Natural airway as an alternative to intubation for pediatric endoscopic esophageal foreign body removal: A retrospective cohort study of 326 patients

BACKGROUND

Anesthesia is required for endoscopic removal of esophageal foreign bodies (EFBs) in children. Historically, endotracheal intubation has been the de facto gold standard for airway management in these cases. However, as more elective endoscopic procedures are now performed under propofol sedation with natural airway, there has been a move toward using similar Monitored Anesthesia Care (MAC) for select patients who require endoscopic removal of an EFB.

METHODS

In this single-center retrospective cohort study, we compared endoscopic EFB removal with either MAC or endotracheal intubation. Descriptive statistics summarized factors stratified by initial choice of airway technique, including intra- and postanesthesia complications and the frequency of mid-procedure conversion to endotracheal intubation in those initially managed with MAC. To demonstrate the magnitude of associations between these factors and the anesthesiologist's choice of airway technique, univariable Firth logistic and quantile regressions were used to estimate odds ratios (95% CI) and beta coefficients (95% CI).

RESULTS

From the initial search, 326 patients were identified. Among them, 23% (n = 75) were planned for intubation and 77% (n = 251) were planned for MAC. Three patients (0.9%) who were initially planned for MAC required conversion to endotracheal intubation after induction. Two (0.6%) of these children were admitted to the hospital after the procedure and treated for ongoing airway reactivity. No patient experienced reflux of gastric contents to the mouth or dislodgement of the foreign body to the airway, and no patient required administration of vasoactive medications or cardiopulmonary resuscitation. Patients had higher odds that the anesthesiologist chose to utilize MAC if the foreign body was a coin (OR, 3.3; CI, 1.9-5.7, p < .001) or if their fasting time was >6 h. Median total operating time was 15 min greater in intubated patients (11 vs. 26 min, p < .001).

CONCLUSIONS

This study demonstrates that MAC may be considered for select pediatric patients undergoing endoscopic removal of EFB, especially those who have ingested coins, who do not have reactive airways, who have fasted for >6 h, and in whom the endoscopic procedure is expected to be short and uncomplicated. Prospective multi-site studies are needed to confirm these findings.

Maximal Mouth Opening in Infants: A Single-Group Prospective Cohort Study

BACKGROUND

Detection of mandibular range of motion variations in infants may allow for early diagnosis of pathologic conditions to the temporomandibular joint.

PURPOSE

The purpose of this study was to determine the normal ranges for maximal mouth opening (MMO) in healthy infants under 12 months of age.

STUDY DESIGN, SETTING, SAMPLE

A single-group prospective cohort study of consecutive patients below 12 months of age was conducted in an outpatient setting at the Florida Craniofacial Institute in Tampa, Florida. Patients were excluded if they had trismus, presented with signs of obstructive sleep apnea, suffered a facial fracture, or were diagnosed with a craniofacial syndrome.

PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE

Age (in months) at the time of presentation, measured as a continuous variable.

MAIN OUTCOME VARIABLE(S)

The main outcome variable was MMO. This was measured by placing a thumb and forefinger in the infant's mouth and applies slight pressure to encourage MMO. In older infants with erupted central incisors, MMO was measured from the gingival margins.

COVARIATES

The covariates were sex, race, and gestational age.

ANALYSES

Findings were presented as means with 95% confidence intervals. A multivariate linear regression analysis was conducted to evaluate changes in MMO with increasing age.

RESULTS

The sample was composed of 151 infants with a mean age of 5.2 months (95% confidence interval [CI] 4.8 to 5.6), and 33% were female. The mean MMO was 32.1 mm (95% CI 31.5 to 32.7). Results of the linear regression analysis showed MMO to significantly increase with increasing age, increasing at a mean rate of approximately 1 mm per month (coefficient 1.06, 95% CI 0.88 to 1.23, P < .001). In neonates <1 month of age, the mean MMO was 22.0 mm (95% CI 20.4 to 23.6), compared to a mean of 36.7 mm (95% CI 34.8 to 38.6) in infants 11 months of age.

CONCLUSIONS AND RELEVANCE

The results of this study provide normative data of the association of age with MMO, which may be of value in assessing for infants with jaw mobility disorders.

Overjet in Infants: A Cross-Sectional Study

OBJECTIVE

The purpose of this study was to determine the normal ranges for overjet in healthy infants under 12 months of age.

DESIGN

A cross sectional study of consecutive patients below 12 months of age.

SETTING

The study was conducted at a private practice in Tampa, FL that specializes in pediatric craniomaxillofacial disorders.

PATIENTS

All patients under the age 12 months were considered for entry into the study. Patients were excluded if they had temporomandibular joint pathology, sleep disordered breathing, facial trauma, or were diagnosed with a craniofacial anomaly.

INTERVENTIONS

Measures of overjet, defined as the distance between the anterior surfaces of the alveolar ridges when in centric relation, were obtained.

MAIN OUTCOME MEASURE

The primary study outcome was the overjet of the enrolled patients.

RESULTS

A total of 152 infants were included in this study. Of these, 51 were female, and 40 were born prematurely (ranging from 32-37 weeks of gestation). In neonates below 1 month of age, the mean overjet was 2.25 mm (95% CI 1.31-3.19). Multivariate linear regression analysis showed overjet to significantly decrease with age, at a mean rate of approximately 0.1 mm per month (coefficient of -0.09, 95% CI -1.61 to -0.02, p = 0.01). When controlling for potential confounders, average overjet was not shown to vary significantly between the sexes, with prematurity, with race, or with primary diagnosis at presentation.

CONCLUSION

This paper establishes normative values for overjet in infants below 12 months of age.

Endoscopic Assessment and Serial Balloon Dilatation in a Toddler With Dyskeratosis Congenita-Hoyeraal-Hreidarsson Syndrome Following Bone Marrow Transplant: A Case Report

We report a 3-year-old patient with suspected oropharyngeal graft-versus-host disease (GVHD) who developed progressive dysphagia to solids and liquids. The patient has a history of Dyskeratosis Congenita-Hoyeraal-Hreidarsson Syndrome with associated bone marrow failure requiring a nonmyeloablative matched sibling hematopoietic stem cell transplant. Esophagram revealed significant narrowing in the cricopharyngeal region. Subsequent esophagoscopy showed a proximal, high-grade pinhole esophageal stricture that was very difficult to visualize and cannulate. High-grade esophageal strictures are uncommon in very young children with GVHD. We believe the patient's underlying Dyskeratosis Congenita-Hoyeraal-Hreidarsson Syndrome in the setting of inflammatory changes seen in GVHD following hematopoietic stem cell transplant set the stage for a high-grade esophageal obstruction. The patient's symptoms improved with serial endoscopic balloon dilation.