, the ear, nose and throat (ENT), audiology and education services have conducted a joint clinic for annual ENT health and hearing surveillance of all preschool children with Down's syndrome in Greater Glasgow. The aim of this study is to report the prevalence of ENT problems in this well-defined birth cohort, and the proportion of children for whom ENT surgery is required. A prospective database has been kept since 2004, detailing the ENT health status of every child attending the community-based surveillance clinic. Between September 2004 and September 2008, 87 preschool (aged 9 months to 6 years) children with Down's syndrome were sent appointments for the clinic. Of these, 48 (55%) were female and 39 were male. Data were available for 79 (91%). Over the course of the study, 37% were listed for surgery at some point, either adenotonsillectomy for obstructive symptoms or grommet insertion for otitis media with effusion (OME). The prevalence of OME was 93% at age 1, falling to 68% by age 5. None had significant sensorineural hearing impairment. Obstructive symptoms were also common, with 79% of children having either currently symptomatic upper airways obstruction or a history of adenotonsillectomy by age 5. One child had laryngomalacia and two had symptomatic congenital subglottic stenosis. The prevalence of ENT problems in these children is high. Surgical intervention is frequently required. We advocate a proactive approach of regular ENT and audiology surveillance leading to early intervention, with the aim of maximizing health and educational achievement in the long term.

A case of a nasal dermoid presenting as a median upper lip sinus

Nasal dermoids are uncommon developmental abnormalities. Median upper lip fistulas are even rarer and recognized as a separate pathology. The authors present the unusual case of a child with a sinus on the philtrum of the upper lip and a sinus tract passing all the way to the anterior skull base through the nasal septum. The authors propose that nasal dermoids and medial upper lip fistulas have a common aetiology, and may be the same entity. The authors suggest they should all be managed like nasal dermoids and have MRI scanning prior to theatre. If the lesion extends into the nose, excision by external rhinoplasty is the preferred option.

The external rhinoplasty approach for congenital nasal lesions in children

OBJECTIVE

Congenital lesions of the nose can be challenging to excise. While some lesions carry infection risks, in most cases surgery is primarily performed for cosmesis. Some lesions may extend up to the skull base and this can occasionally be missed on MRI scans. Surgical access has to allow complete excision in all circumstances, but access must be balanced against cosmetic results. We present our experience of the external rhinoplasty approach which allows wide access with little visible scarring.

METHODS

Retrospective chart review of all cases performed between November 2003 and October 2009.

RESULTS

15 children underwent excisional surgery using the external rhinoplasty approach. They were aged 1-5 years at the time of surgery, and 12 were male. Pathology comprised congenital midline nasal dermoid cysts in 13 (of which 4 extended intracranially), extranasal glioma in 1 and non-resolving haemangioma in 1. The surgical approach provided adequate visualisation in all cases. The children with intracranial dermoids had resection and repair of the dura as part of their procedure. No post-operative CSF leaks occurred. One child with nasal dermoid had a small cyst recurrence in the skin of the nasal tip requiring further surgery but no deep recurrences occurred. Follow up ranges from 3 months to 6 years. Children with widened nasal bones before surgery have all shown rapid bony remodelling after surgery.

CONCLUSIONS

The external rhinoplasty approach offers excellent access in young children, even for intracranial lesions.

Long-term follow-up of children after submucosal diathermy to the inferior turbinate for rhinitis

BACKGROUND

There is currently poor evidence base to support turbinate surgery in children. Submucosal diathermy (SMD) is a day case procedure offered to children who have refractory rhinitis. There is currently no well-defined population who will benefit from this procedure. The Glasgow Children's Benefit Inventory (GCBI) is a validated questionnaire that can be used to assess benefit following an intervention.

METHODS

In September 2009, questionnaires were sent by post to the parents of 70 children who underwent SMD between 2003 and 2006. If no response was received, an attempt to contact the parents by telephone was made. These questionnaires were then analysed to ascertain benefit scores.

RESULTS

Returned questionnaires were received for 47 children (68%). 70% (33) felt that this had been a worthwhile procedure. Residual nasal symptoms were recorded, of which rhinorrhea was the most frequent (30, 64%), followed by nasal blockage (28, 60%). Of these children, 23 had a positive radio-allergosorbent test (RAST) and 21 were negative. Overall the median GCBI for children receiving SMD was 19.5. This was elevated in the RAST positive group (median score 27) and lower for the RAST negative group (median score 14).

CONCLUSION

This study highlights some benefit to inferior turbinate study in children by using the GCBI. Improved benefit was not demonstrated significantly in older or younger children or in RAST positive or negative children. Further studies, by means of a randomised controlled trial are required to provide a better level of evidence for this procedure.

Intraoperative dexamethasone and the risk of secondary posttonsillectomy hemorrhage

OBJECTIVE

to determine whether intraoperative dexamethasone is a risk factor for secondary posttonsillectomy bleeding.

DESIGN

retrospective chart review.

SETTING

tertiary care referral centres in Scotland.

METHOD AND PATIENTS

the charts of 530 pediatric patients undergoing tonsillectomy were reviewed over a 3-year period (January 2004 to December 2006), and data were collected regarding the use of dexamethasone intraoperatively. Data were analyzed using the SPSS for Windows statistical package (SPSS Inc, Chicago, IL).

MAIN OUTCOME MEASURES

incidence of secondary posttonsillectomy bleeding. The relative risk of posttonsillectomy bleeding was measured in those receiving dexamethasone. Logistic regression analysis was performed.

RESULTS

Thirty-seven episodes of secondary hemorrhage were encountered in 36 children: 9 of 253 (3.6%; 95% CI 1.6-6.7) patients receiving intraoperative dexamethasone compared to 28 of 277 (10.1%; 95% CI 6.8-14.3) not receiving dexamethasone. Six patients had to undergo an emergency reoperation to arrest bleeding, only one of whom had received dexamethasone. When added to a stepwise logistic regression model with age, gender, indication for surgery, surgeon grade, and operative technique, dexamethasone and the presence of obstructive symptoms were the only significant factors influencing the risk of bleeding. The odds ratio indicates that patients with obstructive symptoms (OR 0.16; 95% CI 0.04-0.70) and those receiving dexamethasone were less likely to develop secondary bleeding (OR 0.44; 95% CI 0.20-0.96).

CONCLUSION

based on our study data, the use of intraoperative dexamethasone does not appear to increase the risk of posttonsillectomy bleeding.