Technique of laryngoscopy

The role of the pediatric laryngologist has changed. He now manages a greater range of clinical problems in the upper airways. Direct laryngoscopy under general anesthesia is fundamental for correct diagnosis and management in infants and children. It is a precise procedure utilizing a range of modern miniaturized instruments. Major technological improvements include quartz iodine and xenon light sources, flexible light carrying leads, fiberoptic rod lighting, special purpose laryngoscopes, rigid telescopes, versatile techniques of anesthesia, microlaryngeal surgery, laser surgery and reliable photographic documentation.

Comparison of use of outpatient mental health services in an HMO and fee-for-service plans. Sensitivity to definition of a visit

Whereas previous authors have used a variety of strategies to identify use of mental health services, the sensitivity of estimates to the definition of a visit has been little studied. The authors examined the sensitivity of estimates of use of outpatient mental health services in both HMO and fee-for-service plans to the method of identifying outpatient mental health visits. The HMO and fee-for-service plans had identical benefits (i.e., free care). Data were from the Rand Health Insurance Study. Mental health visits were identified using two definitions: presence of a mental health diagnosis or procedure; and presence of a mental health procedure, diagnosis, or prescription for psychotropic medication in the absence of physical disorders requiring such medications. The major policy conclusions about lower levels of use in the HMO compared to fee-for-service plans were insensitive to the definition of a visit. Nevertheless, estimates of use of general medical providers were higher when psychotropic medications were included in the definition of a mental health visit; this sensitivity to definition was significantly greater for fee-for-service than HMO participants (P less than 0.05). Further, conclusions about the comparability of enrollment mental health status of patients treated by general medical providers in HMO and fee-for-service plans were somewhat sensitive to the definition of a visit.

Vocal nodules in children

We reviewed 27 pediatric patients who had vocal nodules removed surgically in a 5-year period. Age of operation, duration of symptoms, indications for operation, and the results of removal are analyzed. The techniques of laryngoscopic assessment with telescopes and of microsurgical removal are described in detail. The 27 children had 53 nodules removed. Almost all had normal or improved voices as judged by the parents' answers to a written questionnaire. From the results of this series, microsurgical removal of vocal nodules in children is justified in selected patients.

Pachyonychia congenita with laryngeal involvement

Pachyonychia congenita (Jadassohn-Lewandowsky Syndrome) is a rare autosomal dominant disorder characterized by nail dystrophy, hyperkeratosis of the palms and soles, leukoplakia of the mucosa of the upper respiratory tract and anus, follicular keratoses especially about the knees and elbows, and palmar and plantar hyperhidrosis. We present a patient with pachyonychia congenita and an exophytic lesion in the larynx at the posterior commissure. He is the youngest of 4 family members with this disorder covering 3 generations. Each of the 4 patients also exhibited both oral leukoplakia compatible with the Jadassohn-Lewandowsky syndrome (Ikonograph Dermatol. Lab., 1 (1906) p. 29), and subcutaneous cysts of the face and scalp as described by Jackson and Lawler (Ann. Eugenics (1951) 142.

Use of outpatient mental health services over time in a health maintenance organization and fee-for-service plans

The authors compared the use of outpatient mental health services in a health maintenance organization (HMO) and fee-for-service plans over a 5-year period, using data from a randomized controlled trial. In any given year, enrollees in the HMO and a fee-for-service plan with identical benefits were equally likely to visit a mental health specialist. Over several years, the HMO enrollees were about 50% more likely ever to visit a mental health specialist; fee-for-service enrollees were more likely to receive mental health care in more than 1 study year.

Severe upper airway obstruction

This article describes management of newborn and older children with severe upper airway obstruction, that is, those needing or likely to need airway support for their intact survival. These children have more to gain from optimal care, and more to lose from any error than most other children requiring admission to a pediatric intensive care unit.

The role of the paediatric endoscopist

The role of the paediatric endoscopist has been a changing one. When I first commenced at the Royal Alexandra Hospital for Children in Sydney 25 years ago, paediatric endoscopy of the upper respiratory tract and oesophagus was a limited and poorly defined field. Most endoscopic examinations were requested, often reluctantly, by a paediatrician in the investigation of stridor. In fact my first consultation involved instructions to perform a laryngoscopy, but not a bronchoscopy and general anaesthesia was not to be used! How different the situation is now--the paediatric endoscopist is regarded as a true consultant and his opinion is sought in the investigation and management of congenital or acquired airway and intra-thoracic problems.

Posterior glottic pathology

In infants and children, pathology in the posterior glottis is usually congenital or acquired due to endotracheal intubation. Diagnostic errors and omissions are less likely to occur with an anaesthetic technique where no endotracheal tube is used, where the posterior commissure and arytenoids are deliberately separated by a laryngoscope and where movements of the vocal cords and arytenoids are carefully assessed.

A comparison of the effects of sociodemographic factors and health status on use of outpatient mental health services in HMO and fee-for-service plans

The authors compared the effects of age, sex, socioeconomic status, and mental and physical health status on the use of outpatient mental health services in one well-established health maintenance organization (HMO) and in fee-for-service plans. In the Seattle site of the Rand Health Insurance Study (HIS), families were randomly assigned to HMO or fee-for-service coverage. Adults incur much greater expense for outpatient mental health services than children in both an HMO and a fee-for-service plan with identical coverage (i.e., free care). However, the difference in use between adults and children is significantly greater for the fee-for-service plan than the HMO (P less than 0.01). Similarly, education has significantly greater effects on use for the fee-for-service than the HMO plan. Increased income has a significant negative effect on use in both the HMO and fee-for-service plans. Mental and physical health status have similar large effects on use in both fee-for-service and HMO plans.

Use of outpatient mental health services in HMO and fee-for-service plans: results from a randomized controlled trial

Does a prepaid group practice (PGP) deliver less outpatient mental health care than the fee-for-service (FFS) sector when they serve comparable populations with comparable benefits? To examine this issue, we used data from the Rand Health Insurance Study, which randomized families into a prepaid group practice or FFS insurance plans. Participants in a FFS plan with no cost sharing (i.e., free care) are equally likely to visit a mental health specialist in a year, but incur 2.8 times the costs of prepaid participants (p less than .05). This difference is due to fewer visits per user, substitution of psychiatric social workers for psychiatrists and psychologists, and reliance on group rather than individual therapies in the prepaid plan. Because of the experimental design, these differences are due to institutional and incentive differences rather than adverse selection. We found no evidence of appreciable or significant adverse selection into or out of the prepaid group practice. A full evaluation of the desirability of prepaid or fee-for-service care requires data on health outcomes, which are not presented here.

A new adult microlaryngoscope

A new "slimline" binocular microlaryngoscope has been designed for use in adults in whom the larynx is difficult or impossible to visualize with standard microlaryngoscopes.

Vocal cord granulomas

A series of 16 vocal cord granulomas in adults and children were studied; of these, seven occurred postintubation. All granulomas were removed at least once and the recurrence rate was high. On average, there were three removals, and some patients are still under observation. The recurrence rate did not seem to be related to removal by surgical excision or by laser. We postulate, contrary to conventional teaching, that vocal ulcer and vocal cord granuloma should be regarded as separate entities which occur at the same anatomical site.

Evaluation of choanal atresia

A series of 65 cases of choanal atresia seen in 19 years is reviewed. We use a wisp of cotton fiber held under the nose and a plastic catheter passed into each nasal cavity to test nasal patency. Horizontal computerized tomography is confirmed as the radiological study of choice, and a standard endoscopic technique used during surgical correction is described.

Alcohol intoxication, an underdiagnosed problem?

To show that alcohol intoxication may be underdiagnosed in childhood, we describe four patients in whom it was not suspected until blood alcohol concentrations were measured as part of a toxicology screen.

The demand for dental care: evidence from a randomized trial in health insurance

Using data from a randomized trial in health insurance, this paper examines the effect of cost sharing on use of dental services. The data come from a sample of the nonaged, noninstitutionalized civilian population of six urban and rural sites. We find that: reducing the level of cost sharing increases demand for dental services; and dental expenses rise 46% when the coinsurance rate falls from 95% to 0%, subject to a catastrophic limit on out-of-pocket expenses. Of this increase, two-thirds is attributable to an increase in the likelihood of visiting a dentist during the year. Moreover, there is a substantial surge in demand during the first year of more generous coverage. The first-year response to cost sharing is nearly twice the second-year response.

Tracheomalacia in infants and children

The clinical features of tracheomalacia depend on the location, length, and severity of the weakness of the tracheal wall. There is firm evidence that tracheomalacia in association with tracheoesophageal fistula is due to malformation and deficiency in the tracheal wall, but in other types of tracheomalacia the evidence is less conclusive. A classification is proposed, based on the known histopathologic and endoscopic changes. Endoscopy is considered the most reliable diagnostic examination.

The sensitivity of mental health care use and cost estimates to methods effects

The authors determined the sensitivity of estimates of the use and cost of outpatient mental health care to two methods effects: the definition of a mental health visit and strategies for allocating mental health care costs. They use data from the Rand Health Insurance Study, which has a random sample of the nonaged noninstitutionalized civilian population in six United States sites. Estimates of the use of mental health specialists are insensitive to alternative methods. However, estimates of the use and cost of the mental health care delivered by nonpsychiatrist physicians (e.g., internists) are quite sensitive to methods effects. Nevertheless, the cost of care from nonpsychiatrist physicians is so low that the total cost of outpatient mental health care is not meaningfully affected by methods effects.

A new pediatric microlaryngoscope

A new pediatric microlaryngoscope has been designed for use in children from infancy to adolescence.

Anesthesia for laryngoscopy

The requirements of anesthesia for laryngoscopy and microlaryngeal surgery must be compatible with maximum safety and minimum patient discomfort. Some techniques require the use of an endotracheal tube while some do not. Others use a modified tube or a jetting system. In general, for pediatric endoscopy we prefer spontaneous respiration with inhalational anesthesia supplemented by topical lignocaine (lidocaine), and in adults, a relaxant technique with controlled jet ventilation supplemented by topical lignocaine. A new pediatric microlaryngoscope and a new tube for jet ventilation in older children and adults are described.

A case report of subglottic stenosis

A case of idiopathic subglottic stenosis treated by endoscopic laryngeal laser. A brief review of other forms of treatment and the place of Respiratory Function Tests in diagnosis and management.

Technique of laryngeal photography

Many techniques for photography during direct laryngoscopic examination have been described over the years. At present the best quality laryngeal photographs are obtained using a modern 35-mm single-lens reflex camera with the Hopkins telescopes and a synchronized electronic flash generator. This versatile system gives consistently reliable results.

Congenital laryngeal hemangioma

Congenital subglottic hemangioma consistently occurs in a site below the vocal cord. It is a distinct clinical entity with typical clinical features. However, congenital hemangioma in other sites can cause airway obstruction. An anatomical classification is proposed on the basis of review of 23 consecutive cases. It is important to accurately identify the site and distribution of the lesion before commencing treatment. Radiation has been an acknowledged form of treatment, and in our hospital we have confirmed that radiation therapy, either by external beam, or by insertion of a radioactive gold grain, gives good results. The theoretical possibility of radiation-induced malignancy in the thyroid gland is reduced to an absolute minimum by use of a radioactive grain for localized tumor-dose with minimum radiation of surrounding tissue.

Ten-year review of pediatric tracheotomy

One hundred sixty-four consecutive tracheotomies are reviewed over the 10-year period 1972-1981. Early in the series acute inflammatory airway obstruction was the major indication for tracheotomy, being 60% of cases in the first 3 years. In the last 3 years this fell to approximately 15%. After 1975 nasotracheal intubation replaced tracheotomy for acute epiglottis. More recently it has become the treatment of choice for acute laryngotracheobronchitis. Tracheotomy prior to reconstructive surgery for major craniofacial abnormalities is becoming more frequent. Acquired subglottic stenosis is not a problem in our hospital despite the use of long-term nasotracheal intubation in premature infants, and no tracheotomies were performed for this indication. There were few major complications. Decannulation difficulties were due to obstruction by stomal granulation tissue or displaced flap of anterior tracheal wall. There was no case of hemorrhage, no posttracheotomy stenosis, and no death was attributable to tracheotomy. These results demonstrate that in a major pediatric hospital tracheotomy is a relatively safe and effective procedure with minimal morbidity.