Variations of the anterior cricoid split: the effect on airway cross-sectional area in the rabbit.

The anterior cricoid split (ACS) operation has been documented as a successful treatment for the difficult-to-extubate infant or child. The exact mechanism by which this operation is successful is still being investigated. In an effort to further elucidate the effect of the ACS procedure on the subglottic airway, four groups of rabbits were studied. Both size and shape of the subglottic area after surgical manipulation were evaluated, comparing control rabbits with ACS, anteroposterior cricoid split (A-PCS), and partial cricoid split with sparing of soft-tissue lining (partial ACS). The animals were sacrificed 4 weeks after surgery, and the larynxes were harvested. Analysis showed a significant enlargement of the subglottic lumen in all experimental groups as measured at the inner lamina of the cricoid cartilage. However, the true subglottic lumen was significantly enlarged only in the ACS group. Findings showed that true enlargement of the subglottic lumen was limited in all experimental groups to increased thickness in the soft-tissue lining of the subglottic lumen, which was most marked in the A-PCS group. A significant change in subglottic lumen shape occurred in the A-PCS group as well. These results suggest the A-PCS should be approached clinically with caution when a stent is not used.

Modifications of the Furlow palatoplasty (six- and seven-flap palatoplasties).

OBJECTIVE: To assess and compare the Furlow palatoplasty, a modified Furlow palatoplasty, and traditional palatoplasty methods. DESIGN: A retrospective analysis of the results. MAIN OUTCOME MEASURES: Cases were evaluated for operating time and complications, including oronasal fistula and blood loss. RESULTS: There were no fistulas in any of the 19 patients who were included in our study. The modified Furlow palatoplasty was found to increase operating time and blood loss. CONCLUSION: The use of the modified Furlow palatoplasty is feasible in select cases; however, this technique increases operating time and blood loss, which must be balanced against the theoretical advantages of increased palatal function with the Furlow palatoplasty.

Factors influencing palatoplasty and pharyngeal flap surgery.

An experience of 154 patients undergoing palatoplasty or pharyngeal flap surgery at the University of California, Davis, Medical Center (Sacramento) was retrospectively analyzed. There were 114 palatoplasties, 37 pharyngeal flaps, and three combined palatoplasty and pharyngeal flap procedures performed. Factors that could affect postoperative airway compromise, as well as those thought to influence the number of days hospitalized postoperatively, were evaluated using a three-way analysis of covariance. Some degree of airway compromise occurred in 24 patients. The duration of mouth-gag usage strongly correlated with the incidence and severity of airway compromise. Neither steroids nor antibiotics decreased the incidence of respiratory compromise. However, steroids were associated with a decrease in number of days hospitalized (2.7 days vs 4.2 days). The use of intraoperative antibiotics was also associated with a shorter hospitalization (3.5 vs 4.0 days) and with fewer cases of postoperative fever. The high correlation between significant respiratory compromise and duration of mouth-gag usage, as well as clinical observations, suggest that airway compromise in these patients is due to edema of the tongue and related structures secondary to ischemia.

The use of interferon alfa-2a for life-threatening hemangiomas.

Hemangiomas are the most common benign neoplasm in the neonatal period. While most small hemangiomas involute spontaneously, up to 20% may grow to a massive size and never completely involute. Massive hemangiomas are also frequently associated with life-threatening complications, such as airway obstruction, platelet trapping (Kasabach-Merritt syndrome), and high-output heart failure. The use of interferon alfa-2a for the treatment of massive hemangiomas not responsive to traditional therapy has recently been reported. We present the successful use of interferon alfa-2a in a series of five patients with massive hemangiomas complicated by airway compromise, congestive heart failure, need for tracheotomy, Kasabach-Merritt syndrome, and failure to thrive, despite traditional therapy.

A prospective, double-blind, randomized study of the effects of perioperative steroids on palatoplasty patients.

OBJECTIVE: To determine whether perioperative steroids affect the outcome of patients who undergo palatoplasty. DESIGN: A prospective, double-blind, randomized study. SETTING: A university medical center. PATIENTS: Twenty patients undergoing primary repair of a cleft palate. INTERVENTION: A prospective double-blind technique was used to randomly assign patients to receive a placebo or dexamethasone sodium phosphate perioperatively. MAIN OUTCOME MEASURE: Patients were monitored for postoperative airway distress, fever, oral fluid intake, days of hospitalization, and wound healing. RESULTS: The use of perioperative steroids was associated with shorter hospitalizations. No adverse sequelae from the administration of steroids were identified. CONCLUSIONS: In our current managed care environment, the use of perioperative steroids may play an important role in reducing health care costs.

Airway management in the obese child.

Airway management in severely obese children requires familiarity with the equipment and techniques used for establishing a patent airway. Normal anatomic landmarks are obscured in these patients, making assessment a challenge. Therapy should be individualized, and because the airway is marginal in many of these patients, small insults, such as respiratory tract infection or loss of muscle tone during sleep, can result in a perilous airway. Pediatric airway charts should be maintained and reviewed frequently in emergency departments and clinics caring for these patients. Currently, the body of literature devoted to airway management in obese children is small. Inconsistencies in parameters make comparison of studies difficult. Continued, consistent reporting of airway-management issues in these patients is needed.

Pathologic analysis of routine tonsillectomy and adenoidectomy specimens.

OBJECTIVES: Recent literature has suggested that histopathologic analysis of routine tonsillectomy and adenoidectomy (T&A) specimens may be unnecessary. This study investigates T&A specimen handling practices in the United States between 1989 and 1999. METHODS: Surveys were sent to 4715 members of the American Academy of Otolaryngology. Surveys assessed practice type, pathologic processing practices (full, gross, no pathology), and reasons for change. The authors also performed a retrospective analysis of 1583 pediatric T&A specimens for evidence of occult malignancy. RESULTS: Practice types were 80% private, 12% academic, 6% salaried, and 2% military. Chi squared analysis revealed a significant increase (P < 0.001) in respondents ordering "gross only" and "no pathology." The retrospective analysis found no occult malignancies. CONCLUSIONS: There is a statistically significant increase in the number of otolaryngologists sending routine T&A specimens for "gross only" and "no pathology." There was no correlation between the type of practice and changes in pathologic analysis performed.

Transient sensorineural hearing loss after overuse of portable headphone cassette radios.

Noise-induced sensorineural hearing loss has been associated with industry for many years. One conservative estimate suggests that 10 million Americans may have industry-related, noise-induced hearing loss. Acoustic trauma from any source, whether associated with work or recreations, is detrimental to hearing. The Occupational Safety and Health Administration has set industrial standards for noise levels, with current standards limiting noise exposure to 95 dBA for 2 hours daily. To date, however, there are no recreational standards. Many portable headphone cassette radios produce peak outputs of more than 100 dBA. Temporary threshold shifts could result from listening levels near the maximum output. Permanent sensorineural loss may result with repeated exposure. A pilot study was conducted in which 16 volunteers listened to headphone sets for 3 hours at their usual maximum level. Six volunteers showed transient shifts of 10 dB, and one volunteer showed a transient shift of approximately 30 dB. These shifts returned to normal within 24 hours. As expected, transient shifts frequently occur with recreational use. Therefore, recreational warnings and standards should be established.

Management of benign fistulae between Zenker's diverticulum and the trachea.

Cases of acquired benign fistula of the respiratory tree and esophagus have been reported in relation to Mycobacterium tuberculosis and trauma. Fistula formation between the trachea and a Zenker's diverticulum is a similar type of condition in which nutritional and immunological deficiencies can rapidly result in further complications which may mimic a malignancy. Spontaneous fistula formation and vocal cord paralysis may result. Surgical management of this condition includes interposing viable muscle between the esophagus and trachea at the repair site.

The intrinsic response of the cricoid cartilage to vertical division.

The explanation for the separation in the cricoid cartilage after the anterior cricoid split procedure has been a matter of speculation. Whether it is caused by extrinsic factors such as stenting, contraction of laryngeal muscles, fibrosis, or whether it is due to the intrinsic nature of the cricoid cartilage itself has yet to be defined. Whole organ in vitro cultures of juvenile gerbil cricoid cartilages were utilized to study the intrinsic response of cricoid cartilage to anterior vertical division. Our results showed the cricoid cartilage to immediately separate, and that separation to markedly increase during whole organ culture. These results suggest that while extrinsic factors may modify the gap after the anterior cricoid split procedure, the intrinsic nature of the cricoid cartilage itself results in the gap formation.

Independent effects of denervating the cricothyroid muscle and stenting on the anterior cricoid split: canine model.

The anterior cricoid split (ACS) has gained in popularity since its introduction in 1980, for the treatment of the difficult to extubate child. The procedure allows a successful extubation and avoids a tracheotomy about 75% of the time. How the ACS allows extubation remains poorly understood. Animal research has shown that in the canine model the ACS results in a gap in the cricoid cartilage with a subjective increase in the subglottic space (Senders and Eisele, 1978). This gap in the cricoid cartilage develops whether or not an endotracheal tube stent is used. This experiment was designed to quantitatively evaluate the effect of the ACS on the subglottic space with or without the use of the stent, and to evaluate the effect of the cricothyroid muscle on the ACS procedure. The results show that the ACS does result in an increase in the subcricoid space, and that the use of an endotracheal tube stent does result in a larger increase. The cricothyroid muscle has a strong immediate effect on the gap in the cricoid cartilage, which is eliminated by sectioning the external laryngeal nerve. The long-term effects of sectioning the external laryngeal nerve on the gap in the cricoid cartilage were not conclusive.

Lingual pressures induced by mouthgags.

Airway obstruction from tongue edema following intraoral procedures is uncommon. However, the insidious nature of postoperative lingual edema and the gravity of acute airway obstruction requires diligent monitoring by the surgeon. The etiology of lingual edema is likely related to tissue ischemia, secondary to venous or arterial obstruction. This study shows that during normal usage the mouthgag can easily generate pressures which typically exceed venous pressure and often exceeds arterial pressure. Suspension of the mouthgag almost always exceeds arterial pressure. Whether that pressure is transferred to the respective arteries and veins is likely highly variable and relates to the patient's individual dentofacial anatomy. Avoidance of these high pressures should minimize the risk of postoperative lingual edema. The U.C. Davis Mouthgag Usage Protocol is presented.

The anterior cricoid split explored via the canine model, preliminary studies.

Since Cotton and Seid introduced a new surgical procedure, the anterior cricoid split in 1980, the treatment of the difficult-to-extubate infant or child has changed dramatically. The mechanics of how the procedure works are poorly understood. This study was undertaken to investigate the effects of the anterior cricoid split on the cricoid cartilage. The technique was modified so as to allow placement and maintenance of an endotracheal tube but still allow normal activity in the canine subjects. Australian Shepherd puppies were divided into 3 groups. Group 1 underwent the anterior cricoid split procedure with placement of an endotracheal tube stent, Group 2 underwent the anterior cricoid split procedure without the use of a stent, and Group 3 served as controls. All animals were sacrificed at 12 weeks of age. The results show that there was an actual gap in the cricoid cartilage in all animals that underwent the anterior cricoid split procedure. Stenting with an endotracheal tube significantly increased this gap. These results suggest that in the canine model the anterior cricoid split may be used to actually increase the size of the subglottic space.

Laser supraglottoplasty for laryngomalacia: are specific anatomical defects more influential than associated anomalies on outcome?

OBJECTIVE: To evaluate different CO2 laser procedures on children with various types of laryngomalacia and determine the role of associated anomalies on the outcome. DESIGN: Retrospective chart review. SETTING: Academic tertiary referral center. PATIENTS: Twenty-three children who underwent laser supraglottoplasty for laryngomalacia between 1991 and 1998 at the UC Davis Medical Center. INTERVENTIONS: CO2 laser vaporization of redundant supraglottic mucosa of the aryepiglottic fold, arytenoid, and the epiglottis, or modification of the latter, either individually or in combination, based on the obstructing anatomy. OUTCOME MEASURES: Immediate, short term, intermediate and long term relief of respiratory symptoms, feeding difficulties, effect of associated anomalies on outcome, effect of specific anatomic obstructing site and surgical procedure performed on outcome, and the incidence of complications inherent to the procedure. RESULTS: Children without associated anomalies invariably did very well, with 78% immediately resolving their respiratory symptoms and 100% within a week. Twelve of the 14 patients with unfavorable immediate results (P<0.01) and all ten with short term unfavorable results (P<0.05) had neurologic or anatomic associated anomalies. Seven patients, all with associated anomalies, were considered surgical failures (P<0.05). These patients also had a significantly longer hospital stay (P<0.01). The presence of associated anomalies was significant (P<0.01) in determining surgical treatment of reflux or the need for an NG tube in treating feeding problems. The anatomic site of abnormality and the specific procedure performed did not affect the outcome. There were no serious complications inherent to this procedure. CONCLUSIONS: Laser supraglottoplasty, in its different modalities, is a safe and effective treatment for all types of laryngomalacia, but children with associated neurologic or anatomic anomalies will have a more complicated immediate and short term course, as well as a significant incidence of failure. Gastroesophageal reflux is an important associated condition that requires investigation in these patients, and in severe cases will merit surgical procedures to manage. The high incidence of associated neuromuscular anomalies suggests that this component has an important role in the etiology of laryngomalacia.

Congenital hairy polyp of the nasopharynx associated with cleft palate: report of two cases.

Congenital hairy polyp of the nasopharynx is an unusual but well-recognized entity. These benign lesions have not been reported in the modern literature in association with cleft palate. We report two cases of hairy polyp in association with cleft palate, and discuss the pathology of the tumor with emphasis on embryology and pathogenesis.

Evaluation of a stented laryngoplasty for correction of cranial glottic stenosis in four dogs.

After laryngeal surgery, cranial glottic stenosis secondary to laryngeal web formation was diagnosed as the cause of upper airway obstruction in 4 dogs. Initial treatment of 3 dogs by peroral laryngeal web excision resulted in rapid recurrence of clinical signs. Subsequently, these 3 and the fourth dog were treated by scar excision, mucosal flap coverage, and placement of a silicone intraluminal laryngeal stent for 14 days. By 5 months (average) after surgery, on the basis of clinical evaluation of exercise intolerance, respiratory distress, and stridor, all dogs had alleviation of upper airway obstruction.

Otolaryngological manifestations of factitious disorders--a case and literature review.

Otolaryngological manifestations of factitious disorders are rare. The case of a health care worker who injected her face and orbits with air in order to masquerade as facial cellulitis is presented. The literature and treatment strategies are reviewed.

Management of velopharyngeal competence.

Velopharyngeal dysfunction is common in patients with a repaired cleft palate or unrepaired submucous cleft palates. The optimal time of surgical repair is 4 to 6 years of age after a thorough speech evaluation and speech therapy. Assessment of the velopharyngeal defect during speech allows the surgeon to customize the surgery to the patient. Patients require careful monitoring postoperatively for obstructive sleep apnea.

Mandibular distraction osteogenesis: at what age to proceed.

OBJECTIVE: To evaluate if there is a difference in mandibular distraction osteogenesis (MDO) treatment success rates and adverse outcomes in newborns, early infants, and older pediatric patients. DESIGN: Retrospective medical review spanning a nine-year period. Ten newborn (≤ 35 days old), five early infant (36 days-5 months) and eight older pediatric (> 5 months) patients underwent MDO for treatment of micrognathia with a severe tongue-based obstruction. Success was defined as avoidance of tracheostomy or CPAP, and decannulation of patients with tracheotomies. Postoperative complications were grouped into minor and major. RESULTS: MDO successfully treated 90% of newborns, 100% of early infants and 100% of older pediatric patients. There was no difference in the rates of success (p=0.48), minor (p=1.00) and major (p=1.00) postoperative complications between newborns and early infants. Older pediatric patients had no treatment failures, tended to have fewer minor (p=0.18) and significantly fewer major (p= 0.04) postoperative complications compared to younger patients. The distractor pin mobility (9%) and scar revisions (13%) were uncommon. CONCLUSIONS: Mandibular distraction osteogenesis is a reliable method for relieving severe tongue-based obstructions in pediatric patients. When comparing newborns and early infant patients, treatment success rates and the occurrence of complications were not found to be different. Older pediatric patients had no treatment failures, and tended to have fewer postoperative complications compared to younger patients.