Endobronchial Non-Tuberculosis Mycobacterium Infection Presenting in a Healthy Child.

OBJECTIVES: To describe a safe and effective treatment for endobronchial Mycobacterium avium complex. METHODS: Case report and literature review. RESULTS: We present a case of endobronchial M. avium complex in a healthy child treated with serial carbon-dioxide laser excisions and antibiotic triple therapy using azithromycin, rifampin, and ethambutol. No current guideline for the treatment of these lesions in the pediatric population exists. CONCLUSIONS: In patients with airway impingement, serial endoscopic surgical resection combined with antibiotics can provide safe and effective management.

Spontaneous retropharyngeal and mediastinal thoracic duct cyst in an infant with respiratory distress.

Thoracic duct cysts (TDC) within the retropharyngeal space and mediastinum are exceedingly rare lesions, with the majority related to trauma or neoplasm. We describe a case of an otherwise healthy 8-month-old boy who presented with severe respiratory distress, which was found to be caused by a large, spontaneous TDC occupying most the retropharyngeal and mediastinal space. To our knowledge, this is the youngest patient to date presenting with TDC. Ultimately, his TDC was completely resolved with sclerotherapy, however the patient's age and size presented unique challenges to his medical management, which we describe below.

A 7-year review of the safety of tonsillectomy during short-term medical mission trips.

OBJECTIVE: To evaluate the safety of tonsillectomy in a short-term medical mission setting. STUDY DESIGN: Retrospective chart review. SETTING: Catholic mission hospital in Guatemala. SUBJECTS AND METHODS: During 7 consecutive annual mission trips from 2004 to 2010, patients received tonsillectomy and adenotonsillectomy. Established safety protocol requires candidates for tonsillectomy to agree to stay within 1 hour of the hospital for 10 days following the operation. This study includes all tonsillectomy patients regardless of age or indication for tonsillectomy. The primary outcome measures include posttonsillectomy hemorrhage, nasopharyngeal reflux, readmission for dehydration, and mortality. This is a novel study as the work performed by most short-term medical missions is unregulated and unevaluated. RESULTS: Medical charts were available for 197 (96.6%) of the 204 patients receiving tonsillectomy in the 7-year period; this was the only inclusion criterion. Ninety-nine (50.3%) patients had tonsillectomy concomitantly with adenoidectomy. Patients ranged in age from 3 to 66 years. The mean (SD) age was 17.2 (14.0) years. The study team found documentation of postoperative complications in 3 (1.5%) patients; 2 experienced postoperative hemorrhage, 1 within the first postoperative hour and 1 at 96 hours. The final patient returned to the hospital within 24 hours symptomatic for dehydration. CONCLUSIONS: The authors have evaluated a protocol for tonsillectomy patients in a specific setting and believe their data represent satisfactory outcomes for the reviewed patients. The generalizability of this information is uncertain, but safety protocols should be established on all short-term medical missions to prevent untoward complications.

Practice patterns after tracheotomy in infants younger than 2 years.

OBJECTIVES: To report survey results of members of the American Society of Pediatric Otolaryngology (ASPO) on the practice patterns of surveillance endoscopy and management of suprastomal granuloma (SSG) in children younger than 2 years with indwelling tracheostomy tubes and to review our internal practice patterns. PATIENTS: All patients younger than 2 years who underwent tracheotomy between 1996 and 2006 at a tertiary children's hospital. INTERVENTIONS: (1) Retrospective medical chart summary and (2) ASPO-approved and -administered online surveys to the membership of a 14-question survey on indications for infant tracheotomy, indications for bronchoscopy after tracheotomy, and treatment preferences for SSG in this population. MAIN OUTCOME MEASURES: Summary and findings of survey results and of data collected from medical chart review, including demographics, medical comorbidities, age at time of tracheotomy, indications for tracheotomy, frequency of bronchoscopy after tracheotomy, frequency of observed SSG, and interventions for SSG. RESULTS: Seventy-five ASPO members completed the online surveys. Practice patterns varied for frequency of bronchoscopy: only as needed, every 12 months, every 6 months, and every 3 months were reported by 38% (n = 26), 25% (n = 17), 24% (n = 17), and 9% (n = 6) of ASPO members, respectively. Most important indications for bronchoscopy were preparation for laryngotracheal reconstruction and decannulation (100% [n = 65] and 92% [n = 60], respectively), bleeding (76% [n = 59]), and difficult tracheostomy tube changes (70% [n = 57]). Lumen obstruction of 25% to 50% and 50% to 75% by SSG would likely receive intervention (30% [n = 22] and 14% [n = 11], respectively) with skin hook eversion and removal being the most popular technique. We reviewed the medical records of a total of 201 infants who underwent tracheotomy at our institution (110 boys [54.7%]). Indications included ventilator dependence (32.2%), craniofacial anomaly (15.0%), cardiopulmonary insufficiency(15.0%), neuromuscular indication (15.0%), and subglottic stenosis (6.7%). Thirty patients (14.9%) were premature (mean gestational age, 27 weeks). Median age at time of tracheotomy was 4 months for premature infants and 3 months for term infants. Practice patterns regarding endoscopy and SSG management varied widely within our own institution. A total of 205 bronchoscopies were performed on 109 patients during the study period. At the time of first bronchoscopy 43 of 109 patients were noted to have an SSG (39.4%). Elective removal of SSG occurred in 20 of 43 cases (46.5%), and 9 of 20 patients were noted to have recurrent SSG at subsequent endoscopy (45%). In addition, of the 23 children who did not have intervention for their SSG, 15 of 23 had spontaneous resolution and no appreciable SSG at the time of follow-up endoscopy (65.0%). CONCLUSIONS: There are currently various practice patterns for surveillance endoscopy and management of SSG in children younger than 2 years with indwelling tracheostomy tubes. Development of clinical practice guidelines on this topic may improve patient care and reduce unnecessary procedures.

Emergence delirium and postoperative pain in children undergoing adenotonsillectomy: a comparison of propofol vs sevoflurane anesthesia.

BACKGROUND: Emergence delirium (ED) is a frequent postoperative complication in young children undergoing ENT procedures and it may be exacerbated by sevoflurane anesthesia whereas propofol maintenance has been suggested to decrease the incidence of ED. The aim of this randomized, prospective, double-blind study was to evaluate the effect of sevoflurane vs propofol anesthesia on the quality of recovery after adenotonsillectomy. METHODS: Forty-two patients were randomized to maintenance with either propofol or sevoflurane for adenotonsillectomy. At the conclusion of surgery, patients were extubated awake. ED and pain were assessed using the Pediatric Anesthesia Emergence Delirium (PAED) and the Children's Hospital of Eastern Ontario Scale (CHEOPS), respectively. Higher PAED scores (0-20) indicate greater severity of ED. Nursing and parental satisfaction, hospital length of stay, postoperative nausea and vomiting (PONV), anesthetic complications, and subsequent emergency room admissions were also assessed. RESULTS: Median PAED score was 14 in the propofol group and 17 in the sevoflurane group (NS). Propofol was associated with less pain medication required during recovery and a lower incidence of PONV (5.3% vs 36.8%, P < 0.05). Nursing and parental satisfaction as well as time spent in recovery room was similar for the two groups. CONCLUSION: Propofol anesthesia does not influence agitation after adenotonsillectomy, as measured by the PAED score. A PAED score of ≥ 10 was not useful in identifying patients with ED. However, propofol maintenance is associated with less need for pain medication in the recovery room and a lower incidence of PONV compared to sevoflurane anesthesia.

Incidence of and risk factors for airway complications following endotracheal intubation for bronchiolitis.

OBJECTIVE: To identify risk factors predisposing to postextubation complications and the incidence of subglottic stenosis following endotracheal intubation for bronchiolitis. STUDY DESIGN AND SETTING: A review of 144 consecutive infants and children intubated for bronchiolitis between 2000 and 2005 at a regional children's hospital. RESULTS: The mean age at diagnosis was 6.4 months. Follow-up data were available in 93 patients (64.6%), and average length of follow-up was 9.3 months. One hundred and three patients (71.5%) had positive RSV detection. Average duration of intubation was 5.5 days. Twenty-six patients (18.1%) required reintubation during the same admission. Children intubated for less than 3 days and those greater than 12 months of age were more likely to experience postextubation difficulties. Approximately 40% of patients experienced postextubation difficulties. Subglottic pathology was found on endoscopy in 6 patients (4%). There were no cases of long-term subglottic stenosis. CONCLUSION: Immediate postextubation complications are common after bronchiolitis, especially in patients intubated for less than 3 days and greater than 12 months of age. We found no evidence of long-term subglottic stenosis in this population.

A retrospective study of tonsillectomy in the under 2-year-old child: indications, perioperative management, and complications.

OBJECTIVE: To retrospectively review the experience with tonsillectomy in the under 2-year-old child at an urban children's hospital. METHODS: The medical records of 94 patients under 2 years old undergoing tonsillectomy between May 1, 1995, and May 31, 2000, were reviewed. The methods of tonsil and adenoid excision were noted, as was the use of perioperative steroids, antibiotics, and antiemetics. Outcome measures studied included the duration of postoperative inpatient observation, complications, time to first oral intake, prevalence of postoperative vomiting, type and duration of respiratory support, and improvement relative to operative indications. RESULTS: Eighty-two patients (87%) underwent tonsillectomy and adenoidectomy (T&A). Twelve patients (13%) underwent tonsillectomy without adenoidectomy. Patient ages ranged from 12 to 23 months (mean 19.6+/-3.1). Indications included obstructive sleep apnea (OSA) in 51 patients (54%), chronic or recurrent tonsillitis in 30 (32%), both OSA and infection in 11 (12%), and acute tonsillitis with airway obstruction in two (2%). Comorbid conditions were numerous. Preoperative polysomnograms were obtained for eight patients (8%). Hospital stays ranged from 4 h to 16 days. Complications included hemorrhage in four patients (4%) and pneumonia in two (2%). Oxygen was required after discharge from the recovery room in 27 patients (29%), with seven more (7%) requiring either reintubation, continuous positive airway pressure, or nasopharyngeal airways. Of the 88 patients on oral diets, only five (5%) took longer than 24 h to resume oral intake. Two patients (2%) experienced significant emesis after surgery. Four patients (4%) required treatment for dehydration after discharge. CONCLUSIONS: Tonsillectomy is a procedure with low morbidity in the otherwise healthy child under 2 years of age. However, we advocate routine postoperative overnight inpatient observation in this age group. We found that young children with comorbid conditions had a higher incidence of complications and required special postoperative management strategies.