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.

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.

Resistant bacteria in middle ear fluid at the time of tympanotomy tube surgery

This study was performed to determine the prevalence of resistant Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis isolated from middle ear fluid of children undergoing placement of ventilation tubes. The extent of resistance to commonly prescribed antibiotics and the risk factors associated with this resistance were also examined. Children who had fluid present in their middle ears at the time of ventilation tube placement from May 1996 to May 1997 were included in the study. Middle ear fluid was plated onto culture media in the operating room, and antimicrobial resistance of cultured organisms was ascertained. Risk factors for this resistance were determined from the medical history and analyzed. Cultures of 244 patients (355 ears) were positive for organisms in 29.6%. Penicillin resistance was found in 38.2% of S pneumoniae cultures. Beta-lactamase production was found in 65.1% and 100% of H influenzae and M catarrhalis specimens, respectively. Risk factor analysis revealed young age, day care attendance, and number of antibiotic courses to most reliably predict the presence of resistant microorganisms.

Initial results from the national registry for juvenile-onset recurrent respiratory papillomatosis. RRP Task Force

OBJECTIVE

To characterize the spectrum of juvenile-onset recurrent respiratory papillomatosis (RRP) in the United States and to obtain data about the natural course of the disease and its response to treatment.

SETTING

Twenty tertiary-care pediatric otolaryngology centers throughout the United States.

PATIENTS

All patients with active RRP aged less than 18 years at the participating sites.

MAIN OUTCOME MEASURES

Number of surgical procedures performed per year, progression of papillomas to previously nondiseased anatomical sites, drug interventions and other adjuvant therapy, and need for tracheostomy.

RESULTS

Data were collected from 399 children enrolled from January, 1, 1997, through December 31, 1998. There were 51.9% male; 62.7% white, 28.3% black, 9.0% other or unknown racial group; 10.8% Hispanic ethnicity. Mean age at diagnosis was 3.8 years (range, 0.1-16.3 years) and mean duration of disease was 4.4 years (range, 0.03-18.9 years). The mean number of surgical procedures per child was 4.4 per year (range, 0.2-19.3 per year). Children whose RRP was diagnosed at younger ages (<3.0 years) were 3.6 times more likely to have more than 4 surgical procedures per year (P=.001) and almost 2 times more likely to have 2 or more anatomical sites affected (P=.008) than were children whose RRP was diagnosed at later ages (> or =3.0 years), after adjusting for sex, race, and years of treatment.

CONCLUSIONS

Children whose disease was diagnosed before age 3 years were more likely than children aged 3 years or older to have more severe disease as measured by the mean number of surgical procedures performed and by the number of anatomical sites affected. The registry will form the basis for future analysis on the outcome of disease, natural course of RRP under management strategies, prevention strategies, and public health importance.

Anatomy and physiology of pediatric swallowing disorders

The anatomy and physiology of the act of swallowing is complex. Because the swallowing mechanism matures with age, it is important to understand this maturation process from neonate to older child to appreciate the impact of this changing physiology on pediatric swallowing disorders. This article reviews the relevant anatomy, neurologic control mechanism, and physiology of swallowing in neonates and children.

Tube placement: a prospective, randomized double-blind study

Bilateral myringotomy with tympanostomy tube placement is the second most frequently performed pediatric surgical procedure, next to circumcision. Postoperative pain relief for children undergoing this procedure has been an ongoing concern. The authors undertook a prospective, randomized, double-blind, placebo-controlled clinical study in 200 consecutive children to investigate the efficacy of oral acetaminophen, acetaminophen with codeine, ibuprofen, and placebo administered preoperatively in relieving postoperative pain in children undergoing this procedure. All children received topical analgesia consisting of antibiotic eardrops mixed with 4% lidocaine intraoperatively. There was no significant difference in postoperative pain score between the four groups (P > 0.4447). Thus it is likely that the intraoperative administration of antibiotic eardrops mixed with 4% lidocaine is all that is required to alleviate postoperative pain in children undergoing myringotomy with tympanostomy tube placement. Preoperative oral analgesics are apparently of little added benefit.

Outpatient tonsillectomy and adenoidectomy clinical pathways: an evaluative study

PURPOSE

The purpose of this study is to examine two different dimensions of an outpatient pediatric tonsillectomy and adenoidectomy (T&A) clinical pathway at a tertiary care children's hospital. First, the analysis investigates whether the T&A clinical pathway effectively aids in the decision to discharge a pediatric patient as a day surgery (DS) (less than 12 hours) rather than as an outpatient observation surgery (OPO) (12 to 23 hours). Second, the pathway's impact on quality and financial outcomes is explored.

PATIENTS AND METHODS

Forty prepathway pediatric T&A patients were randomly selected and matched to 40 pathway pediatric T&A patients by age, gender, medical history, and surgeon to form a retrospective cohort. Using chi-square and analysis of variance, the two groups were compared by type of discharge (DS or OPO), length of stay, readmission rates, and costs.

RESULTS

The results show that patients on a pathway were more likely to be discharged as a DS. The shift toward DS discharges effected significant reduction in average length of stay and overall direct costs. Furthermore, there was no difference in readmission rates.

CONCLUSION

These results indicate that the development and implementation of a pathway is an effective method in reducing length of stay and overall direct costs while maintaining quality outcomes.

The utility of preoperative hemostatic assessment in adenotonsillectomy

Routine preoperative coagulation screening in patients undergoing tonsillectomy and/or adenoidectomy (T and A) is considered by some to be mandatory. T and A is often the first hemostatic challenge in children; therefore, screening is thought to be useful in predicting patients who may experience postoperative hemorrhage. On the other hand, in today's cost-conscious medical environment, routine screening is considered by some to be an unnecessary added expense. At our institution, among 4373 patients who underwent T and A between 1989 and 1994, 43 returned with postoperative bleeding (0.98%). We retrospectively evaluated the usefulness of prothrombin time (PT) and activated partial thromboplastin time (PTT) in predicting intraoperative and postoperative bleeding. All children had extensive bleeding histories taken; however, preoperative laboratory screening was left to the discretion of the attending physician. Preoperative PT/PTT did not predict intraoperative or postoperative bleeding. In our experience, laboratory screening has a very low positive predictive value in detecting occult bleeding disorders or perioperative hemorrhage; thus, we feel it should be used selectively. Routine preoperative PT/PTT is not recommended to screen T and A patients and does not appear to be cost-effective.

Management of children with von Willebrand disease undergoing adenotonsillectomy

PURPOSE

Children with von Willebrand disease (vWD) are at greater risk for hemorrhage following adenotonsillar surgery. We report the favorable results of 12 consecutive adenotonsillar procedures performed since 1989 in children with vWD, with minimal use of blood products.

MATERIALS AND METHODS

Patients were prospectively managed with careful local control, desmopressin (DDAVP), and antifibrinolytic agents. Cryoprecipitate or intermediate purity factor VIII concentrates containing von Willebrand factor (vWF) were used for three patients who did not tolerate DDAVP.

RESULTS

Based on this experience, we propose a prospective treatment protocol.

CONCLUSIONS

The literature regarding the use of DDAVP is reviewed, and our screening algorithm and treatment protocol for managing these challenging cases is presented.

Water precautions in children with tympanostomy tubes

OBJECTIVE

To compare the effectiveness of antibiotic ear drops (suspension of polymyxin B sulfate, neomycin sulfate, and hydrocortisone [Pediotic]), prefabricated ear molds, or no precautions in decreasing the incidence of posttympanostomy water-related otorrhea.

DESIGN

Five-year prospective controlled study.

SETTINGS

University referral center.

PATIENTS

Five hundred thirty-three pediatric patients who were undergoing tympanostomy tube placement (including those who were undergoing tonsillectomy, adenoidectomy, or both) were self-selected into four groups.

INTERVENTIONS

The use of antibiotic ear drops that contained polymyxin B, neomycin, and hydrocortisone and the use of prefabricated ear molds. Group 1 comprised patients who were not given any water precautions with swimming regardless of the depth or type of water; group 2 comprised patients in whom antibiotic ear drops were applied after all forms of swimming; group 3 comprised patients who used ear molds with all forms of swimming (all children were advised against diving and swimming more than 180 cm below the surface, and parents were cautioned to avoid the entrance of soapy water into their child's ears during bathing); and group 4 comprised patients who were selected not to swim at all (they served as a control group).

RESULTS

No statistically significant difference was observed in the incidence of posttympanostomy swimming-related otorrhea among the three swimming groups (11%, 14%, and 20% of children in groups 1, 2, and 3, respectively, reported swimming-related otorrhea [P=.26, df-2, chi-square=2.66]). Children who did not swim at all (group 4) did not differ significantly in their overall incidence of otorrhea (59%) from the three swimming groups combined (68%) during the follow-up period (P=.11, df=1, chi-square=2.54).

CONCLUSION

Young children with tympanostomy tubes who surface swim and do not dive receive no additional benefit from the taking of water precautions in the form of earplugs or antibiotic ear drops.

Role of cesarean section in prevention of recurrent respiratory papillomatosis--is there one?

Recurrent respiratory papillomatosis (RRP) is a benign yet aggressive neoplasm that produces considerable morbidity in children. Previous studies have linked RRP in children to mothers with genital tract human papillomavirus infections (HPV). Risk factors for vertical transmission have not been well identified. Controversy exists among obstetricians and otolaryngologists regarding the role of cesarean section in preventing the transmission of HPV disease from mother to child. We address this issue by presenting the results of a national survey of otolaryngologists, the American College of Obstetrics and Gynecology position statement, the relevant literature regarding the association between RRP and maternal HPV, and the proposed mechanisms for HPV transmission at birth. We postulate a very limited role for cesarean section in preventing transmission of RRP, given our present knowledge of this disease.

Pediatric tonsillectomy and adenoidectomy procedures

The most common pediatric surgical procedures performed in the United States today are tonsillectomies and adenoidectomies (T&A). Surgical team members must be highly trained and efficient to ensure optimal patient outcomes, reduce surgical costs, and decrease the risk and potential complications inherent in T&A procedures. The authors review current surgical indications for T&A procedures; recommended preoperative, intraoperative, and postoperative patient care; and the management of potential complications.

Task force on recurrent respiratory papillomas. A preliminary report

OBJECTIVE

To obtain pilot data about the incidence, need for surgical intervention, and demographics of recurrent respiratory papillomas in the United States.

DESIGN

Otolaryngologists were surveyed using a questionnaire with structured and open-ended questions.

PARTICIPANTS

One thousand board-certified otolaryngologists practicing in the United States as of January 1, 1993, through a random mailing list provided by the American Academy of Otolaryngology-Head and Neck Surgery and all active US members of the American Society of Pediatric Otolaryngology and the American Bronchoesophagological Association. A total of 1346 questionnaires were distributed.

MAIN OUTCOME MEASURES

Physician's responses to questions about their current patient load of children and adults with recurrent respiratory papillomas, their surgical and anesthetic management of the disease, and their clinical experiences with risk factors for developing recurrent respiratory papillomas.

RESULTS

Projected totals for recurrent respiratory papillomas among children were 2354 new cases (95% confidence interval [CI], 1448 to 3260) and 5970 active cases (95% CI, 3465 to 8474), requiring 16,597 surgical procedures (95% CI, 6938 to 26,255) at a cost of $109 million (95% CI, $45 to 172 million) for March 1, 1993 to March 31, 1994. Projected totals for adult recurrent respiratory papillomas were 3623 new cases (95% CI, 2359 to 4887) and 9015 active cases (95% CI, 6435 to 11,591) requiring 9284 surgical procedures (95% CI, 6003 to 12,565) at a cost of $42 million (95% CI, $27 to $59 million) for March 1, 1993 to March 31, 1994. The incidence of recurrent respiratory papillomas among children is estimated at 4.3 per 100,000; among adults, 1.8 per 100,000. The carbon dioxide laser was favored by 92% of respondents. No consensus was reached on the role for cesarean section. Forty-six percent of respondents favored the use of a laser-safe endotracheal tube for anesthetic management.

CONCLUSION

A registry of patients with recurrent respiratory papillomas would benefit future research protocols and provide long-term follow-up of patients.

The effect of very early cleft palate closure on the need for ventilation tubes in the first years of life

The otologic consequences associated with cleft palates are well known. Closure of palatal clefts within the first weeks of life has many potential benefits, including improved feeding and cosmesis. The potential otologic benefits of very early closure are not known. Eighteen newborns have undergone closure of their palatal clefts within the first month of life with subsequent otolaryngology follow-up through our craniofacial center. Thirteen (72%) of the 18 still required placement of ventilation tubes during their first 3 years of life because of persistent effusion (for more than 120 days) or recurrent infection (more than four episodes in 6 months or more than six episodes in 12 months). Very early cleft palate closure may not significantly alter the need for ventilation tubes in children with palatal clefts.

Uvulopalatopharyngoplasty: treatment of obstructive sleep apnea in neurologically impaired pediatric patients

Bona fide obstructive sleep apnea is rare in the pediatric age group. Traditional surgical management for pediatric obstructive sleep apnea (OSA) is adenotonsillectomy alone, however, severely affected children may require uvulopalatopharyngoplasty (UPPP) or tracheostomy to relieve their obstruction. Children with OSA along with other medical maladies (e.g. cerebral palsy, down syndrome) pose an additional challenge to the otolaryngologist due to poor muscular tone and other medical problems which may complicate postoperative management. We report on 15 children (aged 23 months-13 years, mean 7.4 years), 12 with severe mental insufficiency, with documented OSA who underwent classical or modified UPPP. Twelve of 15 had clinical and/or objective improvement. We conclude that UPPP has a role in the management of neurologically-impaired children with OSA.

Haemophilus influenzae type B epiglottitis after immunization with HbOC conjugate vaccine

INTRODUCTION

US Food and Drug Administration (USFDA) has licensed four Haemophilus influenzae type B (Hib) vaccines for use in children. Haemophilus influenzae type B is by far the most common pathogen in childhood epiglottitis and it is hoped that with the introduction of the Hib vaccine that a corresponding decrease in epiglottitis cases will be appreciated.

MATERIALS AND METHODS

A retrospective study of all children admitted with the diagnosis of epiglottitis for the 11-year period of 1982 to 1992 was conducted in order to determine the incidence of epiglottitis and Hib vaccine failure. Fifty-nine cases were included in the study by documentation of an inflamed epiglottis. The case of Hib epiglottitis in a 4-year-old child immunized with HbOC conjugate vaccine at 18 months of age is detailed.

RESULTS

A statistically significant decrease was found in the incidence of epiglottitis since introduction of the vaccines; however, the overall trend in decrease for the 11-year period was not statistically significant. Vaccination status was difficult to accurately document with only two cases of vaccine failure identified.

CONCLUSION

The incidence of Haemophilus influenzae type B epiglottitis at our regional Children's hospital has decreased since the introduction of the Hib vaccine. Reasons for vaccine failure are postulated.

Retrieving foreign bodies from upper aerodigestive tracts of children

Ingestion is foreign body lodgment in the esophagus, whereas aspiration is lodgment of foreign bodies in the larynx, trachea, or bronchi. Foreign bodies constitute an emergency when actual or potential airway obstruction occurs, when there is an esophageal perforation, or when disc batteries are ingested and lodged in the esophagus. A ventilating bronchoscope of appropriate size is essential to the removal of a foreign body in the airway or esophagus. Successful management of foreign bodies in the upper aerodigestive tracts of children is directly proportional to the time and effort spent in preoperative preparation.

Pediatric otolaryngology procedures in the United States: 1977-1987

Common pediatric otolaryngology inpatient procedures for the years 1977 through 1987 are analyzed utilizing data provided by the National Hospital Discharge Survey (NHDS) of the National Center for Health Statistics. The data available reveal that adenotonsillar surgery remains the most frequent inpatient surgical procedure performed on all children under age 15 in spite of a decline in both the total number of adenotonsillar procedures and the rate per 100,000 population of greater than two-fold over this 11 year period. The total number of myringotomies with and without insertion of ventilation tubes and the rate per 100,000 children also decreased by greater than threefold during the same time span. Although representative of inpatient, non-institutionalized health care, the NHDS suffers from its lack of data concerning surgery performed in freestanding, ambulatory surgical facilities and military hospitals.

Water precautions in children with tympanostomy tubes

PURPOSE

The necessity and effectiveness of taking precautions around water with children who have tympanostomy tubes is a source of some controversy among otolaryngologists. This study was undertaken to survey the practice standards of otolaryngologists treating these children.

MATERIALS AND METHODS

A total of 1,266 board-certified otolaryngologists practicing (mean 14.8 years in practice) in the southern and eastern United States were surveyed to determine current recommendations.

RESULTS

Among those surveyed, 13.1% forbid children with tympanostomy tubes from swimming, whereas 3.1% feel that no water precautions are needed. Limitations are placed in the depth of swimming by 68% and the type of swimming water by 18%. The most commonly recommended form of protection is the use of ear plugs, which is favored by 53.4%. Liberalization of recommendations concerning the need for water precautions was noted by 79% of respondents who cited personal experience as the single most influential factor. An overwhelming percentage of respondents indicated they would be willing to alter their current practice based on new information generated from a clinical trial.

CONCLUSION

This survey demonstrates that diversity of opinion does exist among otolaryngologists relative to their recommendations for water precautions after placement of tympanostomy tubes. This survey demonstrates the need for a prospective randomized clinical trial designed to address this issue.

Kawasaki disease: five-year experience at Children's National Medical Center

Kawasaki Disease (KD) is an acute multisystem disease that predominately affects infants and children. Coronary artery aneurysms or ectasia may develop in 15-25% of children with the disease and may lead to myocardial infarction or sudden death. Head and neck manifestations are often the presenting symptoms, thus the otolaryngologist may be asked to evaluate a child early in the course of the disease. Otolaryngologist need to be familiar with the early symptoms of this disease so that prompt diagnosis may be made and appropriate therapy instituted. Recent therapeutic advances have been shown to be effective in reducing the prevalence of coronary artery abnormalities. The authors retrospectively reviewed cases of KD seen at Children's National Medical Center over a 5-year period. Sixty-nine cases were included in the reviews and all children exhibited head and neck manifestations upon admission. Our data and review of the relevant literature underscore the need for heightened awareness among our profession in regards to KD.

Management of otolaryngic patients susceptible to malignant hyperthermia without dantrolene

Malignant hyperthermia (MH) is an adverse reaction most frequently associated with the administration of halogenated inhalational anesthetic agents and the depolarizing muscle relaxant succinylcholine. Characteristic findings are a hypermetabolic state accompanied by extreme hyperpyrexia, acidosis, rhabdomyolysis, and generalized muscle rigidity, often involving the masseter muscles. Dantrolene sodium, which was approved in 1979 by the FDA for use in the prevention of MH in high-risk patients, has neurologic and gastrointestinal side effects. At the Children's National Medical Center (CNMC), 24 children identified as being at risk for the development of a MH reaction were anesthetized for otolaryngic procedures by using "non-triggering" anesthetics and without use of dantrolene sodium. These patients represent 56% of all patients at risk for MH or masseter muscle rigidity (MMR) reactions during an 8-year period at the CNMC. There were no complications. Concomitant muscle biopsies were performed, and caffeine/halothane contracture studies were completed in 18 of these patients, demonstrating 11 susceptible or equivocal responses. The data suggest that children undergoing common otolaryngic procedures who are at risk for development of MH may be safely anesthetized without the use of prophylactic dantrolene sodium.

Laryngeal pathology in hearing-impaired children

Eighty-five children enrolled in a total communication elementary school for the severe-to-profoundly hearing-impaired were evaluated prospectively to assess the incidence of laryngeal abnormalities. Direct flexible laryngoscopy and indirect mirror laryngoscopy revealed vocal cord nodules in 3 children, omega-shape infantile epiglottis in 3 children, and normal larynges in the remaining 79 children. These findings suggest that severe-to-profoundly hearing-impaired children develop detectable laryngeal pathology at approximately the same frequency as previously reported by others for normal hearing children.

Vocal quality of decannulated children following laryngeal reconstruction

Laryngotracheal reconstruction with expansion surgery is a reliable method for treatment of laryngotracheal stenosis in children. It allows for decannulation of the patient and restoration of vocal communication. Previous information regarding vocal quality in these patients has been scant. Sixteen children who underwent successful laryngotracheal reconstruction were evaluated using a standardized voice assessment during each of the following: phoneme prolongation, counting, storytelling, and spontaneous conversation. Interjudge ratings were obtained to establish reliability. The location and severity of the laryngotracheal stenosis and the method of treatment were reviewed. Twelve children have a functional voice compared to six preoperatively. Overall, vocal parameters suggested a particular pattern consisting of a lower than optimal pitch and a restricted pitch range. Laryngotracheal reconstruction does make oral communication possible for children who would otherwise have persistent tracheotomy. However, vocal quality appears to be disturbed in most of the patients.

Airway compromise from nasal obstruction in neonates and infants

Nasal obstruction in neonates can cause significant airway compromise and even be life-threatening. In general, otolaryngologists are familiar with management of the neonate born with choanal atresia but there have been few reports and there are no guidelines for management of the neonate or young infant who presents with nasal obstruction and airway compromise but who does not have choanal atresia (NOWCA). This study demonstrates the difficulty in diagnosis, variability in severity of airway compromise, and delineates the problematic aspects of management.

The role of the otolaryngologist in managing suicidal adolescents

From 1978 to 1987, 18 suicidal children were cared for by the otolaryngology service at Children's Hospital of Pittsburgh. The evaluation and treatment of these patients are reviewed, and factors resulting in these self-destructive acts discussed. Pertinent risk factors and warning signals that may enhance the otolaryngologist's ability to make the diagnosis of attempted suicide and avert potential further harm are also presented.

Otitis media in the pediatric intensive care unit: a prospective study

Otitis media has been previously shown to be a source of sepsis in the pediatric intensive care unit; however, pneumatic otoscopy and other otologic instruments are not commonly used in the pediatric intensive care unit. We undertook a prospective study to determine the prevalence of otitis media, to assess the risk factors involved with the development of these nosocomial infections, and to identify the causative organisms. We conclude that otitis media is a common entity in the pediatric intensive care unit, that it is probably caused by prolonged dysfunction of the eustachian tube associated with oral and nasally-placed tubes and that the bacteriology reflects that of the hospital environment and not that of the community.

Posterior nasal packing. Are intravenous antibiotics really necessary?

The use of antimicrobial prophylaxis in the presence of posterior nasal packing for the treatment of posterior epistaxis remains controversial. Twenty patients were prospectively randomized into this placebo-controlled, double-masked pilot study to receive either placebo or cefazolin sodium. Antibiotic-impregnated posterior gauze packing was employed in all patients. No infectious complications were noted in either group. The packings from the patients in the placebo group were foul smelling and heavily colonized with gram-negative bacteria while the packings from the antibiotic group were odor-free and lightly colonized with gram-positive organisms. This preliminary study suggests the usefulness of antimicrobial prophylaxis for preventing complications from posterior nasal packing, although a larger sample size will be needed to decrease the type II (beta) error.

Eustachian tube and nasal function during pregnancy: a prospective study

Eustachian tube dysfunction (ETD) during pregnancy and the so-called "rhinitis of pregnancy" were investigated in a prospective manner by use of sonotubometry, the nine-step inflation-deflation tympanometric test, and computer-assisted anterior rhinomanometry. Twenty pregnant volunteers with symptoms of ETD were compared to 20 asymptomatic trimester-matched pregnant subjects and 20 nonpregnant, age-matched controls. Among the symptomatic women, 16 of 20 (80%) demonstrated ETD, compared to 9 of 20 (45%) of the asymptomatic women and 6 of 20 (30%) of the nonpregnant controls (p less than 0.01). A statistically significant difference was also demonstrated between the symptomatic pregnant group and the control women with respect to nasal conductance and inspiratory work/liter. Resolution of ETD and nasal obstruction were documented upon repeat testing of pregnant subjects 4 to 10 weeks postpartum. Otologic history and current cigarette-smoking habit were found to predispose women toward ETD (p less than 0.05). We conclude that ETD during pregnancy and rhinitis of pregnancy are genuine clinical entities that can be demonstrated in the clinical laboratory and that the natural history of these disorders predicts resolution postpartum.

Evaluation of noninvasive eustachian tube function tests in normal adults

A causal association between eustachian tube (ET) dysfunction and otitis media (OM) has been documented. We present normative data for eustachian tube function (ETF) in an otologically normal population of 107 college-age subjects using two noninvasive methods: nine-step tympanometric testing and sonotubometry. The results show a 78% agreement between the two methods when one test session was performed. The nine-step test showed a 52% repeatability rate on three sequential test sessions while the sonotubometry test showed a 34% repeatability rate. The combined tests showed a 34% agreement for the three sequential tests. The findings reveal that the combination of the two tests identify 96% of normal subjects as having at least some tubal function present. Although both tests provide similar information regarding the presence of tubal opening, the sonotubometry method is more physiologic. Additional information shows that the average category of the nine-step test in a normal population was category 2, the mean duration of tubal dilation was 0.40 seconds, and the mean middle-ear pressure was -12 mm H2O.

Refractory torticollis: an uncommon complication of adenotonsillectomy

We report the case of an 8-year-old boy with refractory torticollis post-adenotonsillectomy who was later found to have Arnold-Chiari malformation. The differential diagnosis, roentgenographic findings and medical and surgical management of this disorder are discussed.