Postsurgical follow-up of children with tympanostomy tubes: results of the American Academy of Otolaryngology-Head and Neck Surgery Pediatric Otolaryngology Committee National Survey

Postsurgical follow-up of children with tympanostomy tubes is becoming a contentious issue in this era of managed care. Primary care providers believe themselves to be capable of evaluating these children. Otolaryngologists, on the other hand, have more specialized equipment available to them (suction apparatus, otomicroscopes, audiology devices, etc) for treating suppurative infections and monitoring the tympanic membrane for structural changes. In addition, the otolaryngologist is placed in an uncomfortable legal and ethical position if access to the patient with a tube-related complication is denied by the primary care provider. Attempts to develop an American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) policy statement have been hampered by a lack of data on the incidence and severity of tube-related complications and the role that otolaryngologists can play in reducing these sequelae. A survey designed by the AAO-HNS Pediatric Otolaryngology Committee was distributed to 1000 board-certified otolaryngologists and all members of the American Society of Pediatric Otolaryngologists and the American Academy of Pediatrics-Otolaryngology Section regarding current practice patterns and practitioners' experiences with tympanostomy tube complications. Specific information regarding complications that could have been avoided with earlier otolaryngology referral was also obtained. The results of the survey and its implications for AAO-HNS policy are presented.

Congenital anomalies of the larynx and trachea

A variety of congenital anomalies arise within the laryngeal or tracheal airway. Symptoms primarily include airway obstruction, hoarseness, and difficulty feeding. The diagnosis is typically made by a combination of clinical presentation, physical examination, and endoscopic evaluation. Definitive intervention may be necessary requiring endoscopic or open laryngeal surgery. Some of the more common congenital laryngeal and tracheal anomalies are discussed with respect to their diagnostic evaluation, clinical presentation, and management.

Risk factors for hearing loss from meningitis in children: the Children's Hospital experience

OBJECTIVES

To identify statistically significant risk factors for hearing loss in children with meningitis, determine the overall incidence of hearing loss in a large group of children with confirmed meningitis, and quantify the percentage of children with progressive or fluctuating hearing loss after meningitis.

DESIGN

Retrospective analysis.

PATIENTS AND OTHER PARTICIPANTS

Four hundred thirty-two children admitted to the Children's Hospital, Birmingham, Ala, from January 1, 1985, to December 31, 1995, with the diagnosis of meningitis.

RESULTS

Of 432 children with meningitis, 59 (13.7%) had the development of hearing loss. Of these 59 children, 46 (78.0%) had stable sensorineural hearing loss and 13 (22.0%) had either progressive or fluctuating hearing loss. Of the variables examined using multiple logistic regression backward-elimination modeling, only 5 appeared to be significantly associated with the development of hearing loss: computed tomographic scan evidence of increased intracranial pressure (estimated odds ratio [OR] = 2.3), male sex (OR= 1.9), the common logarithm of glucose levels in the cerebrospinal fluid (OR = 0.58), Streptococcus pneumoniae as the causative organism (OR= 2.1), and the presence of nuchal rigidity (OR = 1.9). In the children with progressive hearing loss, the time for progression varied from 3 months to 4 years before hearing stabilized.

CONCLUSIONS

In this study of children diagnosed as having meningitis, hearing loss developed in 59 (13.7%). Forty-six (78.0%) of these children with hearing loss had stable auditory thresholds over time, and 13 (22.0%) exhibited deterioration or fluctuation of acuity over time. Evidence of increased intracranial pressure by computed tomographic scan, male sex, low glucose levels in the patients' cerebrospinal fluid, S pneumoniae as the causative organism, and the presence of nuchal rigidity appear to be significant predictors for future hearing loss.

Single central maxillary incisor with nasal pyriform aperture stenosis--CT diagnosis prior to tooth eruption

Two children with nasal pyriform aperture stenosis had the diagnosis of single central maxillary incisor made with CT scanning prior to tooth eruption and the clinical appreciation of this finding. The surgical and clinical implications of this diagnosis will be presented.

High-risk human papillomavirus types and squamous cell carcinoma in patients with respiratory papillomas

Respiratory papillomas (RPs) are benign, virally induced tumors of the larynx and respiratory epithelium that may obstruct the airway and tend to recur frequently. RPs are thought to be the result of infection with the human papillomaviruses (HPVs) types 6 and 11. We surveyed archival RP specimens to determine whether there were correlations of HPV type with patient characteristics or clinical course. Paraffin-embedded papilloma specimens of 45 different patients were analyzed. We assessed HPV types using the polymerase chain reaction with E6 consensus primers, hybrid capture assays (high or low risk), and dot blot hybridization of generic E6 PCR products with E6 type-specific oligonucleotide probes. The presence and type of HPV were correlated with patient data from a retrospective chart review. We found that RPs may have either low- or high-risk HPV types and some contain multiple HPV types. Respiratory infection with high-risk HPV apparently introduces a long-term risk of squamous cell carcinoma development, even in the absence of conventional cofactors. Low-risk HPV infection may also act in association with these cofactors to promote carcinogenesis. Our data also show a racial imbalance in RP that may indicate a difference in genetic resistance and/or susceptibility to HPV infection and the development of RP.

Unilateral choanal atresia: initial presentation and endoscopic repair

The purpose of this study was to investigate the severity of presenting symptomatology in patients with unilateral choanal atresia and to assess the surgical results of patients undergoing transnasal endoscopic repair. A retrospective review of all patients with choanal atresia presenting to the author between 1990 and 1997 was performed, identifying 13 patients with unilateral choanal atresia. These patients were analyzed with respect to presenting symptomatology, preoperative computed tomography scans, appearance, type of surgical repair, and surgical results for patients undergoing endoscopic transnasal repair. Eleven patients underwent successful endoscopic transnasal repair, one patient underwent conversion to transpalatal repair after an unsuccessful attempt at transnasal endoscopic repair and one patient underwent a planned transpalatal repair. Eleven patients who underwent repair by transnasal endoscopic technique have all done well with follow-up ranging from 3 months to 7 years. Although the symptomatology of unilateral choanal atresia is not as dramatic as bilateral choanal atresia, significant airway symptomatology may be present, especially in children presenting at a very young age. It appears that transnasal repair of unilateral choanal atresia is an excellent treatment modality with excellent postoperative surgical results.

Pharyngeal fibrovascular polyp in a child

Fibrovascular polyp of the upper aerodigestive tract is an uncommon tumor that may present in pediatric patients with symptoms ranging from dysphagia to asphyxiation and death. We present a unique case of a pediatric patient with an asymptomatic fibrovascular polyp noted as an incidental finding on a cervical ultrasound evaluation. This lesion extended from the posterior tonsillar pillar and prolapsed freely into the nasopharynx and esophagus. The literature relevant to this case is reviewed, and the etiology, pathophysiology, and management principles are discussed.

Isolated epithelial cysts of the uvula in children: a report of three cases

Epidermoid cysts are unusual benign cysts that occur in the oral cavity less than 2% of the time. Epidermoid cysts isolated to the uvula are rare. A review of the literature has revealed only three confirmed cases of isolated uvular epidermoid cysts. We present a series of three such cases, two of which presented with significant symptomatology. The diagnosis and management of these unusual lesions will be discussed, as well as the differential diagnosis.

Paediatric Airway Clinic: an 18-month experience

OBJECTIVE

The management of paediatric airway disease is an integral aspect of paediatric otolaryngology. Recently, paediatric tertiary referral centres have developed centres of excellence for various aspects of paediatric care. The Pediatric Otolaryngology Airway Clinic at The Children's Hospital of Alabama, was developed as a regional referral centre for the management of children with difficult airway problems. Primary participants include the paediatric otolaryngologist, the airway management nurse, and the speech pathologist, in addition to other health care personnel. Over an 18-month period, 195 patients were seen in the clinic. The purpose of this study was to assess both the demography and the airway pathology in this patient population-specifically evaluating presenting diagnoses, diagnostic evaluation techniques, surgical intervention, geographic and racial distribution, insurance coverage, and referral patterns.

CONCLUSION

This multidisciplinary approach to the management of children with chronic tracheotomies and other conditions involving the airway provides a unique environment that optimizes care for these complex patients.

Erbe constant voltage electrocautery versus conventional variable voltage electrocautery for tonsillectomy in children

This prospective, randomized study was performed to compare postoperative pain, blood loss, and procedure time using the Erbe electrocautery device and conventional electrocautery. The Erbe device differs from conventional cautery devices in that it produces constant voltage and variable wattage whereas conventional devices produce variable voltage and constant wattage. This means that the conventional devices allow voltage surges and constant wattage no matter what type of tissue is encountered. The Erbe device has the inherent capability to maintain constant voltage, i.e. no surging as well as varying wattage according to tissue resistance. This, in theory, allows the Erbe device to impose less tissue damage and, theoretically, less postoperative pain. Fifty-seven patients 5-21 years of age who were scheduled for adenotonsillectomy were enrolled in the study. Results indicated less postoperative pain, although blood loss appeared to be increased compared to conventional electrocautery. The Erbe electrocautery device appears to be a viable device to perform tonsillectomy in children.

Methods of sedation for auditory brainstem response testing

Young children and those who are mentally impaired frequently require sedation to attain accurate results when testing for auditory brainstem response (ABR). There have been no previous studies of appropriate methods of sedation, and there is no consensus on pharmacotherapy, monitoring equipment, facilities, or personnel necessary for safe and effective ABR testing. To obtain a national census of current practice, we sent a survey to 149 free-standing children's hospitals in the US. A prospective study was also conducted to assess the effects of sedation utilized to perform ABR testing at The Children's Hospital of Alabama. Oral chloral hydrate (50 mg/kg) was administered for sedation in an outpatient setting with a registered nurse and audiologist present, while vital signs, skin color, and oxygen saturation were continuously monitored. The cost of testing in an audiology or other outpatient suite was compared with the cost of performing the study in the operating room. Results of the survey illustrated the present lack of national uniformity in sedation administered, as well as various problems and complications encountered with such testing. We found that 50 mg/kg chloral hydrate administered in this setting is safe and effective for children requiring sedation for audiologic testing. Further, the ability to perform ABR's in an outpatient suite in a monitored setting is more cost-effective than testing in the operating room.

Endoscopic vs external drainage of orbital subperiosteal abscess

Periorbital cellulitis is frequently limited to the preseptal region. However, there may be associated postseptal inflammation and orbital subperiosteal abscess (SPA). Surgical management of orbital SPA includes open drainage through an external ethmoidectomy approach, although recently the use of endoscopic techniques has been reported. This study was undertaken to evaluate postseptal cellulitis and orbital SPA in patients with periorbital cellulitis and to assess the safety and effectiveness of endoscopic management of orbital SPA. From 1989 through 1994, 158 patients were admitted with a diagnosis of periorbital cellulitis. Nineteen of these patients were diagnosed with postseptal orbital inflammation, and 14 underwent surgical drainage via an external approach, an endoscopic approach, or a combination of both. Issues addressed include (1) the role of sinus disease as the cause of periorbital cellulitis; (2) the role of computed tomographic scanning; (3) the effectiveness of aggressive medical therapy; and (4) the results of endoscopic drainage of orbital SPA compared with the external approach.

Open surgical excision of subglottic hemangioma in children

Subglottic hemangioma is an unusual entity which may involute spontaneously without aggressive surgical intervention; although tracheotomy is sometimes necessary. The actual time course for involution is not clear by reviewing the literature [1,14]. Numerous treatment modalities are described for the treatment of this condition, including tracheotomy, CO2 laser ablation and intralesional steroid injection with or without endotracheal intubation. Surgical resection of subglottic hemangioma is an option which is described in the literature and may be utilized in certain selected cases. We present seven cases of subglottic hemangioma treated at three institutions which were resected via a crico-tracheotomy approach. Postoperative follow-up for these patients range from 6 months to 4.5 years. Although conservative measures are still advocated as the treatment of choice for subglottic hemangioma, open surgical resection may be indicated in selected cases resulting in a satisfactory outcome.

Upper airway obstruction in Sturge-Weber and Klippel-Trenaunay-Weber syndromes

Sturge-Weber syndrome is a rare congenital angiomatosis of unknown cause that is defined by the following triad: facial port-wine stain, leptomeningeal vascular anomalies, and choroidal vascular lesions associated with glaucoma. Klippel-Trenaunay-Weber syndrome is a related disease with questionable hereditary factors diagnosed by the following triad: superficial nevus of the lower extremity, ipsilateral varicose veins, and hypertrophy of the soft and bony tissues of the lower limb. The two conditions rarely have been reported to coexist. Upper airway obstruction is not a prominent feature of either of these two diseases. We present two patients with both of these angiomatoses in whom severe upper airway obstruction necessitated tracheotomy.

Alternatives in the management of aneurysmal bone cysts of the mandible

Aneurysmal bone cyst (ABC) is an unusual expansile lesion of bone which may arise within the mandible on rare occasions. This lesion may arise with very few signs or symptoms. Surgical treatment consists of complete excision or curettage. The recurrence rate may be high in lesions which are incompletely excised. Three cases of aneurysmal bone cysts in children will be presented, demonstrating the wide variation of clinical presentation. One case required an extensive mandibular resection, necessitating the first reported microvascular mandible reconstruction for this entity in a pediatric patient.

Multifocal amyloidosis of the pediatric airway

Amyloidosis of the upper aerodigestive tract is rare in the pediatric age group. We present the first reported case (to our knowledge) of multifocal primary upper airway amyloidosis in a child. An otherwise-healthy 15-year-old girl presented with hoarseness, nasal congestion, and odynophagia. Diagnostic evaluation included flexible nasopharyngoscopy, rigid nasal endoscopy, direct laryngoscopy, bronchoscopy, and biopsy. The results of Congo red staining of the specimen were characteristic of amyloid. The findings of an extensive immunologic and systemic evaluation were normal. We discuss the treatment and postoperative course of this patient, as well as the clinical and pathologic characteristics of amyloidosis, with particular reference to the otolaryngologic manifestations of amyloidosis.

Radiation therapy as an alternative to surgery in the management of intracranial juvenile nasopharyngeal angiofibroma

Juvenile nasopharyngeal angiofibroma is a benign, vascular tumor which typically presents in adolescent males. Although surgical resection is usually recommended for the management of this tumor, external beam radiation therapy has also been advocated in the literature. We report three cases of large juvenile nasopharyngeal angiofibromas with extensive intracranial extension primarily managed with external beam radiation therapy. Although there was not complete resolution of the tumors, there was significant alleviation of symptomatology with no serious side effects from the radiation therapy. Based on these cases, we feel that external beam radiation therapy in the management of extensive juvenile nasopharyngeal angiofibromas with intracranial extension is warranted in certain select cases.

Giant suprastomal granuloma as a laryngeal mass

The presence of suprastomal granulomas after tracheotomy is a common occurrence. Under most circumstances, this never becomes clinically relevant. However, in the pediatric population, granulomas can on occasion cause partial or complete airway obstruction after decannulation. This report describes 2 cases of giant suprastomal granulomas that presented as laryngeal masses. These cases stress the indications for routine endoscopic evaluation in patients with long-term tracheotomies. Also, the treatment of extensive suprastomal granulomas requires open excision, which differs from the endoscopic approach recommended for smaller granulomas.

Cartilage graft epithelialization. A preliminary study using a goat model

OBJECTIVE

To determine if the presence of a laryngeal stent adversely affects the epithelialization of an anterior costal cartilage graft.

DESIGN

Twelve goats underwent laryngotracheoplasty using an anterior costal cartilage graft. No stent was used in six animals, and a modified endotracheal tube stent was used in the other six. The degree of epithelialization in each group was compared histologically, as well as other histologic criteria (epithelial metaplasia, cilia formation, and inflammatory cell infiltration).

SETTING

Children's Hospital Medical Center of Cincinnati (Ohio) Medical Research Building.

PATIENTS AND OTHER PARTICIPANTS

No human subjects were used in this study.

MAIN OUTCOME MEASURES

Qualitative histologic analysis of cartilage graft epithelialization, epithelial metaplasia, cilia formation, and inflammatory cell infiltration was performed. The stent vs no-stent groups were compared histologically.

RESULTS

In the stented group, one cartilage graft extruded, while five remained in place. All of the no-stent cartilage grafts remained in place. A trend was observed in the no-stent group toward increased cartilage graft epithelialization and cilia formation, while there was a decrease in epithelial metaplasia and infiltration by inflammatory cells.

CONCLUSIONS

Although the study population was small, the presence of a laryngeal stent tended to predispose the graft to increased inflammation and epithelial metaplasia and may adversely affect cartilage graft epithelialization. The goat may be an adequate animal model for laryngotracheal reconstruction and, possibly, subglottic stenosis.

Infected congenital mucocele of the nasolacrimal duct

The authors report their experience with an infant presenting with an infected nasolacrimal duct mucocele, emphasizing correlation of clinical, CT, and surgical findings. CT is the imaging modality of choice to demonstrate the triad of 1) a cystic medial canthal mass, 2) dilatation of the nasolacrimal duct, and 3) a submucosal nasal cavity mass; findings which are diagnostic of this entity. A brief review of the relevant embryology is also presented.

Anastomosis of the cervical trachea in children

Numerous techniques for the surgical management of laryngotracheal stenosis in children have been described in the literature. These surgical modalities include endoscopic management and open laryngotracheal reconstruction using costal cartilage grafts for expansion of the stenotic subglottic region. Although tracheal resection with primary reanastomosis for the management of tracheal stenosis is reported frequently in the adult population, children rarely have stenotic lesions that are amenable to this particular technique. Laryngotracheal stenosis in children most commonly involves the subglottis. This makes tracheal resection with anastomosis technically difficult to perform, due to the close proximity of the vocal cords. We have found a subpopulation of children at our institution with high tracheal stenoses, with minimal lower subglottic involvement, who were amenable to tracheal resection with primary anastomosis. We review our experience with this technique. The indications for this surgical modality in children are discussed, as well as the surgical technique.

Functional endoscopic sinus surgery in the immunocompromised child

Fungal sinusitis in the immunocompromised child is an aggressive, invasive process that may result in a fatal outcome if not diagnosed early. As a result of increasing use of bone marrow transplantation and new cytotoxic chemotherapeutic agents resulting in severe agranulocytopenia, more patients have become susceptible to fungal sinus disease. Functional endoscopic sinus surgery has emerged recently as an important surgical modality in the treatment of sinus disease in adults and children. Use of this technique in immunosuppressed children has allowed early diagnosis of fungal sinonasal disease, resulting in earlier surgical intervention. The high-quality fiberoptic capability of nasal endoscopes allows very detailed visualization of the internal anatomy of the nose and detects early mucosal changes as a result of intranasal fungal disease. Our experience using functional endoscopic sinus surgery in immunocompromised children over an 18-month period is reviewed. Our philosophy for diagnosis and management of immunocompromised children with suspected fungal sinonasal disease is discussed.

Atypical tracheobronchial vascular compression

Vascular compression of the tracheobronchial tree frequently presents early in infancy with significant airway compromise. For this reason, the pediatric otolaryngologist is often consulted early in the assessment of these patients. Three unusual cases of tracheobronchial vascular compression are presented. The diagnosis and management of children with tracheobronchial vascular compression is discussed, stressing the importance of synchronous airway anomalies and associated congenital cardiac anomalies. Although surgical intervention may be corrective in most cases of vascular compression, persistent tracheomalacia may necessitate tracheotomy for a prolonged period.

Complications of adenotonsillectomy in children under 3 years of age

Adenotonsillectomy in children may be performed safely on an outpatient basis in the majority of cases without an increase in complication rates. However, very young children comprise a unique patient subpopulation with regard to adenotonsillar surgery. Surgical indications in older children tend to be dominated by chronic recurrent infections, whereas younger children usually require surgery for chronic upper airway obstruction related to adenotonsillar hypertrophy. This study was undertaken to evaluate the adenotonsillectomy patient population under 3 years of age. Complication rates related to airway problems, hemorrhage, and dehydration were determined. Children under 3 years of age demonstrated an increased incidence of postoperative airway complications, manifested by oxygen desaturation and transient upper airway obstruction. It is recommended that adenotonsillectomy be performed on such patients on an inpatient basis with close postoperative monitoring including pulse oximetry.

Magnetic resonance imaging in the diagnosis of innominate artery compression of the trachea

In the past, the diagnosis of tracheal compression by intrathoracic arterial structures has been made by using bronchoscopy alone or in combination with one of a variety of imaging techniques, including barium contrast esophagography and cineangiography. However, all of these imaging techniques involve exposure of patients to ionizing radiation and, in the case of angiography, an invasive procedure. The use of magnetic resonance imaging in the diagnosis of thoracic arterial disease is well documented and, more specifically, has been found to be useful in the diagnosis of innominate artery compression of the trachea and congenital vascular rings. This report documents the use of magnetic resonance imaging at the Children's Hospital Medical Center, Cincinnati, Ohio, in the diagnosis of innominate artery compression of the trachea. In addition, the radiographic appearance of this entity is contrasted with other compressive lesions of the trachea.

Rhabdomyosarcoma of the ear and temporal bone

Rhabdomyosarcoma, the most common soft tissue sarcoma of childhood, involves the temporal bone in approximately 7% of reported cases. Until recently, the outcome of this disease was always fatal. The recent Intergroup Rhabdomyosarcoma Study Group (IRS-I) reported on the efficacy of multimodality therapy consisting of multiagent chemotherapy, radiation, and surgical resection when indicated. Twelve patients with rhabdomyosarcoma involving the temporal bone were treated between 1966 and 1988. Three patients were treated according to the IRS-I protocols and the remaining nine patients received various combinations of treatment modalities. Ten patients succumbed to their disease, most with distant metastases or intracranial extension. Two patients are alive; one at 5 1/2 years and one at 19 years. It is apparent that, although survival for rhabdomyosarcoma in general has improved with the use of IRS-I protocols, prognosis remains poor for disease involving the temporal bone and other parameningeal sites.

Innominate artery compression of the trachea: current concepts

One common vascular anomaly that causes airway obstruction in neonates and infants is innominate artery compression of the trachea. A great deal of controversy exists regarding the effect of this anatomic variant on symptom production. Several cases are presented that demonstrate the unique features of innominate artery compression of the trachea: 1. Innominate artery compression can occur in adolescent patients. 2. Flow volume loops are an effective method of documenting airway compromise in this condition. 3. Exercise intolerance should be considered as a relative indication for surgical intervention in these patients. 4. Reimplantation of the innominate artery is a viable surgical alternative in the treatment of affected patients. 5. Telescopic bronchoscopy during surgical correction of this condition will ensure that there has been successful correction of the tracheal compression. 6. Urgent repair is advocated in patients who experience periods of apnea.

Giant cell reparative granuloma of the ethmoid sinus

This article represents the fourth and fifth reported cases of GCRG that involve the ethmoid sinus. The problems encountered in establishing the diagnosis are emphasized, as are the features that differentiate it from the giant cell tumor, aneurysmal bone cyst, and hyperparathyroidism, the conditions with which it is most commonly confused. The unusually aggressive behavior, as demonstrated by these two cases, is highlighted.