Irradiated homologous costal cartilage grafts for single-stage open airway reconstruction in severe subglottic stenosis for children under the age of one

We present two cases of premature infants with Cotton-Myer grade 3 subglottic stenosis where endoscopic balloon dilation failed. In an attempt to avoid tracheostomy, both patients underwent open single stage anterior graft larnygotracheoplasty (LTP) with irradiated homologous rib and temporalis fascia grafts. After postoperative reconstruction, the airway was resized to grade 1 in one child, and to grade 2 in the other. One child remained free of stridor post-operatively and avoided the need of a tracheostomy tube. The other child ultimately required a tracheostomy, though she is now in the process of being decannulated. Homologous costal cartilage grafts in open anterior airway LTP may be a reasonable alternative to tracheostomy in young patients with advanced SGS.

The effect of tonsillectomy on the immune system: A systematic review and meta-analysis

IMPORTANCE

The immunological sequelae of tonsillectomy in children have been a source of debate among physicians and a continuous concern for parents. Contradictory pertinent results exist in the literature.

OBJECTIVE

To understand the real effect of tonsillectomy on the immune system.

DATA SOURCES

MEDLINE, EMBASE and COCHRANE.

STUDY SELECTION

Articles addressing the effect of tonsillectomy on the immune system, up to Dec 2014. Related keywords and medical subject headings were used during the search. The abstracts were reviewed to determine suitability for inclusion based on a set of criteria. Manual crosscheck of references was performed.

DATA EXTRACTION

We checked the tests results and the conclusion of each study to classify it as supporting or refuting the hypothesis of a negative effect of tonsillectomy on the immune system.

RESULTS

We reviewed 35 articles, published between 1971 and 2014, including 1997 patients. Only Four studies (11.4%), including 406 patients (20.3%) found that tonsillectomy negatively affects the immune system. We performed a separate meta-analysis on various reviewed humoral and cellular immunological parameters (e.g. total and specific serum Ig's, SecIgA, cellular immunity, and Ag specific Ig). There is more evidence to suggest that tonsillectomy has no negative clinical or immunological sequalae on the immune system. Study limitations included heterogeneity in the diagnostic tools, timing of testing, indication for tonsillectomy and patients' age.

CONCLUSION

It is reasonable to say that there is enough evidence to conclude that tonsillectomy has no clinically significant negative effect on the immune system. It will be important for future studies to uniformly use both preoperative and control laboratory tests' levels to compare the postoperative levels with, to have short and long term follow-up levels, and to include both humoral and cellular immunity in their measurements.

RELEVANCE

The results should reassure both surgeons and parents that tonsillectomy has no proven clinical sequalae. If more research is to be done in the future, it should be performed in a standardized way to avoid the heterogeneity seen in the literature.

New insights on age-related association between nasopharyngeal airway clearance and facial morphology

OBJECTIVES

To evaluate the relation between adenoid hypertrophy and facial morphology across age in a pediatric population.

SETTING AND SAMPLE POPULATION

The American University of Beirut Department of Otolaryngology. Two-hundred consecutive children (age 6.00 ± 2.62 years) referred from the Pediatric Otolaryngology unit to the Orthodontic division and requiring a lateral cephalogram for adenoid hypertrophy assessment.

METHODS

Cephalometric measurements included relations among cranial base, maxilla and mandible, and airway clearance measured from adenoid to soft palate (AD). The children were classified into two age groups, Group 1: ≤ 6 years (n = 124) and Group 2: ≥ 6.01 years (n = 76), and also stratified in four subgroups (A, B, C, D) based on maxillo-mandibular divergence (palatal to mandibular plane angle, PP-MP): A- PP-MP ≤ 27.5°, n = 34; B- 27.5° < PP-MP ≤ 32°, n = 68; C- 32°<PP/MP<36.5°, n = 67; D- PP-MP ≥ 36.5°, n = 31. Statistics included t-tests and anova for group differences.

RESULTS

  Differences between groups 1 and 2 were statistically significant (p < 0.05) for AD (Group 1: 3.19 ± 2.32 mm, Group 2: 4.78 ± 2.80 mm), ANB (5.38 ± 2.24°, 4.38 ± 2.54°), LFH (56.61 ± 1.95%, 55.38 ± 1.84%), PP-H (-8.41 ± 3.28°, -6.49 ± 3.46°), and overbite (0.55 ± 2.00 mm, 1.16 ± 2.36 mm). Among subgroups, statistically significant differences (p < 0.05) occurred mainly between the most hyperdivergent group (D) and the hypodivergent (A) and normodivergent (B) groups.

CONCLUSIONS

Airway measurements were smallest in children ≤ 6 years and those presenting severe hyperdivergent pattern, which denoted the most severe airway obstruction. The findings suggest airway clearance before age 6 in the most severely affected children, but follow-up research on actual adenoidectomies in younger children is needed to determine guidelines.