Comparison of polysomnography and sonography for assessing regularity of respiration during sleep in adenotonsillar hypertrophy.

Increasing awareness of the role of adenotonsillar hypertrophy in the etiology of chronic airway obstruction and disturbed respiration during sleep has created interest in the diagnostic methods available to assess the effects of obstruction. This study evaluates and compares simultaneously-obtained recordings of polysomnography and sleep sonography in children obstructed by adenotonsillar hypertrophy. Four hundred sixty-five 4-minute samples obtained from 18 patients in a clinical studies unit were analyzed and rated as to severity. Agreement between polysomnography and sleep sonography was very high in scoring the respiratory pattern (r = 0.79) and detecting apnea (r = 0.89). These findings demonstrate that sleep sonography is a reliable method for evaluating patients with upper airway obstruction due to adenotonsillar hypertrophy.

Vocal cord paralysis in children.

Bilateral vocal cord paralysis is a common cause of stridor in infants and children. There are significant differences in this entity between children and adults with regard to etiology, diagnosis, management, and outcome. A review of 10 years' experience at Children's Hospital of Philadelphia identified 51 children seen with the diagnosis of vocal cord paralysis. These cases were evaluated with respect to etiology of paralysis, whether unilateral or bilateral, delay in diagnosis, need for tracheotomy, abnormality of voice, surgical treatment, and outcome. Guidelines for management for a child with vocal cord paralysis are presented with emphasis on flexible endoscopic evaluation and conservative management.

Physicochemical properties of human middle ear effusions (mucus) and their relation to ciliary transport.

Middle ear effusions were collected from 10 patients (14 ears) with secretory otitis media. Mucoid samples were pooled and reconstituted to various concentrations of nondialyzable solids. Viscoelasticity was studied using a magnetic microrheometer and compared with mucociliary transport rates measured on the frog palate. Results indicate that the viscoelastic properties of middle ear mucus correlate with mucociliary transport. A transport maximum was found at a 2% nondialyzable solids content. Implications relative to ineffective mucociliary transport in secretory otitis media are discussed.

Is outpatient tonsillectomy appropriate for young children?

The current literature suggests that outpatient tonsillectomy is a safe, cost-effective procedure. These reports have based their conclusions on the low rates of postoperative bleeding and dehydration. Generally, they have not examined other factors that may influence the postoperative course or identified groups of patients in whom outpatient management may not be appropriate. The literature regarding tonsillectomy in young children is conflicting. A retrospective analysis of the records of 223 children, 36 months of age and younger who had tonsillectomies, was performed. Postoperative airway complications including oxygen desaturation and airway obstruction developed in 115 patients. Seventeen (7.6%) children required postoperative care in an intensive care unit while an additional 117 (52.5%) patients received more than standard management. Preoperative apnea, an age of less than 12 months, and the presence of accompanying medical conditions were associated with a higher incidence of postoperative airway complications. It is recommended that tonsillectomy in patients under 36 months of age be planned as an inpatient procedure.

Nasopharyngeal malignancies in children.

A retrospective analysis identified 29 children with nasopharyngeal malignancies who were evaluated at the Children's Hospital of Philadelphia from 1970 through 1989. Rhabdomyosarcoma (15) and carcinoma (9) were the most common tumor types, and there were distinct differences in the clinical presentations of these two malignancies. Patients with rhabdomyosarcoma were generally younger than those with carcinoma and enjoyed longer survival. Six (67%) of the children with carcinoma were black; all of the patients with rhabdomyosarcoma were white. Patients with carcinoma were also more likely to present with cervical metastases. The presentation, evaluation, and methods of treatment for pediatric nasopharyngeal malignancies are discussed.

Glomus tympanicum in infancy.

A glomus tympanicum tumor, limited to the cochlear promontory, was excised from the middle ear of a 6-month-old girl. To our knowledge, there have been no reports of temporal bone paragangliomas occurring at a younger age. Diagnosis, therapy, and the special characteristics of pediatric glomus tumors are discussed.

Type 1 tympanoplasty in children.

OBJECTIVE: To identify factors affecting the surgical success rate and reperforation rate in type 1 tympanoplasty. Controversy continues regarding the advisability of this procedure in young children, largely because of the likelihood of recurrent middle ear disease and eustachian tube dysfunction. DESIGN: Retrospective medical record review of a case series. SETTING: Pediatric hospital that serves both as a primary care and referral center. PATIENTS: All private patients younger than 18 years, undergoing type 1 tympanoplasty from 1985 through 1989, for whom at least 6 months' follow-up was available. Two hundred nine tympanoplasties on 183 patients were included; 22 patients were excluded for insufficient follow-up. MAIN OUTCOME MEASURES: Surgical success was defined by confirmation of an intact tympanic membrane at least 6 months postoperatively. Procedures were deemed long-term successes if the tympanic membrane remained free of perforation to the end of follow-up. RESULTS: The overall short-term surgical success rate was 92%, with 87% of ears remaining free of reperforation to the end of follow-up. If the perforation involved the margin, the surgical success and long-term success rates dropped to 86% and 77%, respectively. Although reperforation was more likely in patients younger than 6 years or in those with contralateral otitis media at surgery, even these groups had long-term success rates of 81% and 74%, respectively. CONCLUSIONS: Tympanoplasty may be considered at any age. Even in young children, there is a high likelihood of return to normal function.

Nodular fasciitis of the head and neck in children. A deceptive lesion.

Nodular fasciitis represents a discrete, benign, presumably reactive proliferation of fibroblasts. However, its rapid rate of growth and a sarcomatous histologic appearance are often deceptive. Multiple pathologic reviews are frequently conducted in an attempt to distinguish nodular fasciitis from other lesions. Such confusion is especially problematic in the pediatric otolaryngic population in which nodular fasciitis is not commonly encountered and mesenchymal malignancies of the head and neck are of fundamental concern. Between 1976 and 1988, 12 cases of nodular fasciitis were diagnosed at the Children's Hospital of Philadelphia (Pa). Six children presented with head and neck lesions and ranged from 6 to 13 years of age. The clinical and histopathologic features of these cases are reviewed.

Depression in children after tonsillectomy.

Postoperative depression has been reported in adults undergoing open heart surgery and mastectomy. Tonsillectomy is a commonly performed procedure and can be associated with significant morbidity including pain, difficulty swallowing, dehydration, and bleeding. While adults may be able to express their feelings about the postoperative course, children often are unable to express themselves. Because postoperative depression may manifest itself in unusual behavior that is dismissed as "expected," it may go unrecognized. We present three case reports in which the child demonstrated signs of depression following tonsillectomy. We believe that depression following tonsillectomy occurs more frequently than has been recognized. We describe the diagnosis and management of posttonsillectomy depression to increase the otolaryngologist's awareness of this entity.

Tracheobronchomalacia in children.

Tracheobronchomalacia (TBM) is an important cause of airway distress during infancy, but it generally resolves as the airway enlarges. To assess the origin and natural history of TBM, a chart review and telephone survey were conducted for 50 patients with TBM at the Children's Hospital of Philadelphia (Pa). This study revealed that TBM is a relatively common airway abnormality and is found on 15% of all diagnostic bronchoscopies. Prematurity, low birth weight, bronchopulmonary dysplasia, and prolonged ventilation predispose patients to the most severe symptoms. In our study, a tracheotomy with continuous positive airway pressure was required by 75% of the premature infants and 25% of the full-term infants with TBM. Seventy-one percent of all patients underwent decannulation without any other surgical intervention and remained nearly asymptomatic. Some patients could not undergo decannulation because of other airway lesions. In most instances, TBM is a self-limited disease that resolves without surgery.

Mandibular fractures in the pediatric patient.

Seventy-three patients were admitted to the Children's Hospital of Philadelphia (Pa) between January 1979 and June 1989 with a diagnosis of mandibular fracture. Data were obtained through a retrospective review of these cases. The cases were divided into three age groups that reflected the developing structure of the mandible and the maturation of the dentition. A trend toward a greater number of fractures and a predominance of males is shown with increasing age. Child abuse is a relatively frequent cause of fractures throughout all groups. Associated injuries are more common in young children, except in cases where abuse has been documented. The high osteogenic potential of the pediatric mandible allowed conservative management to be successful in 25% of younger patients and was responsible for a low complication rate overall.

Ventilation tube removal. Indications for paper patch myringoplasty.

Paper patch myringoplasties are commonly performed in children at the time of ventilation tube removal, yet no series documenting their efficacy appears in the otolaryngology literature. Over an 18-month period at the Children's Hospital of Philadelphia (Pa), 163 ventilation tube removals were performed on 131 children aged 1 to 18 years. In 95 of these ears, a paper patch myringoplasty was performed after tube removal. No significant difference (87% vs 85%) in the overall healing rate at 6 months was shown between these two groups. An analysis of the variables potentially affecting outcome revealed that healing following simple tube removal was influenced by the frequency of tube placement and by tube size. Paper patch myringoplasty significantly improved outcome (93% vs 61%) in ears with more than three previous tube placements.

Endoscopic assessment in children with tracheotomies.

Pediatric tracheotomy is a safe procedure, and the tube can be maintained for a prolonged period. There are, however, few guidelines regarding the endoscopic assessment of the airway following tracheotomy. From January 1988 through December 1989, the Division of Otolaryngology of The Children's Hospital of Philadelphia (Pa) performed tracheotomies on 81 patients. Thirty-two children had direct laryngoscopy and bronchoscopy at the time of the procedure, 1 week later, and at 6-month intervals for a minimum of 18 months. Four children had normal airways while 21 had intraluminal stomal granulomas, 16 had development of subglottic stenosis, nine had collapse of the anterior tracheal wall, and three had development of distal tracheal granulations. Sixteen children had multiple lesions. Anatomic changes occur in the airways of the majority of children with long-term tracheotomies, and endoscopic evaluation is an essential part of their care.

Congenital tracheal stenosis. The otolaryngologist's perspective.

Congenital tracheal stenosis is a rare congenital anomaly, with less than 70 reported cases in the literature. The presenting signs and symptoms of stridor, recurrent pneumonia, and respiratory distress are commonly seen in other conditions. The rarity of congenital tracheal stenosis and the diverse presentations make accurate early diagnosis difficult and frequently lead to inappropriate treatment. We treated three patients with congenital tracheal stenosis who presented with different sites of stenosis. Each patient displayed different symptoms and required individualized management. The treatment of congenital tracheal stenosis depends on identifying the site and extent of the stenosis. We reviewed the embryogenesis and treatment of this abnormality and developed a new classification system that will aid in the management of congenital tracheal stenosis.

Microbiology of the tonsils and adenoids in a pediatric population.

To investigate the microbial flora of the tonsils and adenoids, the core tissue from the tonsils and adenoids of 50 children undergoing tonsillectomy and adenoidectomy for either recurrent infection or airway obstruction was cultured aerobically and anaerobically, and the number of bacterial colonies was quantitated. The most common organisms isolated were alpha-hemolytic streptococci, nonpathogenic Neisseria species, Haemophilus species, Staphylococcus aureus, and Corynebacterium species. No anaerobes were identified. Bacterial isolates from the tonsils and adenoids were similar in number and frequency of occurrence. Potential pathogenic bacteria (Haemophilus species, S aureus, beta-hemolytic streptococci, and Streptococcus pneumoniae) were identified in 40 patients. Seventy-three percent of these patients shared a common pathogen in tonsil and adenoid tissue. Haemophilus species were recovered in 54% of patients and S aureus in 46%. No significant difference exists between the type and number of pathogens in patients undergoing adenotonsillectomy for recurrent infection or obstruction.

The effect of antibiotic therapy on recovery after tonsillectomy in children. A controlled study.

Tonsillectomy continues to be a commonly performed operation in the pediatric age group. The postoperative period is often protracted and characterized by throat and ear pain, intermittent fever, foul odor from the oral cavity, and poor oral intake. Consequently, antibiotics are frequently prescribed in an effort to minimize these symptoms and/or avoid complications such as dehydration or secondary infection of the operative site. However, to our knowledge, no study to date has been performed to demonstrate the efficacy of antibiotic therapy in this setting. At the Children's Hospital of Philadelphia, a prospective, randomized, double-blind study was undertaken in which ampicillin (or placebo) was administered intravenously at the time of surgery and for 12 to 24 hours postoperatively. The children then continued to receive oral amoxicillin therapy (or placebo) for an additional seven days. The patients were then evaluated for the incidence and severity of postoperative symptoms and complications. Intraoperative cultures of the oropharynx and tonsillar tissue, as well as cultures of the tonsillar fossa, were obtained following completion of one week of therapy. Our results indicate that ampicillin sodium/amoxicillin trihydrate therapy is well tolerated and safe in the nonallergic child and is effective in minimizing fever and other troublesome postoperative symptoms, such as pain, lassitude, mouth odor, and poor oral intake after tonsillectomy.

Rhabdomyosarcoma of the head and neck in children.

Rhabdomyosarcoma is the most common soft-tissue sarcoma in infants and children, with the head and neck being the most frequent site of involvement. Treatment for this neoplasm has undergone many changes, with a much improved prognosis using a combination of surgery, radiation therapy, and chemotherapy. This retrospective analysis presents the management and outcome of 60 children (aged 3 months to 18 years) with rhabdomyosarcoma of the head and neck evaluated at the Children's Hospital of Philadelphia (Pa) between 1970 and 1987. The overall death rate for all head and neck sites decreased from 50% in 1970 to 1979 to 23% in 1980 to 1987, reflecting the improved management protocol.

Obstructive sleep apnea.

Obstructive sleep disorders and apnea are commonly seen in children of all ages. The obstruction usually causes snoring and varying periods of interrupted breathing during sleep. Obstructive sleep disorders cause multiple physiologic disturbances and should be treated before they become severe.

Total and partial ossicular replacement prostheses in children.

Although ossicular reconstruction in children may carry a risk of failure because of recurrent middle ear disease, the procedure offers the potential for restoring binaural hearing during the school years when it is so critical. Of a series of 45 reconstructions with total and partial ossicular replacement prostheses, 6 were extruded for a surgical success rate of 87%. Of the successful cases, 74% had air-bone gaps of 30 dB or better, and 74% had speech reception thresholds of 30 dB or better on initial postoperative audiogram. Outcomes for these children were comparable with those reported for adults, supporting the value of early reconstruction.

Brain stem response evoked by electrical stimulation of the round window of the guinea pig.

The wave that is believed to correspond to wave V in man is an appropriate indicator of auditory nerve excitability because it is not contaminated by nonauditory neurogenic responses to electrical stimulation. The responses to direct electrical stimulation of the auditory nerve could be distinguished from the electrophonic response by the steep input-output function and constant latency of the former. Myogenic responses are prominent unless a muscle relaxant is administered.