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Benedek P, Balakrishnan K, Cunningham MJ, Friedman NR, Goudy SL, Ishman SL, Katona G, Kirkham EM, Lam DJ, Leboulanger N, Lee GS, Le Treut C, Mitchell RB, Muntz HR, Musso MF, Parikh SR, Rahbar R, Roy S, Russell J, Sidell DR, Sie KCY, Smith RJ, Soma MA, Wyatt ME, Zalzal G, Zur KB, Boudewyns A. International Pediatric Otolaryngology group (IPOG) consensus on the diagnosis and management of pediatric obstructive sleep apnea (OSA). Int J Pediatr Otorhinolaryngol 2020; 138:110276. [PMID: 32810686 DOI: 10.1016/j.ijporl.2020.110276] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/21/2020] [Accepted: 07/21/2020] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To develop an expert-based consensus of recommendations for the diagnosis and management of pediatric obstructive sleep apnea. METHODS A two-iterative Delphi method questionnaire was used to formulate expert recommendations by the members of the International Pediatric Otolaryngology Group (IPOG). RESULTS Twenty-six members completed the survey. Consensus recommendations (>90% agreement) are formulated for 15 different items related to the clinical evaluation, diagnosis, treatment, postoperative management and follow-up of children with OSA. CONCLUSION The recommendations formulated in this IPOG consensus statement may be used along with existing clinical practice guidelines to improve the quality of care and to reduce variation in care for children with OSA.
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Affiliation(s)
- Pálma Benedek
- Heim Pal National Pediatric Institute, Ear Nose Throat Department, Budapest, Hungary
| | - Karthik Balakrishnan
- Stanford University, Department of Otolaryngology Head and Neck Surgery, Lucile Packard Children's Hospital Aerodigestive and Airway Reconstruction Center, Stanford, CA, USA
| | - Michael J Cunningham
- Boston Children's Hospital, Department of Otolaryngology and Communication Enhancement, Harvard Medical School, Boston, MA, USA
| | - Norman R Friedman
- Children's Hospital Colorado, Department of Pediatric Otolaryngology, University of Colorado Anschutz Medical Campus, Colorado, Canada
| | - Steven L Goudy
- Emory University and Children's Healthcare of Atlanta, Department of Otolaryngology Head and Neck Surgery, Atlanta, USA
| | - Stacey L Ishman
- Cincinnati Children's Hospital Medical Center, Department of Otolaryngology Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Gábor Katona
- Heim Pal National Pediatric Institute, Ear Nose Throat Department, Budapest, Hungary
| | - Erin M Kirkham
- Michigan Medicine, Pediatric Otolaryngology, Ann Harbor, MI, USA
| | - Derek J Lam
- Oregon Health and Science University, Department of Otolaryngology Head and Neck Surgery, Portland, OR, USA
| | - Nicolas Leboulanger
- Necker Enfants Malade Hospital, Pediatric Otolaryngology Head and Neck Department, Université de Paris, Paris, France
| | - Gi Soo Lee
- Boston Children's Hospital, Department of Otolaryngology and Communication Enhancement, Harvard Medical School, Boston, MA, USA
| | - Claire Le Treut
- Pediatric Otolaryngology Head and Neck Surgery, La Timone Children's Hospital, Aix-Marseille University, Marseille, France
| | - Ron B Mitchell
- UT Southwestern and Children's Medical Center Dallas, Department of Otolaryngology Head and Neck Surgery, Dallas, USA
| | - Harlan R Muntz
- University of Utah and Primary Children's Hospital, Department of Otorhinolaryngology Head and Neck Surgery, Salt Lake City, UT, USA
| | - Mary Fances Musso
- Texas Children's Hospital, Division of Pediatric Otolaryngology, Bobby R Alford Department of Otolaryngology, Baylor College of Medicine, Houston, TX, USA
| | - Sanjay R Parikh
- Seattle Children's Hospital, Department of Otolaryngology Head and Neck Surgery, University of Washington, Seattle, USA
| | - Reza Rahbar
- Boston Children's Hospital, Department of Otolaryngology and Communication Enhancement, Harvard Medical School, Boston, MA, USA
| | - Soham Roy
- University of Texas, Houston McGovern Medical School, Department of Otolaryngology, Division of Pediatric Otolaryngology, Houston, TX, USA
| | - John Russell
- Department of Pediatric Otolaryngology Children's Health Ireland (Crumlin), Dublin, Ireland
| | - Douglas R Sidell
- Stanford University, Department of Otolaryngology Head and Neck Surgery, Lucile Packard Children's Hospital Aerodigestive and Airway Reconstruction Center, Stanford, CA, USA
| | - Kathleen C Y Sie
- Seattle Children's Hospital, Department of Otolaryngology Head and Neck Surgery, University of Washington, Seattle, USA
| | - Richard Jh Smith
- Carver College of Medicine, Department of Otolaryngology Head and Neck Surgery, University of Iowa, Iowa City, IA, USA
| | - Marlene A Soma
- Sydney Children's Hospital, Pediatric Otolaryngology, Sydney, Australia
| | - Michelle E Wyatt
- Great Ormond Street Hospital, Department of Paediatric Otolaryngology, London, UK
| | - George Zalzal
- Children's National Medical Center, Department of Otolaryngology Head and Neck Surgery, George Washington University, Washington DC, USA
| | - Karen B Zur
- Children's Hospital Philadelphia, Department of Otolaryngology Head and Neck Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - An Boudewyns
- Antwerp University of Antwerp, Department of Otolaryngology Head and Neck Surgery, University of Antwerp, Antwerp, Belgium.
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Rosas A, McCrary HC, Meier JD, Muntz HR, Park AH. Proposal for the surgical management of children with laryngeal saccular Cysts: A case series. Int J Pediatr Otorhinolaryngol 2019; 126:109604. [PMID: 31369973 DOI: 10.1016/j.ijporl.2019.109604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 07/23/2019] [Accepted: 07/23/2019] [Indexed: 10/26/2022]
Abstract
This case series aims to determine the optimal surgical approach for pediatric laryngeal saccular cysts. A retrospective chart review of patients who underwent surgical treatment for laryngeal saccular cysts was completed; 5 patients were diagnosed and surgically treated. Treatment approaches included aspiration, supraglottoplasty, injection of bleomycin, endoscopic subtotal resection (marsupialization with the laser or endoscopic instrumentation of the cyst), endoscopic extended subtotal excision (subtotal resection plus removal of false vocal fold with lasering or coblation of the inner cyst wall), and transcervical approaches for resection. Based on our outcomes, an endoscopic extended subtotal resection of the cyst will achieve the best outcomes for cysts confined to the larynx or for Type 1 cysts. A transcervical approach for resection of the cyst will achieve the best outcomes for Type 2 cysts that extend into the neck or are extralaryngeal.
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Affiliation(s)
- Ana Rosas
- Division of Otolaryngology - Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Hilary C McCrary
- Division of Otolaryngology - Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jeremy D Meier
- Division of Otolaryngology - Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Harlan R Muntz
- Division of Otolaryngology - Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Albert H Park
- Division of Otolaryngology - Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA.
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Goldinq-Kushner KJ, Argamaso RV, Cotton RT, Grames LM, Henningsson G, Jones DL, Karnell MP, Klaiman PG, Lewin ML, Marsh JL, McCall GN, McGrath CO, Muntz HR, Nevdahl MT, Rakoff SJ, Shprintzen RJ, Sidoti EJ, Vallino LD, Volk M, Williams WN, Witzel MA, Wood VLD, Ysunza A, D'Antonio L, Isberg A, Pigott RW, Skolnick ML. Standardization for the Reporting of Nasopharyngoscopy and Multiview Videofluoroscopy: A Report from an International Working Group. ACTA ACUST UNITED AC 2017. [DOI: 10.1597/1545-1569_1990_027_0337_sftron_2.3.co_2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Yamauchi MS, Martin MH, Muntz HR, Day RW. Selective pulmonary artery occlusion to treat hemoptysis associated with pulmonary venous obstruction. Respir Med Case Rep 2017; 22:280-282. [PMID: 29124006 PMCID: PMC5671401 DOI: 10.1016/j.rmcr.2017.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 10/15/2017] [Accepted: 10/17/2017] [Indexed: 11/18/2022] Open
Abstract
Hemoptysis may occur in patients with pulmonary venous obstruction and prominent decompressing vessels in the airways adjacent to the affected pulmonary veins. The options for treatment of hemoptysis are limited, particularly when efforts to alleviate pulmonary venous obstruction have failed. Here we describe a patient with hemoptysis associated with stenosis of the central left upper pulmonary vein and occlusion of the central left lower pulmonary vein. The left upper pulmonary vein was dilated with balloon catheters and a vascular plug was placed in the left lower pulmonary artery. Vascular engorgement regressed in the left bronchus and hemoptysis has not recurred for 4 years despite recurrence of left upper pulmonary vein stenosis. Selective occlusion of branch pulmonary arteries may be an effective option for the treatment of hemoptysis from bleeding in lung segments with inoperable pulmonary venous obstruction.
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Affiliation(s)
- Melissa S.W. Yamauchi
- Pediatric Cardiology, University of Utah and Primary Children's Hospital, 81 North Mario Capecchi Drive, Salt Lake City, UT 84113, United States
| | - Mary Hunt Martin
- Pediatric Cardiology, University of Utah and Primary Children's Hospital, 81 North Mario Capecchi Drive, Salt Lake City, UT 84113, United States
| | - Harlan R. Muntz
- Pediatric Otolaryngology, University of Utah and Primary Children's Hospital, 100 North Mario Capecchi Drive, Salt Lake City, UT 84113, United States
| | - Ronald W. Day
- Pediatric Cardiology, University of Utah and Primary Children's Hospital, 81 North Mario Capecchi Drive, Salt Lake City, UT 84113, United States
- Corresponding author.
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5
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Padia R, Alt JA, Curtin K, Muntz HR, Orlandi RR, Berger J, Meier JD. Environmental contributions to otitis media requiring tympanostomy tubes. Int J Pediatr Otorhinolaryngol 2017; 101:97-101. [PMID: 28964318 DOI: 10.1016/j.ijporl.2017.07.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 07/22/2017] [Accepted: 07/25/2017] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Otitis media requiring tympanostomy tubes (OMwTT) is a prevalent disease process that has been previously shown to have a strong familial link. The impact from the environmental versus genetic contributions to this link is unknown. The objective was to determine the environmental involvement in the development of OMwTT. METHODS Using an extensive genealogical database linked to medical records, we evaluated the risk of OMwTT in children of probands as compared to children of controls, individually matched 5:1 on sex and birth year, from a conditional logistic regression model. The model included adjustments for geographic and socioeconomic environmental risk factors mapped to residence location of study subjects within 63 small health statistical areas of ∼33,500 persons each. RESULTS 37,814 case probands diagnosed with OMwTT and 181,339 controls were included in our analysis. Children of probands with OMwTT had an overall 2.5× higher risk of also having OMwTT as compared to the children of controls (p < 10-9), independent of environmental factors (PM2.5 [particulate matter] air pollution, education level of parents, and density of primary care providers). CONCLUSION After accounting for geographic and socioeconomic differences that may influence risk between cases and controls, our findings suggest evidence of a genetic predisposition in families of OMwTT patients. Further characterization of high-risk pedigrees is needed for future genomic studies.
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Affiliation(s)
- Reema Padia
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, United States
| | - Jeremiah A Alt
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, United States
| | - Karen Curtin
- Division of Genetic Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, United States; Pedigree & Population Resource, Huntsman Cancer Institute, University of Utah, United States
| | - Harlan R Muntz
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, United States
| | - Richard R Orlandi
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, United States
| | - Justin Berger
- Pedigree & Population Resource, Huntsman Cancer Institute, University of Utah, United States
| | - Jeremy D Meier
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, United States.
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Sjogren PP, Mills TJ, Pollak AD, Muntz HR, Meier JD, Grimmer JF. Predictors of complicated airway foreign body extraction. Laryngoscope 2017; 128:490-495. [PMID: 28815616 DOI: 10.1002/lary.26814] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 06/06/2017] [Accepted: 06/27/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To evaluate outcomes of foreign body aspiration (FBA) and to investigate surgeon and hospital volume as risk factors for a complicated course. STUDY DESIGN Retrospective case series. METHODS Children with FBA in a multihospital network were identified from January 2005 to September 2015. Demographic information, surgeon, and hospital location were reviewed. Mean operative time and hospital length of stay were recorded. Cases requiring intensive care unit admission, hospital stay greater than 24 hours, need for more than one bronchoscopy, operative time greater than 1 hour, or death were considered "complicated." RESULTS A total of 450 cases of airway foreign body extraction were performed. Patient ages ranged from 0.6 to 18.8 years, with a median age of 1.9 years. Bronchoscopy with foreign body extraction was performed by 55 different surgeons at 11 different facilities. There were one to 24 surgeons for each facility, with an average number of 5.4 surgeons per facility. A total of 88 (19.6%) cases were considered complicated, including five (1.1%) deaths. Increased rates of complications were seen with unwitnessed aspiration (P = 0.008) and hyperlucency (P < 0.001) or infiltrates (P = 0.001) on chest radiographs. No significant association was found between surgeon type or facility as related to a complicated case. CONCLUSIONS Unwitnessed aspiration events and abnormalities on chest radiograph may be associated with a more complicated course in children with FBA. This multihospital study identified a low number of procedures by many surgeons; however, surgeon and hospital volume did not significantly correlate with higher complication rates. LEVEL OF EVIDENCE 4. Laryngoscope, 128:490-495, 2018.
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Affiliation(s)
- Phayvanh P Sjogren
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, U.S.A
| | - Tyler J Mills
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, U.S.A
| | - Adrianna D Pollak
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, U.S.A
| | - Harlan R Muntz
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, U.S.A
| | - Jeremy D Meier
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, U.S.A
| | - J Fredrik Grimmer
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, U.S.A
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7
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Padia R, Alt JA, Curtin K, Muntz HR, Orlandi RR, Berger J, Meier JD. Familial link of otitis media requiring tympanostomy tubes. Laryngoscope 2016; 127:962-966. [PMID: 27861935 DOI: 10.1002/lary.26360] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 08/08/2016] [Accepted: 09/09/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS Placement of tympanostomy tubes for recurrent or chronic otitis media is the most commonly performed ambulatory procedure in the United States. Etiologies have been speculated to be environmentally based, and studies have suggested a genetic component to the disease. However, no large-scale studies have attempted to define a familial component. The objective of this study was to determine the familial risk of otitis media requiring tympanostomy tubes (OMwTT) in a statewide population. STUDY DESIGN Retrospective observational cohort study with population-based matched controls. METHODS Using an extensive genealogical database linked to medical records, the familial risk of OMwTT was calculated for relatives of probands (46,249 patients diagnosed with OMwTT from 1996-2013) compared to random population controls matched 5:1 on sex and birth year from logistic regression models. RESULTS The median age at time of tympanostomy tube placement was 1 year (interquartile range, 0-2 years). First-degree relatives of patients with OMwTT, primarily siblings, had a 5-fold increased risk of OMwTT (P < 10-16 ). Second-degree relatives were at a 1.5-fold increased risk (P < 10-15 ). More extended relatives (third, fourth and fifth degree) showed a 1.4-fold increased risk (P < 10-15 ). CONCLUSIONS In the largest population-based study to date, a significant familial risk is confirmed in OMwTT, suggesting otitis media may have a significant genetic component given the increased risk found in close as well as distant relatives. This could be influenced by shared environments given a five-times risk observed in siblings. Further understanding the genetic basis of OMwTT and its interplay with environmental factors may clarify the etiology and lead to better detection of disease and treatments. LEVEL OF EVIDENCE 3b. Laryngoscope, 127:962-966, 2017.
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Affiliation(s)
- Reema Padia
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, U.S.A
| | - Jeremiah A Alt
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, U.S.A
| | - Karen Curtin
- Pedigree and Population Resource, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, U.S.A
| | - Harlan R Muntz
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, U.S.A
| | - Richard R Orlandi
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, U.S.A
| | - Justin Berger
- Pedigree and Population Resource, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, U.S.A
| | - Jeremy D Meier
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, U.S.A
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9
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Park AH, Muntz HR, Smith ME, Afify Z, Pysher T, Pavia A. Pediatric Invasive Fungal Rhinosinusitis in Immunocompromised Children With Cancer. Otolaryngol Head Neck Surg 2016; 133:411-6. [PMID: 16143192 DOI: 10.1016/j.otohns.2005.04.014] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2004] [Accepted: 04/22/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES: 1) To determine the factors that predispose towards invasive fungal rhinosinusitis (FS) in immunocompromised children with cancer, and 2) to propose practice guidelines for management of pediatric FS in immunocompromised patients. METHODS: Retrospective chart review of 9 patients who developed invasive FS compared to 8 patients who did not develop invasive FS during the study period. Presenting signs and symptoms, nasal endoscopic findings, radiographs, laboratory studies, histologic and microscopic samples, and outcomes were compared. RESULTS: Seventeen consecutive pediatric immunocompromised patients with hematologic and lymphoid neoplasms underwent nasal endoscopy and biopsy for possible FS. Nine patients were diagnosed with 10 episodes of FS; 1 patient developed FS with different organisms on 2 separate occasions separated by 6 months; 8 patients were not diagnosed with FS. Eight patients had acute myelogenous leukemia (AML); 6 patients had acute lymphoblastic leukemia (ALL); 1 patient had Burkitt's lymphoma, 1 patient had undifferentiated leukemia; and 1 patient had biphenotypic acute leukemia. All patients with FS had an absolute neutrophil count (ANC) 600 or less (range 0-600). All patients with FS had either persistent fevers or sinus symptoms (facial pain, nasal congestion, rhinorrhea). Sinus CT scans were abnormal in all patients with FS and without FS. Two patients with FS had maxillary sinus retention cysts. Operative endoscopic findings were helpful diagnostically when necrosis or ulceration was found. All patients in the non-FS group normalized their ANCs; 2 of the 9 patients in the FS group did not normalize their ANC. These 2 patients died from disseminated FS or from complications due to their immunosuppression. CONCLUSION/SIGNIFICANCE: All patients with FS had either persistent fevers or symptoms localized to the sinuses (facial pain, nasal congestion, or rhinorrhea). Endoscopic examination was helpful when necrosis was detected. We recommend directed biopsies of suspicious lesions, the middle and inferior turbinate, in immunocompromised, neutropenic pediatric patients with cancer who present with either persistent fevers or localizing symptoms to the sinuses. We favor the use of “rush” biopsies over frozen sections because of the better-quality sections and ability to perform appropriate stains.
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Affiliation(s)
- Albert H Park
- Division of Otolaryngology--Head and Neck Surgery, University of Utah, Salt Lake City, 84132, USA.
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Duval M, Tarasidis G, Grimmer JF, Muntz HR, Park AH, Smith M, Asfour F, Meier J. Role of operative airway evaluation in children with recurrent croup: a retrospective cohort study. Clin Otolaryngol 2016; 40:227-33. [PMID: 25409938 DOI: 10.1111/coa.12353] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Determine which risk factors in children with recurrent croup warrant bronchoscopic evaluation. DESIGN Retrospective cohort study. SETTING Tertiary paediatric hospital. PARTICIPANTS Children with recurrent croup who underwent a rigid bronchoscopy between 2001 and 2013. MAIN OUTCOME MEASURES Bronchoscopy findings, classified as normal, mildly abnormal or significantly abnormal. RESULTS Two hundred and thirty-five children underwent a rigid bronchoscopy and 110 underwent a flexible oesophagoscopy. One hundred and forty-five children (61.7%) had a mildly abnormal exam, and 27 children (11.5%) had significant findings that required a surgical intervention or grade 2 or greater subglottic stenosis. The significantly abnormal group included 4 children with laryngomalacia, 2 with a subglottic cyst, 8 with grade 2 or 3 subglottic stenosis and 13 children who underwent a surgical procedure for subglottic stenosis. Sixty-seven children had a preoperative diagnosis of asthma, 62 were atopic and 78 had symptoms of gastro-oesophageal reflux. Oesophagoscopy was diagnostic of gastro-oesophageal reflux in 19 of 110 cases, and 106 children (45.1%) had bronchoscopic findings suggestive of GERD. Eight children had eosinophilic oesophagitis. After multivariate analysis, significantly abnormal bronchoscopy was significantly associated with chronic cough (P = 0.02), have a previous intubation (P = 0.002) or be younger than 3 years old (P = 0.01). CONCLUSION Significant findings on bronchoscopy that warranted further surgical intervention were uncommon in this cohort. Nearly half of the patients had evidence of gastro-oesophageal reflux. In patients without risk factors for significant abnormalities, empiric medical management may be beneficial prior to endoscopy.
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Affiliation(s)
- M Duval
- Division of Otolaryngology, University of Utah, Salt Lake City, UT, USA
| | - G Tarasidis
- Division of Otolaryngology, University of Utah, Salt Lake City, UT, USA
| | - J F Grimmer
- Division of Otolaryngology, University of Utah, Salt Lake City, UT, USA
| | - H R Muntz
- Division of Otolaryngology, University of Utah, Salt Lake City, UT, USA
| | - A H Park
- Division of Otolaryngology, University of Utah, Salt Lake City, UT, USA
| | - M Smith
- Division of Otolaryngology, University of Utah, Salt Lake City, UT, USA
| | - F Asfour
- Division of Pediatric Pulmonology, University of Utah, Salt Lake City, UT, USA
| | - J Meier
- Division of Otolaryngology, University of Utah, Salt Lake City, UT, USA
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Duval M, Grimmer JF, Meier J, Muntz HR, Park AH. The effect of age on pediatric tympanoplasty outcomes: a comparison of preschool and older children. Int J Pediatr Otorhinolaryngol 2015; 79:336-41. [PMID: 25613932 DOI: 10.1016/j.ijporl.2014.12.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 12/12/2014] [Accepted: 12/13/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Determine whether the outcome of tympanoplasty in preschool children is different from that of older children. STUDY DESIGN Retrospective case series. METHODS Retrospective review of children having undergone a primary tympanoplasty by 4 surgeons for a tympanic membrane perforation between 2002 and 2013. RESULTS Data from 50 children age 2-4, 130 children age 5-7 and 105 children age 8-13 years old were reviewed. Median follow-up was 7.5 months. On crude analysis, the incidence of anatomical success was not significantly different between the different age groups (p=0.38), the success rate was respectively 69.4%, 68.5% and 79.1% with an overall rate of 72.5%. 5.9% of all children required later insertion of tympanostomy tubes, 10.2% in preschool children. The post-operative audiology results were similar for all groups with a mean improvement of 9dB in the air-bone gap. When limiting the analysis to the 155 children having at least 6 months of follow-up, the rate of success was respectively 50.0%, 60.8% and 74.0% (p=0.10). After multivariate analysis controlling for the effect of surgeon, approach and etiology, the odds ratio of perforation was respectively 5.48, 2.27 and 1.00 for the different age groups. CONCLUSION Children younger than 4 years of age have the worst outcome after tympanoplasty. It remains uncertain whether the benefits of hearing improvement and quality of life may outweigh that of a high rate of a residual, usually smaller, perforation. Prospective studies are needed to confirm these results and delineate the patient characteristics and technique most likely to lead to successful results.
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Affiliation(s)
- Melanie Duval
- Division of Otolaryngology, University of Utah, 50 N Medical Drive, SOM 3C120, Salt Lake City, UT 84132, USA.
| | - J Fredrik Grimmer
- Division of Otolaryngology, University of Utah, 50 N Medical Drive, SOM 3C120, Salt Lake City, UT 84132, USA
| | - Jeremy Meier
- Division of Otolaryngology, University of Utah, 50 N Medical Drive, SOM 3C120, Salt Lake City, UT 84132, USA
| | - Harlan R Muntz
- Division of Otolaryngology, University of Utah, 50 N Medical Drive, SOM 3C120, Salt Lake City, UT 84132, USA
| | - Albert H Park
- Division of Otolaryngology, University of Utah, 50 N Medical Drive, SOM 3C120, Salt Lake City, UT 84132, USA
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Meier JD, Valentine KJ, Hagedorn C, Hartling C, Gershan W, Muntz HR, Murphy NA. Emergency department use among children with tracheostomies: Avoidable visits. J Pediatr Rehabil Med 2015; 8:105-11. [PMID: 26409864 DOI: 10.3233/prm-150324] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To characterize high emergency department (ED) use by children with tracheostomies and complex chronic conditions, to distinguish avoidable from unavoidable ED visits, and to describe the financial impact of avoidable visits. METHODS Children with tracheostomies in a pediatric tertiary care center with the highest ED utilization were identified via analysis of administrative data. Six experts in interdisciplinary dyads reviewed the records from all ED visits for these children, and distinguished avoidable from unavoidable visits. Hospital cost data for avoidable visits is described. RESULTS Among 75 children with tracheostomies and complex chronic conditions, 23 (31%) were high ED utilizers. These 23 children accounted for 74% of all ED discharges the total group of 75 children from 2008 to 2011. Four of these 23 children with high utilization were excluded, leaving 19 subjects for review. These 19 children had 312 ED visits, of which 103 (33%) were deemed avoidable. Leading reasons for avoidable visits were uncomplicated upper respiratory infections, gastrointestinal infections, and enteral feeding system problems. Avoidable visits cost the hospital {$}67,940. CONCLUSIONS One-third of ED visits by children with tracheostomies and complex chronic conditions may be avoidable. Increased ambulatory access to interdisciplinary teams of providers familiar with these children's unique needs might reduce avoidable ED visits and improve health outcomes. Further studies on how this model of ambulatory care might affect ED utilization and total healthcare costs are needed.
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Affiliation(s)
- Jeremy D Meier
- Division of Otolaryngology, Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Karen J Valentine
- Pediatric Specialty Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA.,Institute for Health Care Delivery Research, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Caroline Hagedorn
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Christine Hartling
- Pediatric Specialty Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - William Gershan
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Harlan R Muntz
- Division of Otolaryngology, Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Nancy A Murphy
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
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Abstract
Objectives: No consensus exists on appropriate timing for the first tracheostomy tube change. The purpose of this study is to evaluate the safety of early tracheostomy change in the pediatric population. Methods: A case series of all children undergoing tracheostomy at a tertiary children’s hospital between 2008-2013 was retrospectively reviewed. Results: A total of 151 children undergoing tracheostomy were identified. The average age was 48.1 ± 66 months and median age was 10 months. The initial tracheostomy tube change occurred on postoperative day 3 (POD 3) in 65 children (43.0%) safely without any complications. Conclusions: Early tracheostomy tube change was safely performed in a significant portion of this population. Routine tube change on POD 3 in many children could save resources by reducing the length of ICU and hospital stays.
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Affiliation(s)
- Nicholas C. Van Buren
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Evan R. Narasimhan
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jonathan L. Curtis
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Harlan R. Muntz
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jeremy D. Meier
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
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Bliss MR, Duval M, Muntz HR. Outcome of Tympanomastoidectomy in Children with Chronic Otitis Media. Otolaryngol Head Neck Surg 2014. [DOI: 10.1177/0194599814541627a242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: Analyze outcomes of tympanomastoidectomy for chronic otitis media in children at a tertiary care referral center with a high prevalence of patients with genetic syndromes, craniofacial anomalies, and medical comorbidities. Methods: A retrospective review of tympanomastoidectomy performed for chronic otitis media at a single pediatric tertiary care hospital from 1995 through 2013 was performed. Factors evaluated included presence of immunodeficiency or craniofacial anomaly, change in air-bone gap and speech reception threshold, and need for additional otologic procedures. Results: Fifty-six tympanomastoidectomies on 47 patients were evaluated. A total of 25% of the children had a genetic syndrome and 17% had an immunodeficiency. Average age at surgery was 7.5 years with an average duration of follow-up of 2.7 years. Previous treatment included prolonged oral antibiotics (43), prolonged intravenous antibiotics (11), and middle ear irrigation and exchange of tympanostomy tube (7). Twenty-nine ears had undergone 2 or more tympanostomy tube insertion. A total of 28 (50%) ears continued to have some otorrhea postoperatively. Complete audiologic data were available for 23 patients. Improvement in air-bone gap was seen in 87% of cases, with an average improvement of 11.9 dB ( P = .01). Improvement in speech reception threshold was seen in 65%, with an average decrease in threshold of 10 dB ( P = .27). Of the cases, 8.9% required revision tympanoplasty following tympanomastoidectomy. Conclusions: Tympanomastoidectomy in children with severe chronic otitis media improves hearing function and may be beneficial in some patients to cease otorrhea. This should be considered as a treatment option in children that have failed previous conservative management.
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Taggart M, Meier JD, Park AH, Grimmer JF, Smith ME, Crockett D, Muntz HR. Endoscopic Frontal Sinus Exploration in Children with Cystic Fibrosis. Otolaryngol Head Neck Surg 2013. [DOI: 10.1177/0194599813496044a310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: Frontal sinus exploration is uncommon in children. Delayed pneumatization of the frontal sinus, technical difficulties, and concerns for postoperative scarring and mucocele formation impact the incidence of this operation in the pediatric population. The objective of this study is to review outcomes after endoscopic frontal sinus exploration in children with cystic fibrosis (CF). Methods: Retrospective case series of children with CF undergoing endoscopic frontal sinus exploration at a tertiary children’s hospital from 2004 to 2012. Pre- and postoperative pulmonary function tests (PFT), surgical complications, and the rate of revision operations were evaluated. Outcomes were compared to a cohort of children without CF that underwent endoscopic frontal sinusotomy for chronic sinusitis. Results: Twenty-three children (12 with CF, 11 without CF) underwent endoscopic frontal sinusotomy. The average age was 11.3 years (range 7-14) in the CF group compared to 13.5 years (range 6-18) in the non-CF population. Four of the 12 CF patients (33%) required at least 1 revision operation, compared to 1 of 11 control patients without CF (not statistically significant). No significant improvement in PFT was noted after surgery (mean FEV1% predicted pre-operative: 97.3 ± 19.9, post-operative: 96.7 ± 27.6). The average time from initial surgery to revision operation was 20.3 months (range 8-30 months). No major surgical complications related to the procedure were identified. Conclusions: The revision rate for frontal sinus exploration in this series is similar to revision rates described in the literature for other sinuses in CF patients. PFT results did not change after the operation.
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Johnson K, Meier JD, Muntz HR. Posterior Pharyngeal Wall Augmentation with Acellular Dermis Implant for Velopharyngeal Insufficiency. Otolaryngol Head Neck Surg 2013. [DOI: 10.1177/0194599813495815a261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: Review outcomes for children with velopharyngeal insufficiency (VPI) after posterior pharyngeal wall augmentation with an acellular dermis implant. Methods: Retrospective case series of children with VPI who underwent augmentation pharyngoplasty from 2002-2011 at a tertiary care children’s hospital. The posterior pharyngeal wall was augmented with rolled acellular dermis inserted in the subfascial plane. Pre- and postoperative nasometry, speech nasal endoscopy, and caretaker and clinician perceptual evaluation were reviewed. Results: Twenty-four children with VPI (average age 8.8 ± 4.0 yrs) who underwent augmentation pharyngoplasty were identified. The majority of these children had a small gap noticed on speech nasal endoscopy. Of the 24 children, 5 were lost to follow-up and were not assessed in the postoperative period. Average follow-up for the remaining 19 patients was 17.6±20.9 months. Fifteen of the 19 patients (79%) had some improvement in VPI symptoms as determined by clinical perceptual evaluation, but only 8 children (42%) demonstrated complete resolution after the operation. One implant extruded. No major complications related to the surgical procedure were identified. Conclusions: We present a novel technique to treat VPI using an acellular dermis implant to augment the pharyngeal wall. Although this approach does not successfully treat all children with VPI, no major complications were seen in this series. Vital tissue that may be used for future speech surgery is preserved if this treatment option fails.
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Abstract
Esophageal foreign body is a frequent pediatric presentation, and eosinophilic esophagitis (EoE) is an important underlying disease. To determine characteristics common in the presentation of esophageal foreign body indicative of underlying EoE and reach a recommendation for the appropriate scenario in which to obtain esophageal mucosal biopsy, 312 pediatric esophageal foreign bodies requiring operative removal were reviewed. Patients older than 18 years or with a known history of esophageal surgery or pathology were excluded. Eligibility criteria were met in 271 cases. Twenty-seven patients were biopsied, and 18 were diagnosed with EoE. The following factors were identified in the EoE population: food impaction (89%), older age (average 12.2 years), male sex (78%), atopic disease (61%), previous esophageal foreign body or frequent dysphagia (83%), and endoscopic abnormalities (100%). These factors are all associated with an underlying diagnosis of EoE, and patients meeting these criteria should be strongly considered for intraoperative esophageal mucosal biopsy.
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Affiliation(s)
- Scott Hudson
- Division of Otolaryngology-Head and Neck Surgery, The University of Utah, Salt Lake City, Utah, USA
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18
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Hudson SK, Sampson C, Muntz HR, Grimmer F, Park AH, Jackson WD, Smith M. Foreign Body as Initial Symptom of Eosinophilic Esophagitis. Otolaryngol Head Neck Surg 2012. [DOI: 10.1177/0194599812451438a202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: 1) Determine characteristics common in the presentation of esophageal foreign body that indicate presence of underlying esophageal pathology. 2) Provide clinical guidelines to consider esophageal mucosal biopsy during foreign body removal. Method: Three hundred twelve cases of pediatric patients with an esophageal foreign body requiring esophagoscopy for removal were reviewed. Patients were excluded if a history of esophageal surgery or pathology was present. Factors common to those patients subsequently diagnosed with eosinophilic esophagitis (EE) were identified. Results: Eligibility criteria were met in 271 cases. Of these, 27 underwent esophageal biopsy and 18 were diagnosed with EE. The following factors were compared between the EE population and the group as a whole: food impaction (89% of EE patients, 11% of non-EE patients), older age (average EE age 11.9, overall average age 4.5), atopic disease (61.1% of EE, 17.0% non-EE), abnormalities on esophagoscopy (94.4% of EE, 8.9% overall), and previous esophageal foreign body or frequent dysphagia (83.3% of EE, 5.9% non-EE). Eighteen percent of EE patients had 2 or more impactions requiring esophagoscopy prior to a biopsy being taken. Conclusion: Older age, food impaction, history of atopic disease or previous esophageal foreign body, and abnormalities on esophagoscopy are all associated with EE. Patients meeting these criteria should be strongly considered for mucosal biopsy during foreign body removal. Failure to do so may lead to repeated foreign body events.
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Abstract
Extragonadal yolk sac tumors are uncommon and usually seen in sacrococcygeal, mediastinal, intracranial, and retroperitoneal sites. Yolk sac tumors of the head and neck region are rare, and the few reported cases have arisen in neonates or infants in conjunction with a teratoma or other germ cell tumor subtypes. We report a unique case of a pure yolk sac tumor presenting as a primary lesion in the right thyroid lobe of a 10-year-old girl. The diagnosis was suspected after fine-needle aspiration, and extensive sampling of the thyroidectomy specimen revealed no teratoma or other germ cell tumor. Serum α-fetoprotein levels were markedly elevated 6 days after excision, and imaging disclosed numerous bilateral pulmonary nodules suggestive of metastatic disease but did not reveal a mediastinal mass. The tumor has shown a favorable response to bleomycin, etoposide, and cisplatin chemotherapy. To the best of our knowledge, this is the 1st description of a primary pure yolk sac tumor of the thyroid.
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Affiliation(s)
- Larissa V Furtado
- Department of Pathology, University of Utah Health Sciences Center, Salt Lake City, UT, USA
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20
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Parikh SR, Lusk RP, Manning SC, Muntz HR. Redefining Pediatric Rhinosinusitis. Otolaryngol Head Neck Surg 2011. [DOI: 10.1177/0194599811415818a73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Program Description: Over a decade has passed since the last comprehensive definition of pediatric rhinosinusitis was developed by an expert panel. In this miniseminar, international leaders in the field of pediatric rhinology will provide the latest evidence and experience regarding the definition of pediatric rhinosinusitis. Specifically, panelists will provide state-of-the-art concepts regarding pediatric rhinosinusitis including contributing factors such as allergy, antigens, fungus, biofilms, and reflux. The panel will discuss the differences between acute and chronic pediatric rhinosinusitis and provide the audience with guidelines for the clinical evaluation of both. Finally, with the use of case presentations, the panel will discuss contemporary medical and surgical interventions for acute and chronic pediatric rhinosinusitis. Educational Objectives: 1) Understand the current definitions of acute and chronic pediatric rhinosinusitis. 2) Understand contributing factors to pediatric rhinosinusitis including allergy, fungus, biofilms, and reflux. 3) Understand contemporary treatment options for acute and chronic pediatric rhinosinusitis.
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Elsherif AM, Park AH, Alder SC, Smith ME, Muntz HR, Grimmer F. Indicators of a more complicated clinical course for pediatric patients with retropharyngeal abscess. Int J Pediatr Otorhinolaryngol 2010; 74:198-201. [PMID: 19963280 DOI: 10.1016/j.ijporl.2009.11.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Revised: 11/05/2009] [Accepted: 11/09/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Determine clinical signs or symptoms associated with a more complicated clinical course in patients with retropharyngeal abscesses (RPAs). DESIGN Retrospective chart review at a tertiary care level Children's hospital. Main Outcome Measures Age, presenting signs and symptoms, laboratory tests, imaging results, antibiotic therapy, surgical approach, pathogens isolated, and duration of hospitalization were evaluated to determine any factors associated with a more complicated clinical course (CCC). RESULTS Fifteen of one hundred thirty pediatric patients with RPA were identified with a complicated clinical course (CCC). Eight of the fifteen required more than one procedure before the abscess resolved. Patients with multiple abscess sites had a statistically significantly greater chance of requiring multiple procedures to clear the infections (p<0.001). Another seven presented with airway obstruction requiring an admission into the Pediatric Intensive Care (PICU) and/or intubation. All the patients requiring admission to the PICU presented with signs or symptoms of airway obstruction compared to ten of the one hundred fifteen patients (8.7%) with a smooth clinical course (SCC) (p<0.001). Five patients from the CCC group required a bronchoscopy to secure the airway; seven patients required intubation following incision and drainage of the abscess for an average of 5+/-3 days. There was no statistically significant difference between the two groups with respect to pathogens isolated, or antibiotics used. CONCLUSION Our study suggests that patients with a CCC are more likely to present with airway obstruction or multiple abscess sites than patients with SCC.
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Affiliation(s)
- Abdelaziz M Elsherif
- Division of Otolaryngology/Head and Neck Surgery, University of Utah, 50 North Medical Drive, 3C 120, Salt Lake City, UT 84132, United States
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Smith ME, King JD, Elsherif A, Muntz HR, Park AH, Kouretas PC. Should all newborns who undergo patent ductus arteriosus ligation be examined for vocal fold mobility? Laryngoscope 2009; 119:1606-9. [DOI: 10.1002/lary.20148] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Uchida DA, Morgan-Wallace V, Richards K, Seidelman J, Muntz HR. Congenital tracheal stenosis masquerading as asthma in an adolescent: the value of spirometry. Clin Pediatr (Phila) 2009; 48:432-4. [PMID: 19224867 DOI: 10.1177/0009922808330778] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Derek A Uchida
- Pediatric Pulmonology, University of Utah School of Medicine, Salt Lake City, Utah 84113, USA.
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24
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Muntz HR, VanWoerkom R. Etiology of Pediatric Recurrent Croup. Otolaryngol Head Neck Surg 2008. [DOI: 10.1016/j.otohns.2008.05.208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective Often pediatric croup is viral in etiology. Children with recurrent croup (greater than 3 episodes a year) may have underlying pathology making them more prone to these episodes. This study was done to define the frequency of these pathologies. Methods 80 consecutive children with the diagnosis of recurrent croup underwent diagnostic endoscopy at a pediatric tertiary care hospital. We carried out a retrospective chart review of these cases. Results Of the 80 children, 26 (33%) were found to have subglottic stenosis. The average narrowing was 32 ± 9% in these children. Of the 26 with subglottic stenosis, 19 (73%) also manifested laryngopharyngeal reflux. Of the 15 (19%) patients previously intubated as neonates or infants, 8 (53%) also had subglottic stenosis. 45 (56%) were felt to have laryngopharyngeal reflux by either laryngotracheal findings or other testing. 26 (58%) of these had concomitant subglottic stenosis. Allergies or asthma were found in 31 (39%) of the patients. Another 16 (20%) were found to have tracheomalacia and an additional 7 (9%) were noted to have innominate artery compression. Many had more than one risk factor. Conclusions The most common factors associated with recurrent croup are laryngopharyngeal reflux and subglottic stenosis. This study will assist the clinician in discussion of possible etiologies with families and insurers. Defining underlying pathology can then assist in the defining treatment options.
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Sie KCY, Starr JR, Bloom DC, Cunningham M, de Serres LM, Drake AF, Elluru RG, Haddad J, Hartnick C, Macarthur C, Milczuk HA, Muntz HR, Perkins JA, Senders C, Smith ME, Tollefson T, Willging JP, Zdanski CJ. Multicenter interrater and intrarater reliability in the endoscopic evaluation of velopharyngeal insufficiency. ACTA ACUST UNITED AC 2008; 134:757-63. [PMID: 18645127 DOI: 10.1001/archotol.134.7.757] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To explore interrater and intrarater reliability (R (inter) and R (intra), respectively) of a standardized scale applied to nasoendoscopic assessment of velopharyngeal (VP) function, across multiple centers. DESIGN Multicenter blinded R (inter) and R (intra) study. SETTING Eight academic tertiary care centers. PARTICIPANTS Sixteen otolaryngologists from 8 centers. MAIN OUTCOME MEASURES Raters estimated lateral pharyngeal and palatal movement on nasoendoscopic tapes from 50 different patients. Raters were asked to (1) estimate gap size during phonation and (2) note the presence of the Passavant ridge, a midline palatal notch on the nasal surface of the soft palate, and aberrant pulsations. Primary outcome measures were R (inter) and R (intra) coefficients for estimated gap size, lateral wall, and palatal movement; kappa coefficients for the Passavant ridge, a midline palatal notch on the nasal soft palate, and aberrant pulsations were also calculated. RESULTS The R (inter) coefficients were 0.63 for estimated gap size, 0.41 for lateral wall movement, and 0.43 for palate movement; corresponding R (intra) coefficients were 0.86, 0.79, and 0.83, respectively. Interrater kappa values for qualitative features were 0.10 for the Passavant ridge; 0.48 for a notch on the nasal surface of the soft palate, 0.56 for aberrant pulsations, and 0.39 for estimation of gap size. CONCLUSIONS In these data, there was good R (intra) and fair R (inter) when using the Golding-Kushner scale for rating VP function based on nasoendoscopy. Estimates of VP gap size demonstrate higher reliability coefficients than total lateral wall, mean palate estimates, and categorical estimate of gap size. The reliability of rating qualitative characteristics (ie, the presence of the Passavant ridge, aberrant pulsations, and notch on the nasal surface of the soft palate) is variable.
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Affiliation(s)
- Kathleen C Y Sie
- Division of Pediatric Otolaryngology, Childhood Communication Center, Children's Hospital and Regional Medical Center, PO Box 5371/6E-1, Seattle, WA 98105-0371, USA.
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Smith ME, Park AH, Muntz HR, Gray SD. Airway Augmentation and Maintenance Through Laryngeal Chemodenervation in Children With Impaired Vocal Fold Mobility. ACTA ACUST UNITED AC 2007; 133:610-2. [PMID: 17576914 DOI: 10.1001/archotol.133.6.610] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Marshall E Smith
- Division of Otolaryngology/Head and Neck Surgery, 3C-120 SOM, University of Utah School of Medicine, 50 N Medical Dr, Salt Lake City, UT 84132, USA.
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Abstract
OBJECTIVES To compare the distribution patterns of topical medication delivery systems in the sinonasal region and upper respiratory tract after functional endoscopic sinus surgery. STUDY DESIGN Prospective descriptive evaluation. METHODS Four topical delivery systems (spray bottle, atomizer, nebulizer, and bulb syringe) were studied. Using a dye solution as a marker, we independently applied the four topical delivery systems to a population of patients with chronic rhinosinusitis who had undergone functional endoscopic sinus surgery. The anatomic distributions were videotaped using flexible fiberoptic endoscopy. Three blinded observers independently rated the anatomic distribution of dye using a 4 point scale. Statistical analysis was performed using analysis of variance (ANOVA) and Dunn posttesting. RESULTS Seven participants completed the study. All participants had undergone bilateral maxillary antrostomies, bilateral total ethmoidectomies, and bilateral sphenoidotomies. Five sinonasal sites and the larynx were evaluated for dye deposition. Interobserver agreement reached 95.6%. There was no statistical difference between the atomizer and spray bottle. The bulb syringe was statistically superior to the nebulizer in all sinonasal sites and statistically superior to the atomizer and spray bottle in the ethmoidal region. Dye was rarely seen within the larynx. CONCLUSIONS The delivery systems tested were shown to have significant differences in their capability to place dye in specific sinonasal areas. Because topical medications are commonly administered to postoperative patients, these differences may have important clinical implications.
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Affiliation(s)
- Timothy R Miller
- Division of Otolaryngology-Head and Neck Surgery, University of Utah, 50 North Medical Drive, 3C120, Salt Lake City, UT 84132, USA.
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28
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Abstract
The pediatric otolaryngologist is often called upon to aid in the diagnosis and management of subglottic stenosis. This report contains an update of our experience using auricular cartilage in laryngotracheal reconstruction. A retrospective review of the medical records at St Louis Children's Hospital identified 43 children with subglottic stenosis. Thirty-one children were treated by use of auricular cartilage with a success rate of 84%, and an overall 94% success rate after revision surgery. Eight children in whom an anterior cricoid split initially failed were secondarily treated with auricular cartilage with a success rate of 75%. Two children initially treated with costochondral cartilage underwent multiple reconstructive procedures with either auricular cartilage or costochondral cartilage with an overall success rate of 50%. The remaining 2 children had long-segment tracheal stenosis and underwent repair with auricular cartilage with a 50% success rate. We find that auricular cartilage grafts are highly effective when used in a primary single-stage procedure in children with grade I or II stenosis. We have had limited success with auricular cartilage in patients with grade III stenosis and are reluctant to use it in grade IV stenosis, long-segment tracheal stenosis, staged reconstruction, or revision of an auricular or costal cartilage graft laryngotracheal reconstruction.
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Affiliation(s)
- A B Silva
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
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Abstract
The pediatric tracheostomy stoma can be matured via a technique that places 4-quadrant sutures from the tracheal cartilage to the dermis. This has the potential of decreasing the risk of accidental decannulation and the formation of granulation tissue. A retrospective analysis of 149 tracheostomies performed between January 1989 and December 1996 was done for the following factors: age, underlying diagnosis, indication for tracheostomy, type of tracheal incision, maturation of stoma, duration of tracheostomy, and early and late (>7 days) complications. Maturation of the stoma was performed in 88 (59.1%) of the 149 tracheostomies. There was an overall complication rate of 21.5% (32/149, not including granulation tissue formation). There were 9 (6.0%) early complications and 23 (15.4%) late complications. The overall incidence of tracheocutaneous fistulas occurred in 11 (11.2%) of the 98 decannulated patients: 6 (10.2%) of the 59 matured stomas and 5 (12.8%) of the 39 nonmatured stomas. Granulation tissue was found on subsequent laryngoscopy in 24 (27.3%) of the 88 matured stomas versus 23 (37.7%) of the 61 nonmatured stomas. There were no tracheostomy-related mortalities. Maturing the tracheostomy stoma resulted in a decreased morbidity from accidental decannulations and did not increase the incidence of tracheocutaneous fistulas or granulation tissue formation.
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Affiliation(s)
- J Y Park
- Division of Pediatric Otolaryngology, St Louis Children's Hospital, Missouri 63110, USA
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Abstract
INTRODUCTION Early vocalization and speech production remains a goal in children who require tracheotomy for airway obstruction or chronic ventilation. Although studies document the efficacy of the Passy-Muir valve (PMV) in adults, none have reviewed its efficacy in children. We performed this study to better understand the clinical complexity of its use in children. MATERIALS AND METHODS Retrospective evaluation of 55 consecutive cases of children with tracheotomy using the PMV. RESULTS The children ranged in age from 3 days to 18 years at the time of their tracheotomies, and nearly half were 12 months old or younger. Successful use often requires patient and family conditioning. Overall, 52 children out of the 55 who were evaluated as candidates for the PMV tolerated its use. Many required two or more trials prior to the patient and family being comfortable with its use. CONCLUSIONS The PMV may be used successfully in children with a variety of airway pathologies as well as diverse medical problems. Discussed is the current protocol for the evaluation of the patient and the introduction of the valve.
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Affiliation(s)
- J E Cho Lieu
- Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, New Haven, CT, USA
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Suskind DL, Park J, Piccirillo JF, Lusk RP, Muntz HR. Conscious sedation: a new approach for peritonsillar abscess drainage in the pediatric population. Arch Otolaryngol Head Neck Surg 1999; 125:1197-200. [PMID: 10555689 DOI: 10.1001/archotol.125.11.1197] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To assess the safety and efficacy of conscious sedation (CS) in children undergoing emergency department incision and drainage (I&D) of peritonsillar abscesses (PTAs). DESIGN A 33-month retrospective chart review of all children presenting to the emergency department with the diagnosis of a PTA or peritonsillar cellulitis. Children who underwent CS prior to I&D were compared with children without CS for complications and efficacy. SETTING St Louis Children's Hospital, an academic tertiary care pediatric hospital. PATIENTS Fifty-two children were enrolled; 30 PTAs were drained with CS in 27 children (3 underwent I&D twice), and 25 PTAs were drained in 25 children without CS. INTERVENTIONS The CS team included an otolaryngologist, a pediatric emergency department physician, and a registered nurse. A standardized CS protocol assessing vital signs and level of consciousness was employed during each procedure. A combination of midazolam, ketamine hydrochloride, and glycopyrrolate was used in appropriately weighted calculated doses. Patients were assessed for major and minor airway complications. MAIN OUTCOME MEASURES Airway complications related to CS were reviewed. Patients who underwent I&D with and without CS were compared with regard to purulent drainage. RESULTS There were no major airway complications in patients undergoing I&D with CS. There was 1 minor complication in this group, oxygen desaturation to 88%, which resolved with stimulation. Of the 55 procedures, 45 (82%) yielded purulence: 29 (97%) of 30 in the CS group and 16 (64%) of 25 in the non-CS group (chi2 = 9.8; P = .002). Of those children undergoing CS, 3 (10%) of 30 were admitted to the hospital from the emergency department as compared with 6 (24%) of 25 without CS (chi2 = 1.95; P = .16). In the CS group, PTAs had a low recurrence rate of 1 (3.3%) of 30 compared with 2 (8%) of 25 in the non-CS group (chi2 = 0.57; P = .45). No one in the CS group required a secondary procedure under general anesthesia. CONCLUSIONS This preliminary study demonstrates CS to be a potentially safe and efficacious approach to drainage of PTAs in children. Given its efficacy and its associated lower levels of anxiety and pain for the patient, CS seems to be a promising new approach to caring for children with PTAs.
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Affiliation(s)
- D L Suskind
- St Louis Children's Hospital, Washington University School of Medicine, Division of Pediatric Otolaryngology, MO, USA
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Abstract
This prospective study was undertaken to assess the long-term stability of velopharyngeal perceptual speech ratings of patients with repaired cleft palate. All patients were evaluated and managed at the Cleft Palate and Craniofacial Deformities Institute, St. Louis Children's Hospital. Patients alternately received palatoplasty with or without intravelar veloplasty. Two senior surgeons standardized their operative procedures and performed or supervised directly all operations. Perceptual speech and language evaluations were conducted by the same experienced speech pathologist when the children were 6 years old and 12 years or older. Data were analyzed from the 28 patients available for long-term follow-up. The intravelar veloplasty (N = 14) and nonintravelar veloplasty (N = 14) groups were similar with respect to cleft anatomy and mean age at palatoplasty and at the second perceptual speech evaluation. Evaluation of the 12-year-old and older ratings indicated that the overwhelming majority of patients improved or maintained clinical stability in perceptual ratings of velopharyngeal function. When assessing direction and magnitude of change (i.e., incremental improvement vs. deterioration), the intravelar veloplasty and nonintravelar veloplasty groups had a similar distribution of perceptual speech ratings at both the 6-year and 12-year or older speech evaluations. Results were consistent with previously published data from our center, that the intravelar veloplasty procedure did not affect demonstrably the incidence of postpalatoplasty auditory perceptual symptoms of velopharyngeal dysfunction.
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Affiliation(s)
- P D Witt
- Department of Surgery, St. Louis Children's Hospital, Washington University School of Medicine, MO, USA
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Lusk RP, Bower CM, Manning SC, Muntz HR, Storch G. Miniseminar: Update on the etiology and management of pediatric chronic sinusitis. Otolaryngol Head Neck Surg 1999. [DOI: 10.1016/s0194-5998(99)80372-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Pediatric airway foreign bodies are potentially life-threatening situations. The otolaryngologist is often consulted to aid in the diagnosis and management of these difficult cases. Although radiographic studies are often obtained, the decision for surgical intervention is usually based on a suspicious history and physical examination. Our hypothesis is that radiographic imaging should not alter the decision for surgical intervention. We retrospectively reviewed the cases of pediatric airway foreign bodies managed by the otolaryngology department at St Louis Children's Hospital between December 1990 and June 1996 with both radiographic imaging and operative intervention. Ninety-three cases of potential aspiration were identified, with a median patient age of 20 months. The most common presenting signs and symptoms were aspiration event (n = 82), wheezing (n = 76), decreased breath sounds (n = 47), cough (n = 39), respiratory distress (n = 17), fever (n = 16), pneumonia (n = 14), and stridor (n = 7). At the time of endoscopy, 73 patients were found to have an airway foreign body. The sensitivity and specificity of the imaging studies in identifying the presence of an airway foreign body in the 93 patients were 73% and 45%, respectively. Our decision for operative intervention was based on the history and physical examination, and was not changed in the presence of a negative radiographic study. The routine use of radiography should not alter the management of airway foreign bodies, providing that there is a well-equipped endoscopic team familiar with airway foreign bodies.
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Affiliation(s)
- A B Silva
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
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Abstract
PURPOSE To evaluate the efficacy of nasopharyngeal cultures in identifying pathogens in middle-ear effusions as an alternative to cultures obtained through tympanocentesis. MATERIALS AND METHODS The study population consisted of 203 children with middle-ear effusions at the time of placement of tympanostomy tubes for recurrent otitis media or persistent otitis media with effusion. Isolates from the nasopharynx were compared with those from the middle ear to determine sensitivity, specificity, and predictive values for each of the three main pathogens. RESULTS The predominant bacterial isolates from both ear and nasopharynx were Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae. Eighty-one percent (42% highly, 39% relatively) S pneumoniae nasopharyngeal isolates were resistant to penicillin. The negative predictive value of the nasopharyngeal cultures was at least 97% for each of these predominant bacteria. CONCLUSION This study supports the conclusion that tympanocentesis is the most useful means of identifying pathogens in otitis media.
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Affiliation(s)
- R A Clary
- Washington University School of Medicine, St Louis, MO, USA
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Witt PD, Miller DC, Marsh JL, Muntz HR, Grames LM. Limited value of preoperative cervical vascular imaging in patients with velocardiofacial syndrome. Plast Reconstr Surg 1998; 101:1184-95; discussion 1196-9. [PMID: 9529200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of this two-part study was to evaluate the safety of surgical management of speech production disorders in patients with velocardiofacial syndrome without preoperative cervical vascular imaging studies. Anomalous internal carotid arteries have been shown to be a frequent feature of velocardiofacial syndrome. These vessels pose a potential risk for hemorrhage during velopharyngeal narrowing procedures. Magnetic resonance angiography, and other forms of cervical vascular imaging studies such as computerized tomography, have been advocated as aids to surgery by defining the preoperative vascular anatomy. However, it remains unclear whether these studies alter either the conduct or outcome of operations on the velopharynx. In the first part of this study, we reviewed the charts and videonasendoscopic evaluations of 39 consecutive patients with confirmed or suspected velocardiofacial syndrome who underwent sphincter pharyngoplasty or pharyngeal flap from 1978 to 1996. The charts were reviewed to determine (1) the frequency of identification of abnormal pharyngeal pulsations; (2) whether such pulsations affected the conduct of the operative procedure; and (3) whether the presence of pulsations affected surgical morbidity and/or surgical outcome. None of the patients underwent any type of cervical vascular imaging study. In the second part of this study, we surveyed plastic surgeons with numerous years of experience participating on cleft-craniofacial teams, to ascertain practice patterns relating to the management of patients with velocardiofacial syndrome. The questions related specifically to the surgeons' behavior in relation to angiography and their awareness of any cases of surgical morbidity related to the cervical vascular system in patients with velocardiofacial syndrome. We were interested in discerning both how commonly this situation arises clinically and the distribution of the various types of operative procedures in common use. Of our 39 patients, 10 patients (26 percent) had detectable pulsations on preoperative nasendoscopy. Of these, five patients underwent sphincter pharyngoplasty and five underwent pharyngeal flap procedures. Preoperative instrumental and intraoperative clinical assessment of pulsatile vessels allowed velopharyngeal reconstruction in all patients without surgical morbidity. Results of the questionnaire indicated that most cleft surgeons do not routinely order cervical vascular imaging studies for all of their patients with velocardiofacial syndrome. About half of the respondents indicated that their operative approach was influenced by information obtained from angiographic studies. None of the surgeons queried were aware of any cases of surgical morbidity related to the cervical vascular system in patients with velocardiofacial syndrome. Nearly 50 percent of surgeons use pharyngeal flap procedures most frequently, whereas 22 percent of surgeons use sphincter pharyngoplasty most frequently. Results of this study support the safety of sphincter pharyngoplasty or pharyngeal flap procedures in patients with velocardiofacial syndrome without preparatory angiography. These procedures can be performed safely, even in patients having aberrant velopharyngeal pulsations. Given the market cost of magnetic resonance angiography ($1600), one must question the cost-efficacy of magnetic resonance angiography for routine use in the velocardiofacial syndrome population.
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Affiliation(s)
- P D Witt
- Department of Surgery, Plastic and Reconstructive, St. Louis Children's Hospital, Washington University School of Medicine, MO 63110, USA
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Witt PD, Miller DC, Marsh JL, Muntz HR, Grames LM, Pilgram TK. Perception of postpalatoplasty speech differences in school-age children by parents, teachers, and professional speech pathologists. Plast Reconstr Surg 1997; 100:1655-63. [PMID: 9393461 DOI: 10.1097/00006534-199712000-00003] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The aims of this study were twofold: (1) to test the ability of parents and teachers to discriminate the speech of children with repaired cleft palate from that of their unaffected peers and (2) to compare these lay assessments of speech acceptability with the critical perceptual assessments of expert clinicians. The subjects for this study were 20 children of school age (age range, 8 to 12 years) who were drawn from a large population (n = 1282) of patients. All subjects had been referred for palatoplasty to the same tertiary cleft center between 1978 and 1991. There were 16 matched controls. The listening team included parents of subjects (n = 32) and teachers of age-matched school children (n = 12). Randomized master audiotape recordings of the study group were presented in blinded fashion to both groups of the adult raters, who were inexperienced in the evaluation of patients with speech dysfunction. An experienced panel of three extramural speech pathologists evaluated the same recordings. In all parameters rated, both parents and teachers showed a consistent tendency to give the subject children more negative ratings than the control children. Expert raters were sensitive to differences in resonance and intelligibility in the control and cleft palate groups. Results of this study differ from similar previous research, indicating that naive peer raters (similar-age children) were insensitive to speech differences in the cleft palate and control groups.
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Affiliation(s)
- P D Witt
- Department of Surgery, St. Louis Children's Hospital, Washington University School of Medicine, Mo., USA
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Abstract
OBJECTIVE To determine whether the lack of private health insurance places children at increased risk for foreign body ingestion or aspiration. DESIGN Retrospective review. SETTING St. Louis Children's Hospital, a tertiary care center. PATIENTS Consecutive sample of 125 patients with esophageal or airway foreign bodies. RESULTS Fifty percent of all patients had private health insurance. Fifty-six percent of all preschool patients and 20% of all school-age patients were uninsured (P < 0.01, Fisher's exact test). Eighty-five percent of patients with airway foreign bodies, and 84% of patients with esophageal foreign bodies were in the preschool group. Sixty-one percent of preschool patients and 21% of school-age patients with esophageal foreign bodies were uninsured (P < 0.05). Forty-six percent of preschool patients with food aspiration lacked health insurance (88% of these children were fed the aspirated item). No school-age group was available for comparison. Fifty percent of preschool children with aspiration of non food items were uninsured, as were 16% of their school-age counterparts. CONCLUSIONS Insurance status must be considered as a risk factor for foreign body aspiration and ingestion. Preschool children are more likely to lack private health insurance than school-age children with the same diagnosis. In a majority of aspiration events, the child was being fed the inappropriate food item, perhaps indicating a lack of caretaker education and anticipatory guidance. A direct focus on 'passive protection', anticipatory guidance in clinics for all patients, and public education with emphasis on preventive care are proposed as means to decrease the incidence of airway and esophageal foreign bodies in children.
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Affiliation(s)
- E M Arjmand
- Department of Surgery (Otolaryngology) and Pediatrics, Southern Illinois University School of Medicine, Springfield 62794-1618, USA
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Witt PD, O'Daniel TG, Marsh JL, Grames LM, Muntz HR, Pilgram TK. Surgical management of velopharyngeal dysfunction: outcome analysis of autogenous posterior pharyngeal wall augmentation. Plast Reconstr Surg 1997; 99:1287-96; discussion 1297-300. [PMID: 9105355 DOI: 10.1097/00006534-199704001-00012] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Posterior pharyngeal wall augmentation has been advocated for patients having velopharyngeal dysfunction with a small coronal gap. Nonautogenous augmentation has not been accepted widely because of migration or extrusion of alloplastic implants and resorption of injected materials. Autogenous posterior pharyngeal wall augmentation has been performed for decades by Italian surgeons. A retrospective study was conducted to evaluate the efficacy of this procedure. Autogenous posterior pharyngeal wall augmentation, using a rolled superiorly based pharyngeal myomucosal flap, was performed on 14 patients, between November of 1989 and June of 1992, who fulfilled two criteria: velopharyngeal dysfunction unresponsive to speech therapy and a small (< 20 percent) coronal gap on velopharyngeal nasendoscopy. Of these, 3 patients had prior prosthetic velopharyngeal management, including 2 patients with Robin sequence. All patients were evaluated preoperatively and 3 months postoperatively with recorded (audio-videotape) perceptual, nasendoscopic, and fluoroscopic standardized speech and airway evaluations. The tapes were used for construction of a randomized master tape that was presented in blinded fashion and random order to three skilled raters for independent assessment of numerous perceptual and instrumental parameters of speech. The raters were uninvolved in the care of the patients or this study, and their intraobserver and interobserver reliabilities were known. Preoperatively, the majority of patients had nasal turbulence. All patients had variable degrees of hypernasality ranging from intermittent to pervasive. Parameters rated included (1) resonance (hypernasality, hyponasality, mixed), (2) auditory nasal emission (including nasal turbulence), and (3) visual characteristics regarding velopharyngeal closure. The visual parameters consisted of questions about whether a pharyngeal bulge was present or absent, descriptions of posterior pharyngeal wall movements with speech, level of closure, completeness of velopharyngeal closure, and quantitative descriptions of the percentage of velopharyngeal closure postoperatively. Examiners were instructed to look for a static and/or dynamic projection or bulge (i.e., Passavant's ridge) and, if a bulge was present, whether the level of velopharyngeal closure was on the same plane as the neoposterior pharyngeal bulge. Results of the extramural judgments of these parameters showed that there was no statistically significant tendency for patients' speech to be rated as more normal after the augmentation procedure than before it. We conclude that (1) autogenous posterior pharyngeal wall augmentation does not result in speech improvement and (2) autogenous posterior pharyngeal wall augmentation does not impair the nasal airway.
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Affiliation(s)
- P D Witt
- Department of Plastic and Reconstructive Surgery, St. Louis Children's Hospital, MO, USA
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Abstract
This report describes postoperative airway compromise following sphincter pharyngoplasty (SP) for treatment of post-palatoplasty velopharyngeal dysfunction. A retrospective review of 58 SPs performed for post-palatoplasty velopharyngeal dysfunction, on 30 male, and 28 female patients, over a 5-year study period was undertaken at a tertiary referral academic institution (Washington University School of Medicine), at the St. Louis Children's Hospital, Cleft Palate and Craniofacial Deformities Institute. Eight patients were identified who had the following inclusion criteria: overt perioperative and/or postoperative airway dysfunction, identifiable syndromes, or microretrognathia. Items reviewed were patient demographic factors, associated medical problems, genetics evaluations, nasendoscopic characteristics of velopharyngeal closure, anesthetic evaluation of the patients, and the incidence and severity of perioperative complications. Particular attention was paid to factors contributing to the airway obstruction. Of the eight subjects with perioperative and/or postoperative upper airway dysfunction following SP, five patients had Pierre Robin sequence/micrognathia, while three patients had a history of perinatal respiratory and/or feeding difficulties without micrognathia or an identified genetic disorder. All but two episodes of airway dysfunction resolved within 3 days postoperatively. These patients were discharged home with apnea monitors; both were readmitted with recurrent airway dysfunction. Continuous positive airway pressure (CPAP) was utilized successfully in all instances, and no patients required take-down of the SP to relieve airway dysfunction. CPAP is an effective, noninvasive treatment strategy for management of iatrogenically induced apnea following SP, without sacrificing the surgical benefit of improved speech intelligibility.
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Affiliation(s)
- P D Witt
- Department of Surgery, Plastic and Reconstructive, Washington University School of Medicine, St. Louis, Missouri, USA
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Muntz HR. Allergic fungal sinusitis in children. Otolaryngol Clin North Am 1996; 29:185-22. [PMID: 8834281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Although allergic fungal sinusitis is rare in the pediatric population, it is an important part of the differential diagnosis of unilateral nasal masses. A brief historical review is offered. The evaluation is discussed, and treatment options are proposed.
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Affiliation(s)
- H R Muntz
- St. Louis Children's Hospital and Washington University School of Medicine, Missouri, USA
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44
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Affiliation(s)
- A L Woolley
- St Louis Children's Hospital, Washington University School of Medicine, MO 63110, USA
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Abstract
The purpose of this investigation was to evaluate the ability of palatal lift prostheses to stimulate the neuromuscular activity of the velopharynx. Nasendoscopic evaluations were audio-videotaped preprosthetic and postprosthetic management for 25 patients who underwent placement of a palatal lift prosthesis for velopharyngeal dysfunction (VPD). These audio-videotapes were presented in blinded fashion and random order to three speech pathologists experienced in assessment of patients with VPD. They rated the tapes on the following parameters: VP gap size, closure pattern, orifice estimate, direction and magnitude of change, and qualitative descriptions of the adequacy of VP closure during speech. VP closure for speech was unchanged in 69% of patients and the number of patients rated as improved or deteriorated was nearly identical at about 15%. Postintervention gap shape remained unchanged in 70% of patients. The extent of VP orifice closure during speech remained unchanged in 57% of patients. Articulations that could impair VP function improved in 30% of patients, deteriorating in only 4%. Results of this study neither support the concept that palatal lift prostheses alter the neuromuscular patterning of the velopharynx, nor provide objective documentation of the feasibility of prosthetic reduction for weaning.
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Affiliation(s)
- P D Witt
- Department of Surgery, Plastic and Reconstructive, Washington University School of Medicine, St. Louis, Missouri, USA
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Witt PD, Rozelle AA, Marsh JL, Marty-Grames L, Muntz HR, Gay WD, Pilgram TK. Do Palatal Lift Prostheses Stimulate Velopharyngeal Neuromuscular Activity? Cleft Palate Craniofac J 1995. [DOI: 10.1597/1545-1569(1995)032<0469:dplpsv>2.3.co;2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Abstract
This paper reports results of surgical management of failed sphincter pharyngoplasties that were performed for velopharyngeal dysfunction. Revisional surgery consisted of tightening of the sphincter pharyngoplasty port or reinsertion of sphincter pharyngoplasty flaps following dehiscence. We critique the anatomic abnormalities associated with unacceptable vocal resonance and nasal air escape following sphincter pharyngoplasty and analyze the effect of sphincter pharyngoplasty revision on ultimate speech outcome. The results of initial sphincter pharyngoplasty surgery were evaluated in 46 patients with velopharyngeal dysfunction. Nine (20 percent) of these patients were considered surgical failures because of persistent hypernasality and/or nasal turbulence on perceptual speech evaluation at least 3 months postoperatively. These patients underwent sphincter pharyngoplasty revision and form the basis of this report. All patients who failed sphincter pharyngoplasty initially underwent both preoperative and postoperative perceptual speech evaluations, lateral phonation radiographic studies with still reference views, and flexible nasendoscopic studies. Evaluations of upper airway status were conducted by the same experienced otolaryngologist. Following sphincter pharyngoplasty revision, 7 of 9 (78 percent) patients demonstrated resolution of velopharyngeal dysfunction, and to some degree, all patients managed with revision became hyponasal. The primary cause of failure was partial or complete flap dehiscence; a secondary cause was hypotonicity of the velopharyngeal mechanism. Failure was not correlated with the level of insertion of the pharyngoplasty flaps with respect to the point of attempted velopharyngeal contact. Sphincter pharyngoplasty is an effective means of management for velopharyngeal dysfunction in many patients. The objective of removing the stigmata of velopharyngeal dysfunction without causing upper airway obstruction may not be realistic in some patients with microretrognathia (i.e., Pierre Robin sequence), in whom anatomic constraints predispose to flap dehiscence. Problems with surgical technique contributing to failure appear to be related to experience of the surgeon, and improvement in outcome can be anticipated as the "learning curve" is overcome.
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Affiliation(s)
- P D Witt
- Division of Plastic Surgery, Cleft Palate and Craniofacial Deformities Institute of St. Louis Children's Hospital, Mo., USA
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49
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Abstract
Velopharyngeal dysfunction (VPD) resulting from an adynamic or hypodynamic velopharynx is an unusual pathology that poses vexing management problems for the Cleft Palate team. Correction of VPD has the potential for airway compromise. Endoscopically, this pathology is recognized by a large velopharyngeal (VP) gap size, which demonstrates little or no dynamic activity of the posterior or lateral pharyngeal walls nor of the velum in response to speech tasks or connected speech. Because of a paucity of literature defining the entity, a retrospective review of 175 patients who were treated for VPD at our center was undertaken. Analysis of management failures revealed an unexpected concentration of patients with hypodynamic or paretic VP mechanisms as documented by nasendoscopic assessments. A subpopulation of 41 (23%) patients with this characteristic was studied to define the patients at risk, to determine etiologic factors, and to critique intervention outcome among various surgical and nonsurgical managements. Results showed that the phenomenon of VP hypodynamism occurred more frequently in patients with submucous cleft palate (p = .014) and with VPD in association with malformation syndromes (p = .009) than in patients in other diagnostic categories. Conversely, VPD not associated with clefting occurred with greater frequency in the nonhypodynamic group than in the hypodynamic group (p = .002). Composite (surgical and prosthetic) primary management failure occurred in 42%. Between one and three procedures were necessary to achieve an acceptable speech result. We present a management algorithm and provide data regarding realistic expectations for various treatment outcomes in patients with this complex disorder, which have not, to date, been previously described.
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Affiliation(s)
- P D Witt
- Department of Surgery, Plastic and Reconstructive, St. Louis Children's Hospital, Washington University School of Medicine, MO 63110, USA
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Lusk RP, Muntz HR, Parsons DS. Pediatric Sinusitis—Medical and Surgical Management. Otolaryngol Head Neck Surg 1995. [DOI: 10.1016/s0194-5998(05)80282-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Educational objectives: To describe the etiology and underlying factors causing pediatric sinusitis and discuss the medical and surgical treatment options and to describe the technique used by the instructors to perform pediatric endoscopic sinus surgery.
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