Unilateral pulmonary agenesis presenting as an airway lesion.

Otolaryngologists are frequently consulted to perform rigid bronchosopy in children with suspected foreign body aspiration, mucous plug occlusion of a mainstem or lobar bronchus, or other bronchial mass lesions. Chest radiographs that demonstrate unilateral lung or lobar collapse with a shift of mediastinal structures toward the affected side often prompt this referral. We describe 2 children, one with unilateral pulmonary agenesis and one with pulmonary aplasia, who presented with these radiologic findings. In each case, the definitive diagnosis was made at the time of bronchosopy. The diagnosis might have been suspected preoperatively if the chest radiographs had been reviewed with this clinical entity in mind. Because of its variable clinical presentation, diagnosis requires a high index of suspicion. Although computed tomography of the chest is diagnostic, the diagnosis may be suggested by chronic changes in the contralateral aspect of the chest wall and lung expansion on chest radiographs. Misdiagnosis may subject the patient to the unnecessary risks of bronchoscopy and to potential perforation of the rudimentary bronchus. Although pulmonary agenesis is a rare entity, it may mimic more common airway lesions. Therefore, unilateral pulmonary agenesis should be considered in the differential diagnosis of pediatric airway lesions. Arch Otolaryngol Head Neck Surg. 2000;126:1386-1389

Impact of tonsillectomy and adenoidectomy on child behavior.

OBJECTIVE: To measure the impact of tonsillectomy and adenoidectomy (T&A) on children's behavioral and emotional problems using a standardized assessment. DESIGN: Prospective study. SETTING: Tertiary care children's hospital. PATIENTS: Thirty-six children, aged 2 through 18 years, with symptoms of nighttime snoring, observed apneas, and daytime mouth breathing and physical examination results demonstrating 3+ or 4+ tonsils scheduled for T&A. INTERVENTION: Parents completed a standard survey of their children's symptoms of sleep apnea and a standardized measure of children's competencies and problems, the Child Behavior Checklist for ages 2 through 3 years or 4 through 18 years, before T&A and 3 months postoperatively. MAIN OUTCOME MEASURE: The Child Behavior Checklist total problem score. RESULTS: The preoperative Child Behavior Checklist total problem score was consistent with abnormal behavior for 10 children (28%). After T&A (n = 15), only 2 scores were abnormal, but the change was not statistically significant. In contrast, the mean total problem score was 7.5 points lower after surgery (95% confidence interval, 5.1-9.7), indicating a significant decrease (P<.001, matched t test). CONCLUSIONS: This pilot study demonstrates a high prevalence (28%) of abnormal behavior in children undergoing T&A for chronic upper airway obstruction. Scores on a standardized measure of behavior improve following T&A, but larger studies with increased statistical power are needed to clarify the degree of improvement and its clinical importance.

Laryngeal cleft and eosinophilic gastroenteritis: report of 2 cases.

Although laryngotracheoesophageal clefts are often found in association with other well-described anomalies, we know of no previous reported association with eosinophilic gastroenteritis, a disorder of unknown etiology characterized by eosinophilic infiltration of the gastrointestinal tract. We treated 2 children who had laryngeal clefts and eosinophilic gastroenteritis. Since the esophageal inflammatory changes found in eosinophilic gastroenteritis may persist despite aggressive therapy, management of the laryngotracheoesophageal clefts is more complicated. The diagnosis of eosinophilic gastroenteritis should not be overlooked in patients with laryngotracheoesophageal clefts and warrants prompt referral to a pediatric gastroenterologist.

Adenotonsillectomy in children with von Willebrand disease.

OBJECTIVE: To review the effectiveness of a perioperative management protocol and our experience with a large population of patients with von Willebrand disease (vWD) who require adenotonsillar surgery (T&A). DESIGN: A retrospective review of the medical records of all patients having the diagnosis of vWD who underwent T&A between January 1, 1992, and July 31, 1996. SETTING: A tertiary care, university-based children's hospital. INTERVENTIONS: Patients having a preoperative diagnosis of vWD received a single intravenous dose of desmopressin acetate, 0.3 pg/kg, approximately 20 minutes before the induction of anesthesia. Beginning January 15, 1994, a standard management protocol involving the postoperative administration of fluids and electrolytes was followed. MAIN OUTCOME MEASURES: Operative blood loss and the incidence of postoperative bleeding and of hyponatremia. RESULTS: Of approximately 4800 patients who underwent T&A during the study period, 69 patients had a diagnosis of vWD. All 67 patients identified preoperatively received desmopressin; 2 were identified by postoperative workup as a result of excessive surgical bleeding. Minimal immediate postoperative bleeding was noted in 7 patients (10%), but none required intervention. Delayed bleeding occurred in 9 patients (13%); all were readmitted to the hospital for observation, 4 (6%) requiring operative cauterization. Substantial postoperative hyponatremia occurred in 3 patients, and 1 patient had seizure activity. Symptomatic hyponatremia has been avoided since a protocol of fluid and electrolyte administration was instituted. CONCLUSIONS: Although T&A can be performed safely in patients with vWD, it is not without an increased risk of postoperative hemorrhage. The administration of desmopressin has been reported to reduce the risk of bleeding, but it is not without risk. A protocol for fluid and electrolyte management is recommended.

A meta-analysis of swimming and water precautions.

OBJECTIVE: To reconcile conflicting reports concerning the incidence of otorrhea in children with tympanostomy tubes who swim without ear protection. STUDY SELECTION: Articles were identified by MEDLINE search, Current Contents, and references from review articles, textbook chapters, and retrieved reports. Controlled trials of water precautions following tympanostomy tube placement were selected by independent observers and scored on 10 measures of study validity. Five English-language articles met all inclusion criteria. DATA EXTRACTION: Data were abstracted for an endpoint of otorrhea following swimming without ear protection with a minimum follow-up of 6 weeks. DATA SYNTHESIS: Pooled analysis of 619 children revealed a rate difference of -5.04 (95% confidence interval [CI], -11.62 to 1.54). No significant difference in the incidence of otorrhea was noted between patients who swam without ear protection and nonswimmers. CONCLUSION: There is no increase in incidence of otorrhea in children who swim without ear protection compared with children who do not swim following tympanostomy tube placement.

Wound management of the airway mucosa: comparison with skin in a rabbit model.

In comparison to the extensive study of skin wound healing, there have been few reports investigating mucosal wound healing. Our primary objective was to compare the natural progression of wound healing in airway mucosa to skin in a rabbit model. Split-thickness skin wounds and subglottic mucosal wounds created by drill injury were compared on days 0, 1, 3, 5, 7, 14 and 21 after injury. Histologic examination was performed by a veterinary pathologist blinded to sample identity. Subglottic wounds showed a 'fibrinous clot' overlying the epithelium, analogous to the fibrin crust in skin wounds. Re-epithelialization started on day 5 in the subglottic epithelium and was complete by day 14; fibroplasia and fibrosis in the lamina propria were present on days 7-21. This wound healing profile paralleled the skin epidermis and dermis, respectively. The epithelial changes, however, were temporally extended in the airway. Our secondary objective was to determine the effects of treating airway mucosa with a bioresorbable membrane, modified sodium hyaluronate and carboxymethylcellulose (modified HA/CMC), placed over the subglottic wounds of four rabbits after drill injury. Subglottic wounds treated with modified HA/CMC showed a more mature epithelium and less fibrosis on day 21. In this pilot study, the application of a bioresorbable membrane improved mucosal wound healing at both the epithelial and lamina propria levels. Clearly, a larger study must be performed to confirm this interesting observation.

Intratemporal complications of acute otitis media in infants and children.

We reviewed our experience with 100 children admitted to Children's Hospital of Pittsburgh between 1980 and 1995 with an intratemporal complication of acute otitis media. Seventy-two patients were treated for acute mastoiditis. Of these 72 children, 54 (75.0%) were treated conservatively with broad-spectrum intravenous antibiotics and myringotomy. Eighteen (25.0%) required mastoidectomy for treatment of a subperiosteal or Bezold's abscess or cholesteatoma, or because of poor response to conservative therapy. Twenty-two children presented with facial paralysis, complete in 5 (22.7%) and incomplete in 17 (77.3%). Eighteen (81.8%) were treated conservatively, but four required mastoid surgery. Nineteen patients had adequate follow-up; of these, 15 recovered normal facial function but 4 were left with partial paralysis. Three patients presented with serous labyrinthitis and recovered completely with conservative therapy. Of the two patients who presented with suppurative labyrinthitis, one was treated conservatively, but the other required tympanomastoidectomy with cochleotomy; both patients had permanent, profound sensorineural hearing loss in the affected ear. Four patients presented with acute petrositis, and in all four it resolved with mastoidectomy. In the antibiotic era, intratemporal complications of acute otitis media still occur in otherwise healthy children, often after inadequate treatment of acute otitis media.

Postoperative complications after tonsillectomy and adenoidectomy in children with Down syndrome.

OBJECTIVE: To compare the postoperative course and complications after tonsillectomy or tonsillectomy and adenoidectomy in children with Down syndrome (group 1) with the postoperative course and complications in children in a control group (group 2). DESIGN: Retrospective review of medical records for the period January 1, 1986, through March 30, 1996. SETTING: Tertiary care children's hospital. PATIENTS: The study included 87 children in group 1 and 64 children in group 2 matched for age, sex, and year of surgery. INTERVENTION: Tonsillectomy and adenoidectomy (group 1, 79 children; group 2, 57 children) and tonsillectomy (group 1, 8 children; group 2, 7 children). MAIN OUTCOME MEASURES: Length of hospitalization and postoperative complications. RESULTS: The length of hospitalization was significantly increased for the children in group 1 compared with that of children in group 2 (1.6 vs 0.80 days; P=.001, Mann-Whitney U test). Twenty-two children (25%) in group 1 required airway management or observation in the pediatric intensive care unit compared with no children in group 2 who required such care (P<.001, Fisher exact test). None of the children in either group required reintubation, continuous positive airway pressure, or tracheotomy. Respiratory complications requiring intervention were 5 times more likely in group 1 (22 [25%] vs 3 [5%]; P<.001, Fisher exact test). The median time until intake of clear liquids and duration of intravenous therapy were significantly increased in group 1 compared with group 2 (5.0 vs 4.0 hours, P=.03; 23.5 vs 16.0 hours, P=.001, respectively; Mann-Whitney U test). CONCLUSIONS: Although tonsillectomy and adenoidectomy can be performed safely in children with Down syndrome, the rate of postoperative respiratory complications is higher and the duration until adequate oral intake is resumed is longer. We therefore recommend that children with Down syndrome be admitted to the hospital overnight after undergoing tonsillectomy and adenoidectomy.

Complications of tympanostomy tubes in an inner city clinic population.

While both prophylactic antibiotics and tympanostomy tube insertion have a role in the treatment of recurrent acute otitis media (AOM) and otitis media with effusion (OME) in children previous work has shown that patients in our urban clinic are not compliant with prophylactic antibiotics. Concerned about the potential for decreased compliance in a non-compliant population, we performed a retrospective review to assess the incidence of complications from the insertion of tympanostomy tubes in the same pediatric clinic population. A total of 391 tubes were placed in 165 patients. Follow-up ranged from 0-49.4 months with a mean of 21.3 months. Three ears (1.14%) had persistent perforations. Tympanosclerosis was found in 30 ears (11.1%). No ear showed a chronic retraction or cholesteatoma. Six ears (1.70%) developed postoperative otorrhea. Thirty-five patients had at least one episode of otorrhea outside of the perioperative period, and a total of 60 episodes (19.6% of ears) occurred during the study period. The mean pure tone average prior to tube placement was 25.0 dB, with tubes in place was 2.44 dB and after the last set of tubes had extruded was 6.97 dB. Our study shows that the incidence of complications of tympanostomy tubes was minimal in our inner city clinic population.

Clinical diagnosis of pediatric obstructive sleep apnea validated by polysomnography.

The decision to perform tonsillectomy and adenoidectomy for treatment of pediatric obstructive sleep apnea syndrome is often made on a clinical basis without formal polysomnography. To examine the accuracy of the clinical diagnosis of pediatric obstructive sleep apnea syndrome, we prospectively evaluated 30 children with obstructive symptoms by a standardized history, physical examination, and review of a tape recording of breathing during sleep. On the basis of this clinical evaluation, patients were divided into three predictive groups: (1) definite obstructive sleep apnea syndrome, (2) possible obstructive sleep apnea syndrome, and (3) unlikely to have obstructive sleep apnea syndrome. Nocturnal polysomnography was used to determine the presence or absence of true sleep apnea. Ten of 18 (55.6%) patients predicted clinically to have definite obstructive sleep apnea syndrome had positive nocturnal polysomnographies. Two of six (33.3%) patients predicted to have possible obstructive sleep apnea syndrome had positive nocturnal polysomnographies. One of six (16.7%) patients predicted to be unlikely to have obstructive sleep apnea syndrome had a positive nocturnal polysomnography. Six nocturnal polysomnographies negative by conventional criteria were suspicious for apnea, but considering these positive for obstructive sleep apnea syndrome did not improve the specificity of the clinical prediction. Our results show that clinical assessment of obstructive sleep apnea syndrome in children is sensitive (92.3%) but not specific (29.4%) for making the diagnosis of obstructive sleep apnea syndrome as compared with nocturnal polysomnography and may contribute to the decision to obtain nocturnal polysomnography in specific circumstances.

Compliance with prophylactic antibiotics for otitis media in a New York City clinic.

Although previous efficacy studies have reported high compliance rates among children treated by private physicians with prophylactic antibiotics for prevention of otitis media, compliance rates in a lower socioeconomic, urban clinic population have not been well described. Eighty children who were placed on daily low dose antibiotics in the Pediatric Otolaryngology Clinic at Bellevue Hospital were prospectively followed in order to estimate compliance in this population. Compliance was estimated by the parent's stated word alone. Of the 77 patients with records adequate for analysis, only 36 (46.8%) families claimed compliance, 18 (23.4%) admitted non-compliance, and 23 (29.9%) did not reliably return for follow-up clinic visits. Statistical analysis revealed that no single characteristic of the patient population or the treatment regimen strongly influenced compliance. The factors examined included: the child's age, sex, race and otologic diagnosis, the type of prophylaxis prescribed, the parent's ability to speak English, national origin, consistency of follow-up, and method of payment. Based on these results, less than half of the children attending an inner city clinic compiled with maintenance medication. The clinician should consider alternate treatment modalities, such as the insertion of middle ear ventilation tubes, if poor compliance with prolonged antibiotic treatment is suspected.

Dendritic morphology of central auditory neurons correlates with their tonotopic position.

We have investigated the morphology of dendritic arbors in a central auditory nucleus, the lateral superior olive, of the Mongolian gerbil. Morphometric observations were obtained directly from Golgi-impregnated material by using a microcomputer-based three-dimensional data acquisition system. In particular, measurements were made to determine the dendritic arborization across each of three axes: the tonotopic axis, the rostrocaudal axis, and the isofrequency axis (i.e., perpendicular to the tonotopic axis). The tonotopic position of each cell was computed on the basis of a topographic map that has been constructed for the gerbil LSO (Sanes et al.: J. Comp. Neurol. 279:436-444, 1989). It was found that the span of a dendritic arbor along the tonotopic axis was directly correlated with the neuron's tonotopic position: Low frequency neurons had much broader arborizations than high frequency neurons. Moreover, the distribution of frequency bandwidths to which single LSO neurons responded showed a striking similarity to dendritic arborizations across the tonotopic axis. Lower frequency neurons responded to a larger number of octaves than higher frequency neurons. There was no correlation between tonotopic position and dendritic arborization in the isofrequency or rostrocaudal axis. Nor was there any correlation between frequency and total dendritic length, number of primary dendrites, or soma area. However, there was a small but significant difference between the primary dendrite diameter of low and high frequency neurons. Low frequency neurons had significantly greater diameters. These results suggest that the frequency selectivity of central auditory neurons may employ, as one morphological substrate, the distance over which their dendrites arborize along the tonotopic axis.