Nasal obstruction in the pediatric patient.

Early signals of pathologic causes of nasal obstruction in childhood may pass unnoticed by the unsuspecting physician because these signals mimic innocuous problems such as the common cold, sinusitis, and allergic rhinitis. The hope for early recognition of the more serious causes of nasal obstruction in children depends upon a high degree of suspicion. Some of the common and uncommon causes of nasal obstruction are enumerated by categorizing the possible etiologies into congenital, traumatic, iatrogenic, inflammatory, and neoplastic classifications. With a systematic approach that utilizes history, physical examination, and special diagnostic studies, misdiagnosis can be avoided and treatment initiated more rapidly and effectively.

Historical perspective on the use of otic antimicrobial agents.

Treatment of otorrhea has been described in the literature since 1500 BC. A multitude of therapeutic options have been described, including the use of astringents, antiseptics, alcohol, benzoin and various powders. Since the middle of the 20th century, antibiotic usage has been promoted as the most effective means of therapy. Until recently none of the agents that were used was found to be safe for middle ear use. Since 1990 there have been publications describing the safety and efficacy of fluoroquinolone drops for acute and chronic otorrhea. This article details the transition from treatment of otorrhea with nonspecific means to an era of antimicrobial therapy based on sound scientific evidence.

Laryngeal cystic hygroma.

An unusual case of cervical cystic hygroma with laryngeal extension is reported. A patient with acute upper airway obstruction due to a laryngeal lesion was seen 18 years after the original cervical surgery. Maintenance of an adequate airway has required a partial laryngectomy in addition to repeated endoscopic procedures for removal of recurrent disease. The rationale for this therapy is discussed in light of the current literature.

Percutaneous transnasal sphenoidotomy with sphenoid window.

Ten percutaneous transnasal sphenoidotomies were performed in nine children; and in seven, a sphenoid window was also created. All procedures were performed in the special procedures laboratory, with biplane fluoroscopic guidance used in each case. Under general anesthesia, with the child in the supine position, a 14-gauge antral trocar was placed transnasally into the sphenoid sinus. The sinus was aspirated and material was obtained for culture. A Takahashi forceps was placed via the same tract into the sphenoid sinus. The cusps were centered across the anterior cortex, and under fluoroscopic visualization, opened and rotated 360 degrees, creating a sphenoid window. All procedures were completed without complication, and no child required further surgery.

Growth of the pediatric skull base: assessment using magnetic resonance imaging.

Minimal information is available concerning the gross anatomic changes that occur with skull base development in children. Because clinical and autopsy material to evaluate skull base growth in this population is rare, the author of this study evaluated normal magnetic resonance imaging (MRI) scans in 76 children ranging in age from newborn to 18 years. Growth of the basicranium was assessed in three dimensions: anterior-posterior, medial-lateral, and superior-inferior. In each dimension, growth was noted to be rapid until age 6 years, with relatively slower growth thereafter. In the superior-inferior and anterior-posterior dimensions, both the amount of growth and the asymptotic value were noted to be greater in males than in females (P < .05). The findings of this study can help surgeons select the appropriate operative approach for skull base masses in children. Certain approaches may involve significant morbidity, including mandibulotomy, loss of teeth, oral contamination, and external auditory canal closure. Representative cases managed through an extrapharyngeal transcervical approach are reviewed.

Laryngotracheal stenosis in spondyloepiphyseal dysplasia.

Laryngotracheal stenosis has not been reported previously as a manifestation of spondyloepiphyseal dysplasia. Two recent cases are reported detailing the upper airway pathology encountered. The clinical features of spondyloepiphyseal dysplasia are reviewed in an attempt to develop a treatment protocol for such patients with laryngotracheal stenosis. The ultrastructural abnormalities found in these patients' cartilages are emphasized. Caution is advised before attempting laryngotracheoplasty.

Blunt laryngeal trauma in children.

The diagnosis of laryngeal trauma in an adult trauma patient is usually readily made. It is frequently overlooked in children, however, because of the severity of their concomitant injuries and the unfamiliarity of pediatricians with this type of injury. The child with laryngeal trauma may develop respiratory distress much more quickly than an adult because of the relatively small dimensions of the pediatric airway and the apparent propensity for children to develop edema of the soft tissues of the larynx. This report retrospectively reviews our experience during the past several years with ten children who experienced blunt laryngeal trauma. Emphasis is placed upon the diverse etiologies of laryngeal trauma in children and the importance of both flexible and rigid laryngoscopy in the diagnosis and management of these patients.

Ectopic gastric mucosa in the cervical esophagus.

Ectopic gastric mucosa is a known entity of the mid and lower esophagus which was initially described by Schmidt in 1805. The presence of ectopic gastric mucosa in the cervical esophagus, however, was not described. A review of the literature reveals that ectopic gastric mucosa of the cervical esophagus is not uncommon, but symptoms rarely have been attributed to its presence. This paper reports five patients with isolated inflamed ectopic gastric mucosa in the cervical esophagus who presented with odynophagia and/or dysphagia. Physical examination was unremarkable in each case, and an acid barium esophagram was negative in four of five patients. Factors that distinguish these patients from other cases of odynophagia and dysphagia, as well as detailed clinical findings and treatment, are described. Debate exists as to whether the origin of ectopic gastric mucosa is congenital or acquired. The embryology, gross and microscopic anatomy, and pathologic features are outlined. Patients with persistent dysphagia should have flexible fiberoptic esophagoscopy with an index of suspicion to the existence of ectopic gastric mucosa. Inflamed or ulcerated ectopic gastric mucosa in the cervical esophagus should be treated to relieve symptoms and because of the potential for complications.

Do steroids reduce morbidity of tonsillectomy? Meta-analysis of randomized trials.

OBJECTIVES/HYPOTHESIS: The study aims to reconcile conflicting published reports regarding the clinical efficacy of a single intraoperative dose of dexamethasone in reducing post-tonsillectomy morbidity. STUDY DESIGN: Systematic overview (meta-analysis). METHODS: To critically evaluate the existing evidence, we performed a formal meta-analysis of eight double-blinded, randomized, placebo-controlled studies of dexamethasone in pediatric patients undergoing tonsillectomy or adenotonsillectomy. Reduction in postoperative emesis and pain, as well as early return to soft or solid diet, were studied as distinct end points. RESULTS: Children being given a single intraoperative dose of dexamethasone (dosing, 0.15-1.0 mg/kg; maximum dose, 8-25 mg) were two times less likely to vomit in the first 24 hours than children being given placebo (relative risk [RR] = 0.55; 95% confidence interval [CI], 0.41-0.74; P < .0001). Routine use in four children would be expected to result in one less patient having post-tonsillectomy emesis (risk difference [RD] = -0.24; 95% CI, -0.38 to -0.10; P = .0006). In addition, children being given dexamethasone were more likely to advance to a soft or solid diet on post-tonsillectomy day 1 (RR = 1.69; 95% CI, 1.02-2.79; P = .04) than those being given placebo. Because of missing data and varied outcome measures, pain could not be meaningfully analyzed as a distinct end point. CONCLUSION: Given the frequency of tonsillectomy, relative safety and low cost of dexamethasone, and the reduction in postoperative morbidity, we recommend routine use of a single intravenous dose during pediatric tonsillectomy.

Congenital nasal pyriform aperture stenosis.

Congenital nasal pyriform aperture stenosis is an unusual and previously undescribed cause of nasal airway obstruction in the newborn. The nasal pyriform aperture is narrowed due to bony overgrowth of the nasal process of the maxilla. This anomaly may produce signs and symptoms of nasal airway obstruction in newborns and infants similar to those seen in bilateral posterior choanal atresia. Computed tomography confirms the diagnosis and delineates the anomaly. A series of six patients with nasal pyriform aperture stenosis is presented. Four patients were treated with surgical enlargement of the nasal pyriform aperture via a sublabial approach. One patient was repaired via a transnasal approach, and one patient did not undergo surgical intervention. Follow-up reveals normal nasal airway and facial growth in all patients. Mildly symptomatic patients with congenital nasal pyriform aperture stenosis may be treated expectantly, while severely symptomatic patients benefit from repair via the sublabial approach.

Airway reconstruction following laryngotracheal thermal trauma.

Care of burn patients is a complex problem for the trauma team involving management of fluid and electrolyte imbalances, infections, and ultimately reconstruction. Patients with burns of the head, neck, and upper thorax present a series of unique problems because of a high incidence of associated upper and lower airway thermal trauma necessitating intubation and ventilatory support. A series of cases requiring laryngotracheal reconstruction following severe burns to the head and neck region is reported. Methods of treatment are discussed as well as modifications of standard burn therapy to decrease the incidence of severe scarring.

Acute suppurative thyroiditis in children.

The ability of the thyroid gland to withstand infection is a well known phenomenon. In this regard, inflammatory disease of the thyroid gland in children is an uncommon occurrence. The frequency with which this proceeds to abscess formation is rare. Review of the literature of the past 25 years reveals only 21 reported cases of acute suppurative thyroiditis in children, only one of which has been reported in the otolaryngologic literature. We report two cases of thyroid abscess in children initially presented as painful swellings in the lower neck. An overview of the management of these patients is detailed, including a discussion of the appropriate utilization of diagnostic studies. Demonstration of an internal fistula originating from the pyriform sinus underscores the need to consider a fourth branchial arch remnant as a possible source of infection. The importance of obtaining appropriate bacterial, fungal, and acid-fast cultures is stressed, as is the role of antibiotic therapy and definitive surgery once the diagnosis of thyroid abscess is made.

Innominate artery compression of the trachea: current concepts.

One common vascular anomaly that causes airway obstruction in neonates and infants is innominate artery compression of the trachea. A great deal of controversy exists regarding the effect of this anatomic variant on symptom production. Several cases are presented that demonstrate the unique features of innominate artery compression of the trachea: 1. Innominate artery compression can occur in adolescent patients. 2. Flow volume loops are an effective method of documenting airway compromise in this condition. 3. Exercise intolerance should be considered as a relative indication for surgical intervention in these patients. 4. Reimplantation of the innominate artery is a viable surgical alternative in the treatment of affected patients. 5. Telescopic bronchoscopy during surgical correction of this condition will ensure that there has been successful correction of the tracheal compression. 6. Urgent repair is advocated in patients who experience periods of apnea.

Pediatric laryngotracheal reconstruction with cartilage grafts and endotracheal tube stenting: the single-stage approach.

Laryngotracheal reconstruction (LTR) comprises five stages: 1, characterization of the stenosis; 2, expansion of the lumen; 3, stabilization of the enlarged lumen framework; 4, healing of the surgical site; and 5, decannulation. Single-stage LTR (SS-LTR) combines and compresses stages 3 through 5 (stabilization, healing, and decannulation) into a brief period of postoperative intubation. At Children's Hospital Medical Center in Cincinnati, Ohio, from January 1987 to December 1993, 116 reconstructive procedures were performed by using postoperative intubation. Nine were tracheoplasty or stoma-revision procedures in isolation, leaving 107 SS-LTR procedures that included the laryngotracheal complex. The use of SS-LTR has increased to 30% of LTRs performed in 1993. Data are presented on the success of SS-LTR as measured by the number of decannulations and extubations achieved.

Pediatric aerodigestive foreign body injuries are complications related to timeliness of diagnosis.

Foreign body (FB) injury from aspiration or ingestion is a common pediatric health problem. Diagnosis relies on clinical judgment plus medical history, physical examination, and radiographic evaluation. A multi-institutional review of 1269 FB events revealed that 85% were correctly diagnosed following a single physician encounter. However, 15% of the children had an elusive diagnosis (>1 week), despite previous evaluation. Delays in diagnosis were seven times more likely to occur in aspirations than in ingestions. Secondary injuries (e.g., pneumonia and atelectasis) occurred in 13% of airway FBs but in only 1.7% of esophageal FBs. Plain radiographs were used in 82% of children, and special studies (e.g., fluoroscopy) in only 7%. We conclude that diagnosis of FB injury in children is frequently achieved at the initial evaluation but that continued surveillance by follow-up visits to health care facilities from parents and other caretakers is important, to reduce pulmonary injuries.

Ventilation tube placement in a managed care population.

To date, little information is available regarding the actual incidence of ventilation tube placement in a known population of pediatric patients. We evaluated the incidence of ventilation tube placement in a known population of pediatric patients whose health coverage is provided through a large managed care organization. Epidemiological data provided by a large managed care organization on a population of 67,995 children from July 1, 1993, through June 30, 1994, were evaluated. A primary care physician referral to an otolaryngologist was required for assessment, and precertification for ventilation tube placement was obtained using explicit criteria developed by a large national health services utilization review organization. In children younger than 24 months, 30.11% underwent ventilation tube placement compared with an overall incidence of 4.49% for all children younger than 18 years. The details of this study are presented to understand better the implications of the epidemiology of otitis media and how it relates to a physician's participation in a managed care organization.

Magnetic resonance imaging in the diagnosis of innominate artery compression of the trachea.

In the past, the diagnosis of tracheal compression by intrathoracic arterial structures has been made by using bronchoscopy alone or in combination with one of a variety of imaging techniques, including barium contrast esophagography and cineangiography. However, all of these imaging techniques involve exposure of patients to ionizing radiation and, in the case of angiography, an invasive procedure. The use of magnetic resonance imaging in the diagnosis of thoracic arterial disease is well documented and, more specifically, has been found to be useful in the diagnosis of innominate artery compression of the trachea and congenital vascular rings. This report documents the use of magnetic resonance imaging at the Children's Hospital Medical Center, Cincinnati, Ohio, in the diagnosis of innominate artery compression of the trachea. In addition, the radiographic appearance of this entity is contrasted with other compressive lesions of the trachea.

Balloon dilatation of esophageal strictures in children.

Traditionally, the treatment of esophageal strictures in children has been done with mercury bougies in a prograde fashion or with Tucker dilators passed along a guide wire in a retrograde manner. An alternative approach has used a balloon dilatation catheter passed over a guide wire previously placed under fluoroscopic guidance. Over the past 5 years, this technique has been used in 43 procedures for both discrete and diffuse strictures. The interventions were performed in a total of 15 patients ranging in age from 8 months to 21 years. In all cases, there was improvement of the preceding symptoms following dilatation. This report details the experience with this technique at Children's Hospital Medical Center, Cincinnati, Ohio, emphasizing the indications, contraindications, and potential complications associated with balloon dilatation of esophageal strictures in children.

Four-quadrant cricoid cartilage division in laryngotracheal reconstruction.

Four-quadrant division of the cricoid cartilage is a relatively new technique of laryngotracheal reconstruction. Division of the lateral walls of the cricoid cartilage, with or without placement of autogenous cartilage grafts, allows for increased expansion of the subglottic lumen. Between October 1, 1986, and January 1, 1990, 185 laryngotracheal reconstructions were performed at our institution. During that time, 31 four-quadrant division laryngotracheal reconstruction procedures were performed in 29 patients (mean age at surgery, 5 years 5 months). Grade 3 or 4 laryngeal stenosis existed preoperatively in 72% (22/31) of cases. The initial decannulation rate after four-quadrant division laryngotracheal reconstruction was 58% (18/31). Of 11 patients requiring revision surgery after four-quadrant division laryngotracheal reconstruction, four were eventually decannulated, for an overall decannulation rate of 76% (22/29). The indications, technique, results, and potential complications of four-quadrant division of the cricoid cartilage in laryngotracheal reconstruction are discussed.

Endoscopic access to the infratemporal fossa and skull base: a cadaveric study.

OBJECTIVES: To demonstrate that the regions of the infratemporal fossa and skull base at the level of the foramen ovale can be visualized endoscopically and that structures can be manipulated within these regions using endoscopic instruments. METHODS: Cadaveric dissection of 3 human cadavers using an endoscopic optical dissector. In all, 6 endoscopic infratemporal fossa and skull base approaches were performed. SETTING: Human temporal bone laboratory. RESULTS: A Gillies incision was coupled with a lateral brow incision, and then subperiosteal planes were developed. Endoscopic visualization and instrumentation was then performed. The infratemporal fossa was readily identified. The skull base at the level of the foramen ovale and the branches of the third division of the trigeminal nerve were seen distinctly. A probe was placed with ease within the foramen ovale itself. CONCLUSIONS: Endoscopic access to the infratemporal fossa is readily accomplished, with excellent visualization and instrumentation ability. This novel technique provides access to this remote region for evaluation, possible biopsy, and potential treatment of infratemporal fossa lesions.