Prospective comparative study of pulsed-electron avalanche knife (PEAK) and bipolar radiofrequency ablation (coblation) pediatric tonsillectomy and adenoidectomy.

PURPOSE: To compare post-operative pain severity, analgesic intake, and complications in children undergoing tonsillectomy and adenoidectomy with bipolar radiofrequency ablation (Coblation) vs. pulsed-electron avalanche knife (PEAK) technology. MATERIALS AND METHODS: This was a prospective, non-randomized, non-blinded comparative cohort study in a private practice setting with three fellowship-trained pediatric otolaryngologists. Patients aged 3 to 12years undergoing tonsillectomy and adenoidectomy were assigned to surgery with either bipolar radiofrequency ablation or pulsed electron avalanche knife instrumentation. Daily telephone contact for the first 14 post-operative days obtained the following data: validated proxy pain scale scores, number of post-operative analgesic medication doses consumed, and occurrence and severity of post-operative hemorrhage. RESULTS: One-hundred adenotonsillectomy subjects were enrolled (50 bipolar radiofrequency ablation, 50 pulsed-electron avalanche knife). There were no clinically relevant differences in post-operative pain scores between the two surgical groups on all post-operative days. Total doses of non-narcotic and narcotic analgesics were similar between the groups, with the exception of less acetaminophen doses being consumed in pulsed-electron avalanche knife patients on post-operative days 9, 10, and 12. Post-operative hemorrhage episodes resulting in re-operation and/or hospitalization were equivalent between the two groups. However, bipolar radiofrequency ablation patients were 2.33 times more likely to experience minor bleeding events at home (that did not require medical intervention). CONCLUSION: Pulsed-electron avalanche knife surgery was found to be an adequate technique for pediatric adenotonsillectomy, with similar amounts of post-operative pain and clinically relevant hemorrhage when compared to bipolar radiofrequency ablation.

Fine needle aspiration biopsy: role in diagnosis of pediatric head and neck masses.

OBJECTIVE: To assess the feasibility and role of fine needle aspiration biopsy (FNAB) as a diagnostic tool in children with neck masses. DESIGN: Retrospective chart review. SETTING: Tertiary care children's hospital. PATIENTS: Consecutive series of 71 children with a head and neck mass who underwent FNAB as the primary diagnostic modality. INTERVENTIONS: FNAB was performed and interpreted by a pediatric cytopathologist. Rapid on-site analysis was performed to allow immediate assessment of specimen adequacy and to attain a preliminary diagnosis, after which routine cytologic staining was performed. Flow cytometry was performed on cytological specimens when malignancy was suspected, and open biopsy was performed when the cytologic diagnosis was in question. MAIN OUTCOME MEASURES: Technical feasibility of FNAB in children, complications, cytopathological diagnoses, accuracy of rapid on-site analysis, need for subsequent diagnostic evaluations, clinical outcomes and follow-up. RESULTS: Mean age was 8.4 years (S.D. 5.3 years), with mean follow-up of 4.1 months (S.D. 9.6 months). FNAB was performed under general anesthesia in 54 cases (76%). There were no technical complications. On-site rapid interpretation was completed in 55 cases, 18/55 confirmed adequacy of specimen only, 37/55 yielded a preliminary diagnosis, and in 34/37 cases, was same as final cytopathologic result. Overall, FNAB biopsy demonstrated 64 benign lesions, 3 malignant diagnoses, 2 follicular thyroid neoplasms, and 2 non-diagnostic specimens. FNAB was the only pathological test performed in 54 (76%) cases. The most common diagnosis was reactive lymphoid hyperplasia (n = 39), followed by benign granulomatous disease (n = 8). Flow cytometry was performed on 7 specimens (non-diagnostic in 5, negative for malignancy in 2). Of the 15 cases with surgical specimens, 3 revealed a pathologic diagnosis different from initial FNAB. There were no cases in which FNAB missed a malignancy, and there were 2 cases where FNAB suggested malignancy, with benign disease subsequently found on open biopsy. CONCLUSIONS: Fine needle aspiration biopsy is developing into a feasible option in diagnosing pediatric neck masses, with its main advantage being its minimally-invasive nature and avoidance of an open surgical procedure for benign persistent lymphadenitis. On-site rapid interpretation can be used successfully to confirm specimen adequacy and to give an accurate preliminary diagnosis for concerned parents. Issues to consider include the need for a specialized pediatric cytopathologist familiar with pediatric differential diagnoses, the need for general anesthesia in many cases, and the possibility of inaccurate diagnosis requiring an open procedure.

Synchronous airway lesions and esophagitis in young patients undergoing adenoidectomy.

OBJECTIVE: To determine the prevalence of synchronous airway lesions and esophagitis in children younger than 18 months undergoing adenoidectomy for adenoid hypertrophy and upper airway obstruction. DESIGN: Retrospective review spanning 4.5 years. SETTING: Tertiary care children's hospital. PATIENTS: All children younger than 18 months who underwent adenoidectomy for upper airway obstruction by 2 pediatric otolaryngologists. EXCLUSION CRITERIA: craniofacial dysmorphism and congenital syndromes. INTERVENTIONS: Simultaneous interventions during adenoidectomy included flexible nasopharyngolaryngoscopy (n = 32), direct laryngoscopy (n = 31), rigid tracheobronchoscopy (n = 30), and esophagoscopy with biopsy (n = 32). MAIN OUTCOME MEASURES: Prevalence of synchronous airway lesions and histologic esophagitis. RESULTS: Thirty-five children younger than 18 months underwent adenoidectomy for airway obstruction (2 also had simultaneous tonsillectomy). Synchronous airway lesions were found in 19 (59%) of 32 patients who underwent airway endoscopy, including laryngeal edema (n = 9), laryngomalacia (n = 8), tracheal vascular compression (n = 4), subglottic stenosis (n = 4), midmembranous vocal fold lesions (n = 3), bronchial stenosis (n = 1), and true vocal fold immobility (n = 1). Among 32 patients who underwent esophageal biopsy, histologic evidence of gastroesophageal reflux disease was found in 10 patients (31%), and eosinophilic esophagitis was found in 4 patients (13%). Overall prevalence of any synchronous finding (airway and/or esophagus) was 27 (77%) of 35. CONCLUSIONS: Synchronous airway lesions and esophagitis (both gastroesophageal reflux disease and eosinophilic esophagitis) were prevalent among children younger than 18 months undergoing adenoidectomy for adenoid hypertrophy and upper airway obstruction. The presence of these findings argues for consideration of endoscopy during adenoidectomy for very young children.

Introduction of visually oriented information handouts in an academic pediatric otolaryngology practice.

OBJECTIVES: To characterize after-hours postoperative caregiver telephone calls received by on-call otolaryngology residents and to determine the feasibility of using visually oriented handouts to affect postoperative telephone call volume. STUDY DESIGN AND SETTING: We conducted a prospective, before-after feasibility study at a tertiary-care children's hospital. Visually oriented handouts describing expected postoperative courses were distributed preoperatively to the parents of all adenotonsillectomy and tympanostomy tube patients. Postoperative caregiver telephone call volume and content were recorded before and after handout introduction. RESULTS: The handouts were well accepted and viewed favorably by caregivers, and they led to some changes in the nature of postoperative telephone call content, but call log compliance was not adequate to fully assess the impact on call volume and content. CONCLUSIONS: We demonstrated the feasibility of implementing visually oriented informational handouts and characterized the nature of postoperative caregiver telephone calls received by on-call residents in an academic pediatric otolaryngology practice. SIGNIFICANCE: Visually oriented instructional handouts may have benefits that deserve further study. Data from this study can help plan a definitive clinical trial.

Computed tomography and magnetic resonance imaging in pediatric unilateral and asymmetric sensorineural hearing loss.

OBJECTIVE: To compare temporal bone computed tomography (CT) with temporal bone and central nervous system magnetic resonance (MR) imaging in children with unilateral or asymmetric sensorineural hearing loss (SNHL). DESIGN: Retrospective chart study. SETTING: Tertiary-care children's hospital. PATIENTS: A total of 131 children with unilateral or asymmetric SNHL, seen consecutively by a single practitioner over 36 months. INTERVENTION: Imaging studies were read by a pediatric neuroradiologist and reviewed by the evaluating otolaryngologist. MAIN OUTCOME MEASURE: Prevalence of clinically significant CT or MR imaging findings. RESULTS: The prevalence of CT abnormalities was 35% for unilateral SNHL, 52% for asymmetric SNHL, and 41% for all patients together. The prevalence of MR imaging abnormalities was 25% for unilateral SNHL, 50% for asymmetric SNHL, and 30% for all patients together. Among 42 subjects who underwent both studies, there were 4 cases in which abnormalities were seen only on MR images and 9 cases in which abnormalities were seen only on CT scans. CONCLUSIONS: Temporal bone and/or central nervous system abnormalities were detected in 42% of 131 patients. When both CT scans and MR images were obtained (n = 42), results were concordant in 69% of cases, and one imaging modality detected clinically significant abnormalities not identified by the other in 31% of cases. The ideal imaging algorithm for children with unilateral or asymmetric SNHL is controversial. We suggest that all children with unilateral or asymmetric SNHL have a high-resolution temporal bone CT scan and that brain and temporal bone MR imaging be obtained in select cases.

Evaluation and management of pediatric oropharyngeal trauma.

OBJECTIVE: To examine the clinical factors that influence medical decision making in children with oropharyngeal trauma. DESIGN: Retrospective chart review (spanning 6 years). SETTING: Tertiary care children's hospital. PATIENTS: One hundred seven consecutive children with traumatic oropharyngeal injuries. INTERVENTIONS: Computed tomographic angiography (CTA) (n = 52), surgical therapy (n = 16), inpatient admission (n = 44), and antibiotic administration (n = 77). MAIN OUTCOME MEASURES: The likelihood of a patient undergoing each of the 4 interventions and having positive radiographic findings or clinical complications was assessed with respect to the following clinical factors: (1) age, (2) sex, (3) mechanism of injury, (4) site of injury, (5) wound severity (3-point scale), and (6) otolaryngology consultation. RESULTS: The following factors were significantly associated with an increased likelihood of a patient undergoing CTA to rule out occult internal carotid artery damage: (1) injury to the lateral soft palate, (2) high wound severity score, and (3) otolaryngology consultation. Radiographic abnormalities (including free air, parapharyngeal edema, and hematoma) were present in 16 (31%) of 52 CTAs but were not associated with any specific clinical factors. Patients with more severe wounds were more likely to undergo CTA, go to the operating room, receive antibiotics, and be admitted to the hospital but were not more likely to have positive CTA findings or an adverse clinical outcome. CONCLUSIONS: We were unable to identify any clinical factors that would help predict which children with oropharyngeal trauma are at high risk of developing neurologic sequelae. Radiographic screening for vascular injury in children with oropharyngeal trauma remains controversial.

Risk factors for pediatric post-tonsillectomy hemorrhage.

OBJECTIVES: To determine pre-operative risk factors for post-tonsillectomy secondary hemorrhage in children, and quantify the magnitude of their risk. MATERIALS AND METHODS: Retrospective case-control study of all pediatric tonsillectomy patients experiencing post-operative bleeding from 2005 to 2010 in a community practice consisting of three fellowship-trained pediatric otolaryngologists were identified. The 91 cases were matched with 151 controls that underwent tonsillectomy by the same surgeon on the same day as each identified case. All charts were reviewed, and 41 pre-operative variables were extracted and statistically analyzed with contingency and regression analysis to calculate significance and odds ratios. RESULTS: Three significant predictors of post-operative bleeding were identified. Performing a tonsillectomy on a child with recurrent tonsillitis (vs. other indications) increased the risk of post-operative hemorrhage by 4.5 times (p<0.0001, 95% confidence intervals 2.41-8.38). Performing a tonsillectomy on a child with attention deficit hyperactivity disorder (ADHD) increased the risk by 8.7 times (p=0.029, 95%CI 1.4-53.6). Older children were more predisposed to post-operative bleeding. For every increase in age by one year, the hemorrhage risk increased by 1.1 times (p=0.0025, 95%CI 1.032-1.162). Children 11 years of age and older had double the risk of bleeding compared to younger children (odds ratio 1.98, p=0.0381, 95%CI 1.04-3.79). None of the remaining 38 variables showed significant differences between cases and controls. CONCLUSIONS: The risk of post-tonsillectomy hemorrhage is significantly increased in older children and those with recurrent tonsillitis and ADHD.

Laryngomalacia and swallowing function in children.

OBJECTIVES/HYPOTHESIS: 1) To determine the prevalence of dysphagia in children with laryngomalacia, 2) To ascertain whether severity of laryngomalacia influences the presence of swallowing dysfunction, and 3) To examine whether patients with medical comorbidities and laryngomalacia have a higher prevalence of swallowing dysfunction. STUDY DESIGN: Retrospective cohort study. METHODS: All patients seen in the aerodigestive center at our institution between January 2007 and December 2012 with the diagnosis of laryngomalacia were included. Swallowing function was assessed by symptoms, clinical swallowing evaluations (CSE) performed by speech pathologists, modified barium swallow (MBS) studies, and fiberoptic endoscopic evaluations of swallowing (FEES). RESULTS: There were 324 patients with laryngomalacia identified (41.4% female, 58.6% male). Severity of laryngomalacia was categorized in 279 patients, with 62.7% mild, 28.7% moderate, and 8.6% severe. Gastroesophageal reflux disease (GERD) was diagnosed in 69.8% of patients. Other medical comorbidities included Down syndrome (3.1%), neurological impairment (6.5%), and congenital heart disease (0.9%). Symptoms of dysphagia or feeding difficulty were present in 163/324 (50.3%), and failure to thrive was present in 31/324 patients (9.6%). At least one abnormal swallowing assessment was present in 97/120 (80.8%) patients presenting with subjective dysphagia and 43/65 (66.2%) patients without subjective dysphagia. A total of 140/185 (75.7%) patients had at least one abnormal baseline swallowing assessment. There was no significant relationship between severity of laryngomalacia and presence of abnormal swallowing function based on symptoms, CSE, MBS, or FEES. However, patients with greater severity were more likely to have failure to thrive. There was not a significant association between the presence of swallowing dysfunction or disease severity and medical comorbidities such as Down syndrome, neurological impairment, or congenital heart disease. However, GERD was more likely to be present in patients with moderate and severe laryngomalacia than in patients with mild disease. CONCLUSIONS: Swallowing dysfunction is common in children with laryngomalacia regardless of disease severity or other medical comorbidities. Swallowing studies are frequently abnormal in laryngomalacia patients presenting both with and without subjective symptoms of dysphagia. Dysphagia assessment should be considered as part of the evaluation of infants with laryngomalacia. LEVEL OF EVIDENCE: 4.

Superstitions among perioperative nurses.

A descriptive study was conducted using a mailed questionnaire to determine the prevalence of work-related superstitions among perioperative nurses. Data analysis included the two-sample t test for continuous data and the two-sided Fisher's exact test for binary data. Study results indicate that although only 23% of respondents view themselves as "generally superstitious," specific work-related superstitions are widespread. Belief in specific superstitions was not statistically related to age or number of years as a perioperative nurse. An analysis of the literature on medical workplace superstitions helps to elucidate possible underlying explanations for the phenomenon of nursing superstitions.

Pediatric sialendoscopy: initial experience in a pediatric otolaryngology group practice.

OBJECTIVES/HYPOTHESIS: To describe the initial results of sialendoscopy as a diagnostic and therapeutic tool in pediatric inflammatory salivary gland disease. STUDY DESIGN: Retrospective review of patient medical records from a private practice consisting of three fellowship-trained pediatric otolaryngologists. METHODS: Consecutive pediatric patients with either recurrent or chronic sialadenitis underwent diagnostic and therapeutic sialendoscopy as an alternative to continued antibiotic therapy or surgical gland excision. Data collected included age, gender, indications for surgery, intraoperative findings, complications, recurrences, follow-up intervals, and need for additional procedures. RESULTS: Twelve pediatric patients underwent sialendsocopy (9 cases of juvenile recurrent parotitis, 3 cases of chronic submandibular sialadenitis. Intraoperative findings included ductal stricture (n = 8), thick intraductal mucus (n = 6), and ductal calculus (n = 1). The only postoperative complication was one case of a submandibular gland, which remained enlarged for 1 month postoperatively before resolving. Average follow-up was 16.5 months (range: 1-49 months), during which time two patients had recurrence (17%). One patient had repeated recurrences that only resolved after salvage parotidectomy. Another patient had one isolated recurrence that resolved with antibiotics. To date, 92% of patients have not required any further surgical intervention after a sialendoscopy procedure. CONCLUSIONS: Sialendoscopy was successfully implemented as a safe and effective technique for management of recurrent and chronic parotid and submandibular sialadenitis in a pediatric otolaryngology practice. LEVEL OF EVIDENCE: 4.

A preliminary report on micronized AlloDerm injection laryngoplasty.

OBJECTIVES: To report the preliminary data of voice and quality-of-life improvement after micronized AlloDerm injection laryngoplasty in patients with unilateral vocal cord paralysis. STUDY DESIGN: A prospective study was conducted in patients with unilateral vocal cord paralysis who underwent injection laryngoplasty with micronized AlloDerm. METHODS: Preoperative and postoperative patient evaluation consisted of videostrobolaryngoscopy, computer voice analysis, airflow, and voice handicap index (VHI) assessment. All injections were conducted with the patient under general anesthesia using the Storz injector system and a 22-gauge spinal needle. RESULTS: Fourteen patients received injection with an average amount of 0.641 mL. Twelve patients were available for evaluation. Initial results at 4 weeks (n = 12) showed significant increase in habitual phonation time from 3.84 to 6.72 seconds (P <.01) and a decrease in airflow from 0.616 to 0.295 I's (P <.01). The VHI rating improved from 62.8 to 37.5 (P <.01). Jitter and shimmer also improved significantly (P <.05). Stroboscopic findings showed complete closure of glottic gap in 10 patients with excellent return of mucosal wave on the injected side. The mucosal wave return after injection was rapid with little evidence of tissue reaction. Postoperative follow-up at 3 months (n = 8) demonstrated slight resorption of the material, but sustained excellent voice was noted in 87.5%. Minimal morbidity and tissue reaction were noted. CONCLUSIONS: Micronized AlloDerm appears to be a safe new material that is suitable for injection laryngoplasty. Long-term results are pending.

Neonatal lingual choristoma with respiratory and gastric epithelium.

Lingual choristomas are rare entities that typically present as benign cystic masses that are lined with a variety of heterotopic epithelia. Lingual choristomas that are lined with respiratory and/or gastric or intestinal mucosa are believed to derive from pluripotential cells of the embryonic foregut. We describe a neonate with a lingual cyst that was lined predominantly by respiratory epithelium and focally by gastric foveolar epithelium, and we review the terminology, etiology, and management of lingual cysts of presumed foregut origin.

Lack of association between esophageal biopsy, bronchoalveolar lavage, and endoscopy findings in hoarse children.

OBJECTIVE: To determine the prevalence of esophagitis (based on esophageal biopsy results) and aspiration (based on bronchoalveolar lavage [BAL]) in children with hoarseness. DESIGN: Retrospective medical chart review spanning 24 months of 127 consecutive children (mean age, 6.9 years; range, 1.8-17 years) who presented with hoarseness to 2 attending otolaryngologists. SETTING: Tertiary care children's hospital.Intervention All subjects underwent direct laryngoscopy, rigid bronchoscopy with BAL, and rigid or flexible esophagoscopy with biopsy. MAIN OUTCOME MEASURES: The BAL result was considered positive if the number of lipid-laden macrophages was "moderate" or "large," and the esophageal biopsy result was considered positive if any 2 of the following 3 histologic criteria were present: basal cell hyperplasia, increased papillary height, and intraepithelial inflammatory infiltrate. Comparisons between subjective endoscopic findings and objective test results were made using the t test and contingency table analysis, where appropriate. RESULTS: Of the 127 children, 104 (82%) had vocal nodules; 53 (43%) had endoscopically visualized laryngitis; 36 (28%) had tracheobronchial inflammatory changes; 60 (47%) had abnormal esophagoscopy findings; 47 (37%) had a positive BAL result; and 38 (30%) had a positive esophageal biopsy result. There was no significant correlation between BAL and esophageal biopsy results (P = .11). The odds of having positive BAL or esophageal biopsy results were unaffected by the presence of vocal nodules; endoscopically visualized inflammation of the larynx, trachea, or esophagus; or symptoms or previous clinical history of gastroesophageal reflux disease. CONCLUSION: Positive esophageal biopsy and BAL results are prevalent among children with hoarseness, regardless of subjective upper aerodigestive tract endoscopic findings.

Intralesional cidofovir for pediatric recurrent respiratory papillomatosis.

OBJECTIVE: To compare disease response among children with recurrent respiratory papillomatosis (RRP) who underwent combined surgical debulking and intralesional cidofovir injections vs repeated surgical debulking only. DESIGN: Retrospective medical record review; follow-up range: 16 to 56 months. SETTING: Tertiary care children's hospital. PATIENTS: Seven children with RRP, including 4 subjects treated with cidofovir and 3 controls matched for age and initial papilloma staging score. INTERVENTIONS: Subjects treated with cidofovir underwent combined surgical debulking and intralesional cidofovir injection every 2 months until disease remission. Control subjects underwent repeated surgical debulking at individually determined intervals. MAIN OUTCOME MEASURES: Intraoperative endoscopic photographs were retrospectively assigned papilloma staging scores. Cidofovir and control group comparisons were made using nonparametric 2-sample Wilcoxon rank-sum (Mann-Whitney) testing, and comparisons of initial and final papilloma staging scores were made using nonparametric matched-pair Wilcoxon signed-rank testing. RESULTS: The final cidofovir group scores were significantly lower than the control group scores (P < .05). Within-group differences between initial and final scores were not significant (cidofovir group, P = .07; control group, P = .29). CONCLUSIONS: Four children with RRP were safely and successfully treated with intralesional cidofovir injection. Consideration should be given to using cidofovir more widely for treatment of pediatric RRP. Larger numbers in the cidofovir and control groups are needed in future studies to determine the true impact of cidofovir on management of this disease.

Management of nontuberculous mycobacterial cervical lymphadenitis.

OBJECTIVE: To review the treatment and outcome of patients with nontuberculous mycobacterial (NTM) cervical lymphadenitis. DESIGN: Retrospective chart review. SETTING: Tertiary care children's hospital. PATIENTS: Thirty consecutive immunocompetent patients (median age, 32 months; age range, 11-147 months) diagnosed as having NTM cervical lymphadenitis over a 77-month period. INTERVENTIONS: Primary therapy for 34 foci of NTM cervical lymphadenitis in 30 children consisted of excisional biopsy (n = 8), incision and drainage procedures (n = 14), fine-needle aspiration biopsy (n = 7), observation only (n = 4), and antimycobacterial chemotherapy only (n = 1). MAIN OUTCOME MEASURES: (1) Time to cure, (2) recurrent adenitis, and (3) complications associated with therapy were determined for each therapeutic option. The average duration of follow-up was 32 months (range, 6-78 months). RESULTS: Nearly all patients (97%) were cured of their disease regardless of which therapeutic option was used. Excisional biopsy, while associated with transient marginal mandibular nerve injury in 1 patient, typically resulted in the most rapid resolution of disease. Observation alone did result in eventual cure, although the disease course was protracted. Simple incision and drainage without curettage was associated with prolonged postoperative wound discharge and hypertrophic scarring. CONCLUSIONS: A variety of therapeutic options were used in children with NTM cervical lymphadenitis. Resolution of infection was an eventual outcome regardless of treatment option, although duration of disease, potential for facial nerve injury, and incidence of hypertrophic scarring varied among the different treatments. An individualized management approach is recommended, with excisional biopsy as the preferred option when feasible.

Mandibular distraction for micrognathia and severe upper airway obstruction.

OBJECTIVE: To determine whether the use of mandibular distraction osteogenesis (DOG) can help to avoid tracheotomy or achieve decannulation in patients with mandibular hypoplasia and severe upper airway obstruction. DESIGN: Retrospective medical record review (spanning a 27-month period). SETTING: Tertiary care children's hospital. SUBJECTS: Group A (n=8) was composed of infants with Pierre Robin sequence and no tracheotomy (mean age, 2.5 months); group B (n=6), older nontracheotomized micrognathic children with obstructive sleep apnea (OSA) (mean age, 69 months); and group C (n=12), tracheotomized children with complex congenital syndromes (mean age, 33 months). INTERVENTION: Bilateral mandibular DOG with endoscopic (n=24) and/or radiographic (n=17) airway evaluation (mean follow-up, 16 months [range, 2-42 months]). OUTCOME MEASURES: Group A, tracheotomy avoidance; group B, resolution of OSA (clinically or on polysomnography); and group C, decannulation. RESULTS: Group A, 7 patients (88%) successfully avoided tracheotomy; group B, 5 patients (83%) had resolution of OSA; and group C, 2 patients (17%) underwent decannulation. CONCLUSIONS: Mandibular DOG (1) allows tracheotomy avoidance in infants with isolated Pierre Robin sequence and (2) relieves OSA in older micrognathic children without tracheotomy. However, mandibular DOG does not frequently lead to decannulation in tracheotomized patients with complex congenital syndromes.

The role of intraoperative rapid parathyroid hormone monitoring for predicting thyroidectomy-related hypocalcemia.

OBJECTIVE: To determine if the intraoperative rapid parathyroid hormone (PTH) assay can be used to accurately predict postoperative calcium levels following total or completion thyroidectomy. DESIGN: A prospective study. SETTING: Tertiary care referral center. PATIENTS: One hundred four patients following a total or completion thyroidectomy.Intervention Intraoperative rapid plasma PTH levels were determined for patients undergoing a total or completion thyroidectomy. MAIN OUTCOME MEASURES: Parathyroid hormone levels were recorded after the induction of anesthesia, before excision, and 5, 10, and 20 minutes after thyroidectomy. Postoperative calcium levels were monitored every 6 hours until hospital discharge. Intraoperative PTH levels were correlated with postoperative calcium levels and clinical symptoms of hypocalcemia. RESULTS: Twenty-two patients (21.2%) required short-term postoperative calcium supplementation, and 2 (1.9%) required long-term calcium replacement. There was a statistically significant difference between those patients requiring calcium replacement and those who did not require calcium supplementation, for postoperative total calcium level (7.2 vs 8.1 mg/dL [1.8 vs 2.0 mmol/L]; P<.001) and ionized calcium level (3.76 vs 4.36 mg/dL [0.94 vs 1.09 mmol/L]; P<.001). In addition, the PTH changes from baseline demonstrated statistically significant differences at 5, 10, and 20 minutes after the excision between the 2 groups (P<.005). In those patients requiring calcium supplementation, 14 (64%) of 22 demonstrated a change in PTH level at 20 minutes of greater than 75% from baseline, and in those patients who did not require postoperative calcium supplementation, 61 (74%) of 82 demonstrated a change in PTH level of less than 75% from baseline (P<.005). CONCLUSION: Intraoperative PTH monitoring may be a useful tool in identifying patients who will not require postoperative calcium supplementation following total or completion thyroidectomy.

Electron microscopic analysis of biofilm on endotracheal tubes removed from intubated neonates.

OBJECTIVES: To determine if the phenomenon of biofilm accumulation and associated microbial colonization occurs on the surface of endotracheal tubes in the region of the subglottis in neonates. METHODS: Endotracheal tubes removed from 9 consecutive neonatal patients intubated for more than 12 hours were processed (range, 13 hours to 8 days). A sterile control tube was also processed. For each, the portion of the endotracheal tube that had been in contact with the subglottis was determined using a previously published nomogram. A 1-cm-long cross-sectional segment of the endotracheal tube corresponding to the level of the subglottis was divided into 2 portions for both electron microscopy and aerobic/anaerobic cultures. RESULTS: Two of 9 (22%) luminal surface cultures grew Staphylococcus species, 1 (11%) grew normal flora, and 6 (66%) had no growth. Three of 9 (33%) outer-surface cultures grew Staphylococcus species, 1 (11%) had gram-negative rods on staining but a sterile culture, and one enterococcal contaminant was found. Electron microscopy revealed that 8 of 9 inner lumen surfaces harbored bacteria and biofilm formation. All outer lumen surfaces had biofilm formation; 6 of 9 had bacterial colonization. There was no obvious difference in the appearance of the inner and outer tube surface accretions. No time-dependent differences were noted except of the longest indwelling tube (8 days). CONCLUSION: This study demonstrates for the first time the presence of biofilm on the outer surface of neonatal endotracheal tubes. The data suggest that the presence of bacteria and/or biofilm does not correlate with other traditional indicators of microbial colonization.

Laryngomalacia induced by exercise in a pediatric patient.

Exercise-induced laryngomalacia (EIL) is characterized by inspiratory stridor that is brought on by exercise (i.e. competitive sports) and fails to respond to treatment with bronchodilators (Smith et al., Ann Otol Rhinol Laryngol 1995;104:537-541). During exercise, (1) spirometric flow volume loops show evidence of variable extrathoracic obstruction, and (2) laryngoscopy shows inspiratory prolapse of supraglottic structures with partial glottic obstruction. Only five cases of probable EIL have been reported in the literature (Smith et al., Ann Otol Rhinol Laryngol 1995;104:537-541; Lakin et al., Chest 1984;86:499-501; Bittleman et al., Chest 1994;106:615-616; Bent et al., Ann Otol Rhinol Laryngol 1996;105:169-175; Chemery et al., Rev Mal Respir 2002;19:641-643). Here, a case of laryngomalacia induced by exercise in a previously asymptomatic 10-year-old athlete with a remote history of laryngomalacia in infancy is presented, and a review of previously reported cases is provided.

Endoscopic KTP laser excision of severe tracheotomy-associated suprastomal collapse.

OBJECTIVE: The purpose of this study was to investigate the feasibility, safety, and clinical utility of potassium-titanium-phosphate (KTP) laser bronchoscopy for excision of severe, obstructing tracheotomy-associated suprastomal collapse. METHODS: A retrospective review was performed of six children at a tertiary care children's hospital with severe tracheotomy-associated collapse of the suprastomal anterior tracheal wall cartilage, precluding decannulation. All subjects had undergone KTP laser endoscopic excision of the collapsed segment of suprastomal tracheal cartilage. Medical records were assessed for: (1) endoscopic demonstration of relief of suprastomal collapse, and (2) successful tracheotomy decannulation. RESULTS: All six patients had endoscopic evidence of relief of suprastomal airway obstruction after KTP laser therapy. Five of six (83%) subsequently underwent successful decannulation. There was one case of minimal thermal airway injury associated with a laser fire during use of the KTP laser, the effects of which were fortunately transient. CONCLUSIONS: KTP laser bronchoscopic excision of severe tracheotomy-associated suprastomal collapse: (1) is a feasible technique; (2) results in relief of suprastomal obstruction with subsequent successful decannulation in selected patients; and (3) avoids the need for more extensive open neck procedures. However, risks of KTP laser therapy are not negligible and strategies must be in place to minimize the occurrence of complications.