Management of paediatric sleep-disordered breathing

Paediatric sleep-disordered breathing is a common condition which varies in severity from snoring to obstructive sleep apnoea. Paediatric sleep-disordered breathing is usually diagnosed clinically, with investigations such as polysomnography reserved for more complex cases. Management can involve watching and waiting, medical or adjunct treatments and adenotonsillectomy. National working groups have sought to standardise the pathway for surgery and improve the management of surgical and anaesthetic complications. Current guidelines use age, weight and comorbidities to stratify risk for these surgical cases. This article summarises these recommendations and outlines the important factors that indicate cases that may be more suitable for management in secondary and tertiary units. Appropriate case selection will reduce pressure on tertiary units while maintaining training opportunities in district general hospitals.

The changing face of paediatric airway endoscopic surgery: An 8-year single surgeon review

INTRODUCTION

As a recently established division, we sought to reflect on the development of our paediatric airway surgery service, and prospectively examine the diagnoses that underwent microlaryngobronchoscopy (MLB) to help quantify the evolving population demographics of paediatric airway disorders.

MATERIAL AND METHODS

This was a prospective longitudinal study conducted of all paediatric MLBs performed by a single surgeon in a tertiary paediatric ENT centre between 2012 and 2019.

RESULTS

A total of 1040 MLBs were performed in 498 patients at the paediatric ENT centre of the Royal London Hospital. Median age at first procedure was 19 months. Median follow-up was 48 months. Primary diagnoses were laryngomalacia (21%), subglottic stenosis (SGS - 18%), laryngeal cleft (13%), and normal anatomy (28.3%). Repeat procedures were needed in 39.1% patients, who underwent a median of 2 repeat procedures. SGS (57.7%) constituted majority of the repeat category, followed by laryngeal cleft (12.36%), laryngomalacia (10.15%), unilateral/bilateral vocal cord palsy(4.24%) and laryngeal papilloma(4.24%). Laryngeal papilloma constituted largest number of procedures per patient (Median = 4, IQR = 5.75), followed by subglottic web and SGS. Mean length of stay(LOS) was 0.67 ± 0.96 days(d), with laryngeal cleft cases recording longest mean LOS. There was a steady increase in proportion of day-surgeries across study period [6.9% (2012) vs 59%(2019)].

CONCLUSION

SGS constitutes the major bulk of paediatric airway surgery, reflective of increasing number of premature births and prolonged intubation among neonates. Day-case MLB is a safe and feasible option in selected patients. This long-term data provides useful information to accurately prognosticate patients regarding potential number of repeat procedures for each diagnosis.

The role of antibiotics in the surgical management of paediatric obstructive sleep apnoea (OSA): a cohort study

PURPOSE

Obstructive sleep apnoea (OSA) describes an irregular night-time breathing pattern that is present in approximately 1.8% of children and can have a negative impact on quality of life. The use of antibiotics postoperatively is controversial. They are commonly prescribed; however, they can also be associated with side effects and resistance. This study explores the role of antibiotics in the post-operative management of children with OSA in a cohort of children.

METHODS

We conducted a retrospective cohort study of children undergoing surgery for OSA or sleep disordered breathing (SDB) at a tertiary paediatric ENT referral centre from November 2018 to November 2019.

RESULTS

This study identified 382 children who had undergone surgical treatment for OSA or sleep disordered breathing (SDB); 319 underwent adenotonsillectomy, 53 adenoidectomy and 10 tonsillectomies. Antibiotics were given post-operatively to 158 (41%) patients and 18 (11%) of these patients presented to hospital with post-operative complications. A higher number of patients re-presented to hospital from the group who did not receive antibiotics (p = 0.982). Bleeding (p = 0.886) and infection (p = 0.823) were also more common in those children who did not receive antibiotics.

CONCLUSION

Antibiotics led to fewer complications and re-presentations to hospital in children undergoing operative management of OSA; however, this trend was not found to be statistically significant.

Prematurity and associated future paediatric airway pathology: experience from a single tertiary paediatric ENT centre

PURPOSE

Enhanced management of the pre-term patient has resulted in improved survival rates in increasingly premature patients. Although prematurity predisposes to congenital airway pathology, there is also increased risk of endotracheal intubation, and therefore acquired subglottic pathology. We sought to evaluate airway pathology in children outside the neonatal period with a history of prematurity to explore the relationship between prematurity and upper airway pathologies.

METHODS

Data for patients undergoing elective microlaryngobronchoscopy (MLB) at our centre were collected prospectively over a 5-year period. Patients identified as premature were sub-classified by the grade of prematurity.

RESULTS

339 patients over 1 month of age underwent MLB, of which 56 (16.5%) were born prematurely. Of those with identified airway pathology, 49 (23.4%) were born prematurely, accounting for 32.6% of subglottic stenosis (n = 30), 24% of laryngomalacia (n = 13) and 19% of laryngeal cleft diagnoses (n = 16). 49 premature patients (87.5%) had one or more airway pathologies diagnosed. Multi-level airway pathology was seen in twelve premature infants (21.4%), demonstrating a statistically significant association (odds ratio 3.396; 95% CI 1.697-6.842; p value < 0.0016). Incidence of airway pathology, the severity of airway disease and multi-level airway pathology were not related to the grade of prematurity.

CONCLUSIONS

Premature patients account for a significant proportion of the workload within our tertiary centre due to improving neonatal care and survival in pre-term infants. We suggest early paediatric ENT evaluation for ex-premature patients with symptoms of airway pathology, with a low threshold for MLB. Improving neonatal survival rates in ever-increasing prematurity will require the further provision of specialist paediatric ENT services to manage their ongoing care.

Paediatric aneurysmal bone cyst: not as easy as ABC

Aneurysmal bone cysts (ABCs) are expansile cystic lesions that can affect any bone of the body. Whilst these lesions are histologically benign, the lesions are locally aggressive and can affect the integrity of the affected bone as well as surrounding structures. ABCs arising in the head and neck region, particularly the paranasal sinuses are rare and they are limited to case reports in the literature. Due to the proximity of critical anatomical structures and the visual apparatus, the potential complications can be devastating. The present article discusses both the clinical and radiological findings of an ABC arising from the ethmoid sinuses in a 6-year-old child and the potentially challenging diagnosis with its complex ensuing surgical management. The identification of an ABC arising in the paranasal sinuses is both a diagnostic and surgical challenge and ideally requires complex management in a joint paediatric ENT and craniofacial unit.

Day case paediatric microlaryngobronchosocopy: A prospective study

AIM

To assess the feasibility and parental acceptance of diagnostic microlaryngobronchoscopy (MLB) as day case surgery.

METHODS

A prospective study was performed over a 26 mo period at a tertiary paediatric ENT centre. Patients were selected in clinic using set criteria. All MLBs were performed using a standardised anaesthetic protocol and patients monitored post-operatively. Six weeks following surgery, parents underwent questionnaire surveys.

RESULTS

Ninety-four out of 101 MLBs was successfully performed as day case surgery over the set period. Seven patients required an overnight stay for further observation. Fifty-seven parents took part in the questionnaire of which 68.4% were highly satisfied with same day discharge.

CONCLUSION

MLB is feasible, safe and acceptable as day case surgery in carefully selected patients.

Paediatric subglottic stenosis - Have things changed? Our experience from a developing tertiary referral centre

BACKGROUND

Paediatric airway disorders are common, particularly in the context of improved ventilation methods for neonates in intensive care units. Management is not standardised.

OBJECTIVES

To assess the number, severity, management and outcomes of all patients diagnosed with subglottic stenosis at a developing tertiary referral centre.

STUDY DESIGN

19 month prospective longitudinal study.

STUDY POPULATION

All patients who underwent microlaryngobronchoscopy (MLB) were included. Subglottic stenosis (SGS) was graded intraoperatively using the Myer-Cotton classification.

RESULTS

102 patients underwent MLB during this period. 33 of 102 patients (32.4%) were diagnosed with SGS+/-other co-pathologies. Mean and median age at diagnostic procedure were 24.7 months (SD 23.5) and 18 months, respectively. At their first MLB, 22 of 33 patients (66.7%) were found to have a Grade 1 SGS, 7 of 33 (21.2%) were Grade 2 and the remaining 4 of 33 (12.1%) were Grade 3. We had no patients with Grade 4 SGS. During this period, these patients with SGS underwent 73 MLBs+/-interventions (2.21 per patient) such as incision and balloon dilatation, tracheostomy (2 of 33) or ultimately, laryngotracheal reconstruction (LTR) (2 of 33). A further 3 patients have since undergone LTR. No significant unexpected events occurred.

CONCLUSIONS

These findings suggest that subglottic stenosis may be evolving in terms of its presentation and management. Management can more often be endoscopic and perhaps avoid tracheostomy or laryngotracheal reconstruction. Further long term prospective studies are required.

Diagnosis and management of laryngeal cleft: A single centre experience and a novel endoscopic technique

AIM: To examine the presentation, diagnosis and outcomes of patients with laryngeal cleft.

METHODS: An 18 mo (from mid-2012 to 2013) prospective longitudinal study was performed at the Barts Children’s and Royal London Hospital, a tertiary referral centre. Chart review was performed for all patients including data extraction of demographics, outpatient clinic review documentation, speech therapy findings, medication list, operative findings alongside technique and follow up. A systematic review of contemporary English medical literature was also reviewed to compare series. The study was approved and registered by the hospital clinical governance and audit board. Biostatistician review was not required.

RESULTS: Twenty-two children aged 1 to 72 mo (mean age 23.5 mo) with a 7:4 male-female ratio. Twenty had Benjamin-Evans type 1 clefts and 2 had a type 2 cleft. All were symptomatic despite medical management including anti-reflux therapy. Patients presented with dyspnoea (81%), feeding difficulty (63%), stridor (54%) and recurrent pneumonia (36%). Several patients had concomitant aerodigestive abnormalities including 7 with laryngomalacia, 4 subglottic stenosis, 2 subglottic webs and 1 tracheo-oesophageal fistula. To date, 18 patients have undergone endoscopic repair, all of whom have shown radiological and/or clinical signs of improvement. All endoscopic repairs were performed with the novel use of a Negus knot pusher, with Baby Benjamin rigid suspension, to more reliably and easily suture at depth.

CONCLUSION: This is a significant single unit series demonstrating the strong association of laryngeal cleft with combined aerodigestive symptoms and other laryngeal abnormalities. Endoscopic management of type 1 and 2 laryngeal clefts is successful. We recommend the use of a Negus knot pusher to facilitate endoscopic repair.

Conservative management of bilateral choanal atresia? Bilateral choanal atresia diagnosed in a 5-year-old girl

Choanal atresia (CA) is an obliteration or blockage of the posterior nasal aperture, limiting or obstructing the nasal airway to the nasopharynx. The presentation of unilateral CA commonly occurs at a later age than those children affected by bilateral CA (BCA) and can often persist undiagnosed into adulthood. BCA, on the other hand, typically presents with respiratory obstruction within the first few days of life, or desaturations with or without cyanosis when feeding or during exertion and traditional teaching is that this is a life-threatening emergency. We present the case of a 5-year-old girl referred to our department with nasal obstruction, snoring and some mild rhinorrhoea. After investigation she was found to have a mixed bony and membranous BCA and no other craniofacial abnormalities. The BCA was subsequently repaired using urethral dilators and a drill and the child is currently asymptomatic of any restenosis. This case prompts discussion of the various presentations and options in management of CA as well as allowing us an opportunity to discuss the literature on the subject.

Paediatric adenotonsillectomy as a daycase for obstructive sleep apnoea: how we do it in a tertiary unit

BACKGROUND

Paediatric adenotonsillectomy is a common ENT operation. Daycase surgery for uncomplicated, elective procedures is encouraged in order to improve efficiency in healthcare. For patients with obstructive sleep apnoea (OSA), most units advocate an overnight stay for adenotonsillectomy, a procedure usually performed as a daycase in other contexts.

METHODS

A retrospective casenote review was carried out from 1st December 2011 to 1st December 2012 for all children undergoing daycase adenotonsillectomy for treatment of OSA at Bart's Children's and the Royal London Hospital.

RESULTS

250 children underwent adenotonsillectomies for OSA as daycase procedures over twelve months. 6% had immediate, unplanned overnight admissions. 3% were readmitted within 30 days. No patients readmitted required surgical intervention.

CONCLUSION

For an appropriately selected child, adenotonsillectomy can be safely performed as a daycase procedure in a tertiary centre.

Severe obstructive sleep apnoea due to adenotonsillar hypertrophy after liver transplantation

Epstein-Barr virus-related adenotonsillar hypertrophy is a precursor to post-transplantation lymphoproliferative disorder. We report a case of a 4-year-old child with severe obstructive sleep apnoea, who had liver transplantation at the age of 7 months. She had gross lymphoid hypertrophy in the oropharynx and supraglottis. We performed an adenotonsillectomy and aryepiglottoplasty which improved her symptoms. We emphasise the importance to consider the diagnosis of post-transplantation lymphoproliferative disorder in post-transplantation immunosuppressed patients who present with adenotonsillar hypertrophy.

Intraoperative Hyperkalemia: Death in Renal Parathyroidectomy

Objective: Recognize potential life-threatening complications of intraoperative hyperkalemia during parathyroid surgery to control secondary hyperparathyroidism in renal patients. We present a case of a 20-year-old renal patient who died from VF arrest intraoperatively during elective surgery for secondary hyperparathyroidism. Understand the importance of intraoperative potassium monitoring.

Method: Prospective analysis of intraoperative monitoring of potassium levels in patients with CRF undergoing total parathyroidectomy from April 2006 to July 2009 at Hull Royal Infirmary (UK). All patients had postdialysis preoperative potassium levels checked, at least 2 intraoperative levels, and 1 postoperative level.

Results: Twenty-nine patients underwent total parathyroidectomy. A total of 17 out of 29 had intraoperative potassium rises, 55% (95% CI 38-71%) had intraoperative potassium rise above the normal limit (5.3 mM). Six patients (21% (95% CI 10-38%)) required intraoperative treatment with dextrose-insulin infusion. Active intervention was taken for patients who had rises greater than 0.5 mM or active ECG changes. Four patients had increasing potassium levels despite treatment indicating that without treatment these could potentially have been very high. Comparative results of postinduction and first intraoperative potassium levels were a good indicator of potassium rise later and the need for treatment ( P = .003).

Conclusion: Hyperkalemia is a recognized complication within the first 24 hours postparathyroidectomy; however, it can occur more commonly intraoperatively in renal patients with potential devastating effects. Our unfortunate mortality complication has led us to change practice and we advocate active intraoperative monitoring and treatment to prevent such complications.

Surgical site infections in paediatric otolaryngology operative procedures

OBJECTIVE

An assessment of the rate of surgical site infections associated with elective paediatric otolaryngology surgical procedures.

METHODS

Prospective data was collected for a 3-week period for all children undergoing surgery where either mucosa or skin was breached. The parents of the children were requested to complete a questionnaire at 30 days after the operation.

RESULTS

Data was collected on 80 consecutive cases. The majority of cases were admitted on the day of the procedure. The procedures included adenotonsillectomy (24), grommets (12), cochlear implantation (6), bone-anchored hearing aid (2), submandibular gland excision (1), branchial sinus excision (1), cystic hygroma excision (3), nasal glioma excision (1), microlaryngobronchoscopy (13), tracheostomy (3) and other procedures (14). Nearly half the cases had more than one operation done at the same time. 26/80 (32.5%) patients had a temporary or permanent implant inserted at the time of operation (grommet, bone-anchored hearing aid, cochlear implant). 25/80 (31%) operative fields were classed as clean and 55/80 (68.7%) as clean contaminated operations. The duration of the operation varied from 6 min to 142 min. Hospital antibiotic protocol was adhered to in 69/80 (86.3%) cases but not in 11/80 cases. In our series, 3/80 (3.7%) patients had an infection in the postoperative period.

CONCLUSIONS

Surgical site infections do occur at an appreciable rate in paediatric otolaryngology. With the potential for serious consequences, reduction in the risk of surgical site infections is important.

Peri-operative complications after adenotonsillectomy in a UK pediatric tertiary referral centre

OBJECTIVES

Adenoidectomy and/or tonsillectomy are commonly performed in tertiary pediatric hospitals for the management of obstructive sleep apnea, often in children with significant comorbidities. This study examines the peri-operative course of a large series of complex patients undergoing such surgery at a major pediatric centre, reporting particularly cases of respiratory compromise requiring intensive care admission, both electively and unplanned.

METHODS

This study was conducted by the pediatric ENT department at Great Ormond Street Hospital. All children undergoing adenoidectomy and/or tonsillectomy from July 2003 to December 2010 were included in this study. This involved a retrospective review of the case notes and hospital databases, with particular emphasis on those children requiring admission to the pediatric intensive care unit.

RESULTS

A total of 1735 consecutive admissions for adenoidectomy and/or tonsillectomy (1627 individual patients aged 4-197 months, median 46 months) were included between 2003 and 2010 (998 adenotonsillectomies, 182 tonsillectomies and 555 adenoidectomies). In this group, 999/1627 patients (61.4%) had a diagnosis of sleep disordered breathing or sleep apnea, including 258 who had polysomnography. 407/1627 (25.0%) had no specific comorbidities which were felt likely to influence their surgical outcome. Established high risk factors included age less than 24 months (292), Down syndrome (99), neuromuscular problems (314), craniofacial abnormalities (94), storage diseases (23), morbid obesity (20), cardiovascular disease (133), respiratory disease (261), hemoglobinopathy (76) and coagulophathy (34). 300/1735 admissions were day cases and 1082/1735 were observed for one night. 353/1735 required more than one night in hospital (294 for two to three nights). 7/1735 had primary hemorrhage necessitating return to the operating room, all after tonsillectomy. 41/1735 (38 with major comorbidities) required peri-operative intensive care admission, mostly for respiratory support. Of these, 7 were admitted pre-operatively to intensive care, and 17 were planned post-operative transfers. Only 17/1735 required unanticipated post-operative admission to intensive care. Odds ratio analysis suggested a significantly higher chance of PICU admission in children with particular comorbidities (Down Syndrome, cardiac disease, obesity, cerebral palsy, craniofacial anomalies, mucopolysaccharidoses and hemoglobinopathy) when compared to children without comorbidities. Adenotonsillectomy was associated with a higher risk of PICU admission than adenoidectomy alone, but patient age less than 24 months was not associated with significantly higher rates of PICU admission. There were no peri-operative mortalities in this cohort.

CONCLUSIONS

The peri-operative course was largely uneventful for the majority of children undergoing surgery during this period, particularly given the high prevalence of sleep apnea and other risk factors in this cohort. Major complications were uncommon, with 2.4% of these selected, typically high risk cases requiring peri-operative intensive care admission. Importantly, only 1% of all admissions required unanticipated transfer to intensive care. This has informed changes in peri-operative management in this unit, with implications for other pediatric tertiary referral centres.

The successful use of the nasopharyngeal airway in Pierre Robin sequence: an 11-year experience

INTRODUCTION

Pierre Robin sequence (PRS) is a congenital anomaly presenting with micrognathia, glossoptosis and a cleft palate. This study describes a decade's experience of the management of upper airway obstruction (UAO) in PRS patients with a nasopharyngeal airway (NPA).

METHODS

This study was conducted by paediatric respiratory and otolaryngology departments. Children with PRS referred with UAO were evaluated according to a standard protocol. Data collected included the degree of airway obstruction, method of airway management, polysomnography data before and after intervention, and longer term follow-up.

RESULTS

Data were collected on 104 PRS patients referred to us for airway assessment in 2000-2010. 64/104 were aged <4 weeks at referral. Airway symptoms were managed conservatively in 27 patients (25.9%), with an NPA in 63 (60.6%) and a tracheostomy in 14 (13.4%). The average duration of NPA use was 8 months (3 weeks to 27 months). Polysomnography results improved in all 63 patients with an NPA. Fourteen severely obstructed patients underwent a tracheostomy. 86.5% (90/104) of PRS patients were managed conservatively or with the help of an NPA. There were no NPA related complications.

CONCLUSION

There is a spectrum of UAO in PRS. This study reports on long-term outcomes in 104 children with PRS and airway obstruction. In most children (86.5%), airway obstruction was managed by conservative measures or with an NPA for a few months. The natural history shows that with normal growth, airway compromise resolves without immediate surgical intervention as advocated by some practitioners. Few PRS children require a tracheostomy.

Laryngotracheal reconstruction and cricotracheal resection in children: recent experience at Great Ormond Street Hospital

BACKGROUND

Surgery for paediatric airway stenosis is constantly evolving. Surgery is the primary treatment modality via either an open or endoscopic approach. The objective of this study was to review the results of laryngotracheal reconstruction (LTR) and cricotracheal resection (CTR) procedures performed at Great Ormond Street Hospital over the past 10 years.

METHODS

All patients who underwent open airway reconstruction surgery from January 2000 to December 2010 were included in this study. Patients treated entirely endoscopically were excluded. The data was collected using the electronic operating theatre database and the discharge summary database.

RESULTS

Complete data was available for 199 patients who underwent open airway reconstruction from January 2000 to December 2010. The procedures included single stage LTR (57, 28.6%), two stage LTR (115, 57.7%), single-stage stomal reconstruction (14), single-stage CTR (8) and two-stage CTR (5). The diagnoses at the initial airway endoscopy were laryngeal web (22), subglottic stenosis (151), posterior glottic stenosis (9), suprastomal collapse (15), supraglottic stenosis (1) and tracheal stenosis (1). For those with subglottic stenosis, the stenosis was grade 1 in 1 patient, grade 2 in 26 patients, grade 3 in 117 patients and grade 4 in 6 patients. At the completion of intervention 175/199 (87.9%) patients reported improvement in their symptoms. Amongst the subglottic stenosis group, post LTR success was achieved in 100% with grade 1 stenosis, 92.3% with grade 2 stenosis, 88.1% in grade 3 stenosis and 83.3% in grade 4 stenosis. Of the two-stage LTR procedures, 100/115 (86.9%) had their tracheostomy removed and 15/115 (13.1%) have failed decannulation. Of the single-stage LTR group, 50/57 (87.7%) patients were better both on airway examination and symptomatically postoperatively. Of the single-stage stomal reconstruction group, 13/14 (92.8%) were better symptomatically and on airway examination. Patients who underwent single-stage CTR had a better airway on examination and were symptomatically improved in all cases (8/8). For the patients who underwent two stage CTR, the tracheostomy was removed in 3/5 (60%) and retained in 2/5 (40%). For the whole group, 15/199 (7.5%) patients underwent a revision LTR. On further analysis, revision LTR was required in 4/57 (7.1%) single-stage LTR, 9/115 (7.8%) two-stage LTR, 1/5 (20%) two-stage CTR and 1/8 (12.5%) single-stage CTR. In this study complications occurred in 13/199 (6.5%).

CONCLUSIONS

Subglottic stenosis in children needs to be approached on the basis of the nature and severity of stenosis and the individual patient's general health. Good outcomes are achieved with both LTR and CTR. Good results are obtained both with single-stage and two-stage LTR, but restenosis remains a problem. An individual approach is required for treatment of paediatric airway stenosis to achieve good final outcomes. The overall success rate has increased only marginally in our institution over the last 20 years.

Surgical aspects of cochlear implantation in syndromic children

OBJECTIVE

The objective of this study was to report surgical results and outcomes of cochlear implantation in a large series of children with syndromes from one centre.

PATIENTS AND METHODS

All syndromic children who underwent cochlear implantation at Great Ormond Street Hospital, from January 2000 to December 2010 were included in this study. The surgical technique was analysed and audiological outcomes were collected.

RESULTS

Over the 10-year period of this study, a total of 88 cochleas in 67 children with syndromes were implanted. The common syndromes implanted in this study were Ushers syndrome (23 patients, 33 cochleas), Wardenburgs syndrome (8 patients, 9 cochleas), Pendreds syndrome (4 patients, 4 cochleas), Jervell-Lange-Neilsen syndrome (3 patients, 4 cochleas), Enlarged vestibular aqueduct syndrome (4 patients, 7 cochleas), Cogans syndrome (3 patients, 4 cochleas), CHARGE (5 patients, 6 cochleas), and Branchio Oto Renal syndrome (3 patients, 4 cochleas). Pre-operative radiological inner ear anatomy was found to be abnormal in 28.4% (25/88) cochleas in this study group. Full insertion of the electrode was achieved in 93.1% (82/88) of cochleas, partial insertion in three cochleas, and insertion was abandoned in three cochleas. Early complications were seen in 6.8% (6/88) of implantations. All the 64/67 children who were implanted are still using the implant.

CONCLUSION

Cochlear implantation in syndromic children is challenging in both its audiological and surgical aspects. Good surgical results and good audiological and speech outcomes were achieved in this study, and subjective improvement in quality of life was achieved in these patients.

Branchial anomalies in children

BACKGROUND

Branchial cleft anomalies are the second most common head and neck congenital lesions seen in children. Amongst the branchial cleft malformations, second cleft lesions account for 95% of the branchial anomalies. This article analyzes all the cases of branchial cleft anomalies operated on at Great Ormond Street Hospital over the past 10 years.

METHODS

All children who underwent surgery for branchial cleft sinus or fistula from January 2000 to December 2010 were included in this study.

RESULTS

In this series, we had 80 patients (38 female and 42 male). The age at the time of operation varied from 1 year to 14 years. Amongst this group, 15 patients had first branchial cleft anomaly, 62 had second branchial cleft anomaly and 3 had fourth branchial pouch anomaly. All the first cleft cases were operated on by a superficial parotidectomy approach with facial nerve identification. Complete excision was achieved in all these first cleft cases. In this series of first cleft anomalies, we had one complication (temporary marginal mandibular nerve weakness. In the 62 children with second branchial cleft anomalies, 50 were unilateral and 12 were bilateral. In the vast majority, the tract extended through the carotid bifurcation and extended up to pharyngeal constrictor muscles. Majority of these cases were operated on through an elliptical incision around the external opening. Complete excision was achieved in all second cleft cases except one who required a repeat excision. In this subgroup, we had two complications one patient developed a seroma and one had incomplete excision. The three patients with fourth pouch anomaly were treated with endoscopic assisted monopolar diathermy to the sinus opening with good outcome.

CONCLUSION

Branchial anomalies are relatively common in children. There are three distinct types, first cleft, second cleft and fourth pouch anomaly. Correct diagnosis is essential to avoid inadequate surgery and multiple procedures. The surgical approach needs to be tailored to the type of anomaly of origin of the anomaly. Complete excision is essential for good outcomes.

Single stage laryngotracheal reconstruction using endoscopic posterior grafting in isolated posterior glottic stenosis in children - how we do it

OBJECTIVE

Posterior glottic stenosis is a well recognised though rare condition. A wide range of treatment options have been proposed including endoscopic laser techniques and open techniques with grafting. The objective of this study was to present our experience of single stage laryngotracheal reconstruction with endoscopic technique of placement of posterior graft in isolated posterior glottic stenosis.

METHODS

This study was conducted at the Department of Paediatric Otolaryngology at Great Ormond Street Hospital, London. The senior authors (ALT, DMA) were involved in the management of two children with isolated posterior glottic stenosis operated on as single stage reconstruction.

RESULTS

The two children in this small series had isolated posterior glottic stenosis. The aetiology in both the cases was previous prolonged intubation. Both patients underwent a successful placement of the posterior graft endoscopically, though it was a challenging task because of space constraints. None of these children required an intra-operative or post-operative tracheostomy. There were no complications in these patients. At follow up endoscopic examinations, both these patients have had their airway widened successfully.

CONCLUSION

Single stage laryngotracheal reconstruction with endoscopic placement of posterior graft in cases with isolated posterior glottic stenosis is a good alternative to open surgical techniques, although is technically a challenging procedure.

Surgical excision as primary treatment modality for extensive cervicofacial lymphatic malformations in children

OBJECTIVE

There has been much recent focus on sclerotherapy treatment of lymphatic malformations with OK432. Surgical treatment however can have a number of advantages, including complete curative excision. The aim of this study was to evaluate the results of surgical excision as the primary (first) treatment for this condition. This group includes a number of children with very extensive disease as well as some with smaller lesions.

METHODS

Prospectively collected database with additional information from medical records of children with cervicofacial lymphangiomas treated over 10 years at a tertiary paediatric referral centre. For this study only children who underwent surgical excision as the primary treatment modality were included.

RESULTS

Total of 118 children with lymphatic malformations were treated under the care of the senior author over a 10 year period. Of these 53 patients, who underwent surgical excision as the primary treatment modality for cervicofacial lymphatic malformations were included in this study. Forty-one patients who underwent sclerotherapy as the initial treatment were excluded. Also excluded were 6 patients who underwent thoracic surgery and 18 who were treated conservatively. The majority of the patients (41, 77.3%) underwent only a single surgical procedure (36 - surgical excision, 5 - laser excision). At the first follow up after the primary surgery, the result was complete resolution of symptoms in 29 patients, near complete resolution in 13 patients (together 79.3%) and partial response in 11 (19.7%) patients. Twenty-three patients with disease localised only to the neck, all (100%) had a complete or near complete resolution of the disease after the primary surgery. Complete/near complete response was achieved in 98% cases with macrocystic disease, regardless of the location. Minor complications occurred in 11.3% patients. No permanent nerve weaknesses occurred.

CONCLUSION

Cervicofacial lymphatic malformations in children should be managed in a multidisciplinary setting. Surgery remains a very important treatment modality. The majority of patients (80%) in this study had complete or near complete resolution with one surgical procedure. Isolated neck lesions have the best outcomes (100% resolution in this study). Patients with macrocystic disease, achieved complete or near complete resolution in 97% of cases, regardless of the location. Some children with extensive disease will need multiple treatments. Surgical excision as the primary treatment modality in selected cases is safe and reliable technique and has good aesthetic and functional outcomes in experienced hands.

A discussion of airway and respiratory complications along with general considerations in obese patients

Obesity is defined as the degree of excess weight associated with adverse health consequences. Within Great Britain, it is reported that a quarter of men and women are obese; these rates have trebled over the past 20 years. In 2001, it was estimated that obesity cost the National Health Service at least half a billion pounds, with a further two billion pounds lost on lower productivity and lost output. Obesity poses a significant risk factor for diseases, such as coronary heart disease, diabetes mellitus and certain forms of cancer, amongst others. Obese individuals pose significant problems to the clinician because of airway and respiratory complications. Sleep apnoea, obesity-hypoventilation syndrome, pulmonary atelectasis are associated with obesity and tracheostomy insertion is made all the more difficult in these patients. This article aims to discuss some of these issues relevant to the clinician and examine present strategies for dealing with them.

Otosclerosis 3: the surgical management of otosclerosis

The surgical management for otosclerosis has evolved from stapes mobilisation to total extraction of the footplate, the so called 'stapedectomy', to a small hole in the stapes footplate, the 'stapedotomy'. The aim of stapes surgery is to restore the vibration of fluids within the cochlear canal. Revision stapedectomy should be approached with caution. Stapedectomy can lead to some minor and other more serious complications.

Otosclerosis 2: the medical management of otosclerosis

The rationale for medical therapy for otospongiosis is to slow down and eventually stop the phase of bone resorption. There is some increase in the incidence of stapedial otospongiosis in a low-fluoride area compared with a high-fluoride area. Sodium fluoride treatment has a role to play in preventing the onset and progression of hearing loss in patients suffering from otosclerosis. Sodium fluoride therapy has been shown to have some beneficial effect on dizziness associated with otosclerosis. In view of the possibility of systemic side effects of sodium fluoride therapy, a regular follow up of patients is warranted. Biphosphonates can be used as an alternative treatment to sodium fluoride in cases where the patient is intolerant to sodium fluoride therapy. Hearing aid is also a treatment option, but it does not halt the disease process.

Diode laser for paediatric airway procedures: a useful tool

OBJECTIVE

A wide range of lasers have been used in the larynx. Diode laser is a portable and relatively inexpensive laser which is delivered via a glass fibre hand-held probe. The objective of this study was to report our experience with the use of diode laser in a variety of paediatric airway pathologies.

METHODS

In this study, 90 diode laser laryngeal procedures were performed on 31 patients in the age range of 1 month to 16 years at the time of the operation. The follow up after the procedure has been in the range of 6 months to 3 years.

RESULTS

As per our records 19/31 (61.3%) patients have been cured of their initial pathologies and were not under further review, 3/31 (9.6%) were having repeated laser treatments. The remaining 9/31 (29.0%) had to undergo further treatment. There was no laser-related intra-operative or postoperative complications.

CONCLUSIONS

Diode laser is a good tool for several paediatric laryngeal pathologies. The ability to guide the laser light using the flexible glass fibre directly onto the area requiring vapourisation enables very precise treatment.

Otosclerosis 1: the aetiopathogenesis of otosclerosis

Otosclerosis is a bone dystrophy localised to the inner ear and the stapes footplate. Otosclerosis is a frequent cause of deafness in adults. The patient with otosclerosis typically presents with a history of slowly progressive conductive or mixed hearing loss that is usually bilateral and often asymmetric, usually between the ages of 15 and 45 years. The disease is characterised by alternating phases of bone resorption and formation. The majority of studies on families with otosclerosis suggest an autosomal dominant mode of inheritance with incomplete penetrance.

Is nasal packing really required after septoplasty?

OBJECTIVE

Septoplasty is one of the most common operations performed by otorhinolaryngologists. Nasal packing is not an innocuous procedure. The most common problem encountered by the patients after septoplasty is the pain and discomfort during removal of the nasal packs. The objective of this study was to evaluate the results of septoplasty without postoperative nasal packing.

METHODS

Septoplasty was performed by standard technique. No nasal packing was used in these cases.

RESULTS

Seventy-eight patients were included in the study. The majority of the patients (64.1%; 50/78) on a morning list were operated. Sixty-two patients were discharged home the same day, the remaining others were discharged the next day. Our postoperative haemorrhage rate was 7.7% (6/78) and only 3.8% (3/78) patients required nasal packing. Majority (84.6%) of the patients were satisfied with the operation at the postoperative follow up 3 months later.

CONCLUSIONS

Septoplasty can be safely performed without postoperative nasal packing. Only 3.8% patients required nasal packing in this study.

The management of general and disease specific ENT problems in children with Epidermolysis Bullosa--a retrospective case note review

OBJECTIVE

Epidermolysis Bullosa encompasses a group of inherited disorders characterized by excessive susceptibility of the skin and mucosa to separate from underlying tissues following mechanical trauma. Information in the literature and guidance on the management of Ear, Nose and Throat problems in such children is scarce. The aim of this study is to report the experience of an Ear, Nose and Throat department in a tertiary paediatric hospital linked to a national Epidermolysis Bullosa unit, describing how children have presented and the care that has been given including a theatre protocol aimed at reducing shearing forces.

METHODS

Retrospective case note review of Epidermolysis Bullosa patients referred to Otolaryngology over an 8-year period.

RESULTS

Reviewing notes of 307 EB patients identified 15 that had been referred to the ENT department. Four children with middle ear effusions were effectively treated by watchful waiting or grommets. Three children with otitis externa had some relief from careful microsuction but reinfection from ulcers on other parts of the children's bodies tended to occur. One child with profound sensorineural hearing loss benefited from cochlear implantation but later passed away from unrelated sepsis. One child with intrinsic rhinitis was treated with steroid and then a salt-water nasal spray. Five children had nasal crusting documented, although this was not a specific reason for referral. When severe this had been treated with topical steroids by the dermatology team. One patient with obstructive sleep aponea had tonsillectomy and examination of the post-nasal space. Of the five patients referred with glottic or supraglottic scarring, the management of four included a tracheostomy. When carried out tracheostomy sites healed well in each case. With repeated endoscopic procedures it was subsequently possible to remove the tracheostomy in the two of the children. Using a special theatre protocol no new ulcers were recorded as being precipitated by any of the procedures children underwent.

CONCLUSIONS

Optimal management depends on the support of a multidisciplinary team, including otolaryngologists, pediatricians, dermatologists, anaesthetists, and specialist nurses. Adherence to a protocol for theatre management can help avoid intraoperative complications.

Otoplasty: experience with a modification using a drill, and literature review

More than 200 techniques have been described for correction of prominent ears, indicating that there is no single, widely accepted procedure that has been adopted by most surgeons. This article presents a simplified surgical method for correction of prominent ears. One hundred and twenty-eight otoplasties were performed on 70 patients using the described technique. The main modification of the technique was the use of a diamond burr drill to thin the cartilage posteriorly. Good aesthetic results were obtained in most patients.

Subglottic haemangioma in children: experience with open surgical excision

Subglottic haemangioma is a potentially life-threatening condition for which various treatment modalities are available. The objective of this study was to evaluate our results for open excision of subglottic haemangioma. The study assessed 18 patients who had been treated at a paediatric tertiary referral centre. Most of these patients (83.3 per cent) had undergone open surgical excision without post-operative tracheostomy and had been intubated for several days post-operatively (single-stage procedure). In most of these patients (66.7 per cent), an anterior cartilage graft had been used for reconstruction. The average follow up in this study was 25 months. All the patients in this series had achieved an adequate airway after the procedure. One patient had developed a recurrence of haemangioma in the trachea at a later date. The results of open surgical excision in this study were very encouraging. Seventeen out of 18 (94.4 per cent) patients had avoided tracheostomy or had been decannulated as a direct result of surgery. One of these 18 patients (5.6 per cent) had required a temporary post-operative tracheostomy for 13 months as the subglottis cleared; this was classed as a partial success. Our experience is that open excision is a highly successful ‘one stop’ treatment for subglottic haemangioma, which avoids prolonged use of steroids and multiple endoscopic procedures. No patient in this series developed subglottic stenosis, which can be a significant complication of laser application.

Laser arytenoidectomy in children with bilateral vocal fold immobility

Bilateral vocal fold immobility in children is a challenging problem because a balance between good airway and voice quality has to be achieved. Surgery to improve the airway is often postponed or avoided because of fear of losing the voice. In this study our results of laser arytenoidectomy in children are described. This was a retrospective case notes review at a tertiary level paediatric ENT department. The six patients in this case series ranged from nine to 16 years old at the time of laser arytenoidectomy. Post-operative airway and voice quality were assessed. All children in the series had an adequate post-operative airway. Four of these patients had tracheostomies pre-operatively and achieved decannulation. All six patients rated their post-operative voice as better than pre-operatively. This is principally due to increased loudness associated with increased airflow through the larynx, particularly after tracheostomy decannulation. It is recommended that special care should be taken not to disturb the anterior two thirds of the vocal fold during the surgery in order to achieve a good post-operative voice outcome.

Surgical approach for congenital midline cervical cleft

This is a report of a case of a rare congenital midline cervical cleft and a description of the surgical approach.

Congenital midline cervical cleft is a very rare developmental anomaly. It represents a failure of the branchial arches to fuse in the midline and presents at birth with a ventral midline defect of the skin of the neck. Associated clinical features could include mandibular spurs, cleft mandible, microgenia, thyroglossal cyst, cleft lip or bronchogenic cysts.

The authors present a case of a midline cervical cleft that was diagnosed and managed at an early age. They discuss the clinical presentation and embryological development of this rare condition. The operative findings, surgical excision and repair of the long vertical defect by Z-plasty are discussed in detail.

The authors report a very satisfactory result following excision and Z-plasty closure of this rare congenital anomaly.

Fine needle aspiration cytology in diagnosis and management of thyroid disease

The objective of this study was to determine the efficacy of fine needle aspiration cytology in diagnosis and management of thyroid nodules. The study also evaluated the predictive value of pre-operative fine needle aspiration cytology (FNAC) in surgical decision making, by comparing the final pathological diagnosis with the initial FNAC result.

All patients who underwent thyroidectomy between 1999 and 2003 were analysed. One hundred and sixty patients who underwent pre-operative FNAC were included in this study.

Fine needle aspiration was accurate in 119 (74.3 per cent) patients. Fine needle aspiration cytology and histology did not correlate in 32 (20 per cent) patients and FNAC was inadequate in nine (5.6 per cent) cases. Failures were mainly noted in cases of follicular neoplasm.

Our results indicate that FNAC is helpful in the diagnosis of thyroid pathology. However, complete histopathological analysis is essential to distinguish follicular adenoma from follicular carcinoma.

From this study, it can be concluded that FNAC is a cost-effective method of evaluating thyroid pathology pre-operatively and plays a useful role in planning the surgical management of thyroid nodules. However, results must be interpreted with the clinical picture in mind.

Maturation sutures for the paediatric tracheostomy – an extra safety measure

Objective: Displacement of the tracheostomy tube in paediatric patients is a potentially fatal complication. We describe an extra safety measure which facilitates tube replacement.

Setting: Tertiary referral specialist paediatric centre.

Materials and methods: The method involves the placement of sutures between the anterior tracheal wall and skin to hasten the formation of a mature stoma (maturation sutures). We also undertook a retrospective case note review on patients from an academic tertiary referral centre. Thirty-five notes were reviewed. The most common indication for tracheostomy was airway obstruction (65 per cent). Fourteen patients had early and 10 had late complications with three tube displacements occurring. No added complications due to the use of sutures were found.

Conclusions: Our complication rates compare well with those in the literature, and we recommend considering the use of such a technique.

Critical clinical appraisal of the role of ultrasound guided fine needle aspiration cytology in the management of parotid tumours

Objective: Fine needle aspiration cytology is a well established tool for investigating many head and neck conditions. Its application in parotid tumours is, however, controversial. This article is aimed at defining the role of ultrasound guided fine needle aspiration cytology (FNAC) in the diagnostic work up of parotid tumours. The accuracy and utility of FNAC of parotid tumours was also assessed.

Design: Retrospective case note review.

Setting: District general hospital.

Participants: Review of 69 patient records who had parotid surgery under one surgeon’s care (JS). Clinical opinion, FNAC results and final pathology findings were examined.

Main outcome measures: The results of the FNAC were compared to the histopathological diagnosis obtained from the surgical specimen.

Results: Histological evaluation revealed 13 malignant tumours and 56 benign lesions. The overall sensitivity of FNAC was 84.6 per cent and specificity was 96.4 per cent. We noted 11 true positive, 54 true negative, two false negative and two false positive results. Positive predictive value for diagnosing malignancy was 84.6 per cent and negative predictive value for malignancy was 96.4 per cent. The overall accuracy of FNAC of parotids in this study was 94.2 per cent.

Conclusions: FNAC results provide useful preoperative information. FNAC enables more reliable patient counselling and reduces pathological surprises. Pre-operative recognition of malignant tumours may help prepare both the surgeon and patient for an appropriate surgical procedure. Its enhancement of the pre-operative recognition of malignant parotid tumours may alert more stringent attention to the operative margin and hence better tumour clearance. Ultrasound guided FNAC was found to be highly specific for malignancy and its sensitivity for malignancy was good.