[Rhinosurgery in children: developmental and surgical aspects of the growing nose]. / Rhinochirurgie bei Kindern: Entwicklungsphysiologische und chirurgische Aspekte der wachsenden Nase.

The anatomy of the nasal skeleton in newborns and adults are not alike. The complete cartilaginous framework of the neonatal nose becomes partly and gradually ossified during the years of growth and is more vulnerable to trauma in that period. Injury in the early youth may have large consequences for development of a nasal deformity which will increase during growth and reach its peak during and after the adolescent growth spurt. To understand more of the underlying problems of nasal malformations and their treatment (septoplasty) these items became the focus of multiple animal studies in the last 40 years. The effects of surgery on the nasal septum varied considerably, seemingly depending on which experimental animal was used. In review, however, it appeared that the very different techniques of surgery might be even more influential in this respect. Study of one of the larger series of experiments in young rabbits comprised skeletal measurements with statistical analysis and microscopic observations of the tissues. The behaviour of hyaline cartilage of the human nose appeared to be comparable to that of mammals. Cartilage, although resilient, can be easily fractured whereas its tendency to integrated healing is very low, even when the perichondrium has been saved. Also surgical procedures - like in septoplasty - may result in growth disturbances of the nasal skeleton like deviation or nasal spine. Loss of cartilage, as might occur after a septum abscess, is never completely restored despite some cartilage regeneration. In this article the many experimental studies are reviewed and compared. Still there remains a lack of real consensus in the literature concerning the developmental effects of rhinosurgry in children. Based on their observations in animals and a few clinical studies, mostly with small numbers of patients but with a long follow-up, the authors have compiled a list of guidelines to be considered before starting to perform surgery on the growing midface in children.

Subglottic stenosis after endolaryngeal intubation in infants and children: result of wound healing processes.

OBJECTIVE: To study the histopathology of subglottic stenosis in children of different ages after treatment during different periods of time, with or without laser application. Partial resection of the anterior cricoid with adhering stenotic subglottic area in the live young patient provides unique material for studying wound healing and scarring processes. METHODS: 25 specimens obtained from partial cricotracheal resection (PCTR) in children, were histologically processed and stained with Haematoxylin and Eosin, Resorcin and Fuchsin (for elastic fibers), and immunohistochemical staining (for the presence of macrophages). RESULTS: All specimens were found to have severe and sclerotic scarring with squamous metaplasia of the epithelium, loss of glands and elastic mantle fibers (tunica elastica), and dilation of the remaining glands with formation of cysts. Also, the cricoid cartilage was affected on the internal and external side, with irreversible loss of perichondrium on the inside and resorption by macrophages of cartilage on both sides. Detrimental effects of laser therapy were demonstrated in four cases. The normal intercellular matrix was completely destroyed and the number of chondrocytes in the cartilage structure diminished. CONCLUSION: Wound healing after laryngeal injury is a process of intense restoration and reorganization of the various tissues involved. This process, however, does not guarantee complete repair. In the severe cases irreversible scarring has replaced normal tissues. There seems to be no direct relationship between the length of the post-lesional period, the age of the patient and the severity of the stenosis. When subglottic stenosis has developed and the majority of the tissues is replaced by dense fibrous tissue, PCTR is strongly indicated to achieve renewed patency of the airway.

A new in vivo model for testing cartilage grafts and biomaterials: the 'rabbit pinna punch-hole' model.

In this study an animal model was developed for evaluation of the feasibility of cartilage grafts. In the cartilage of the external ear of the rabbit multiple holes, 6 mm in diameter, were punched, leaving the adherent skin intact. Different experimental groups were evaluated. First, the punch-hole model was validated under various conditions to study spontaneous or perichondrial initiated regeneration of the cartilage defect. When both cartilage and perichondrium was excised no spontaneous repair of the cartilage defect was observed. When perichondrium is present, variable patch-like closure of the punch hole was found. As 'golden standard' a punched out piece of cartilage was reimplanted directly. This condition showed adequate closure of the punch hole, however, no perfect integration of graft and surrounding cartilage was observed. Secondly, to evaluate the 'punch-hole model' a biomaterial, trabecular demineralized bovine bone matrix (DBM), was implanted and tested as a scaffold for tissue engineering techniques in vivo and in vitro. Direct implantation of DBM did not lead to any cartilage formation to close the defect. In vivo engineered cartilage, generated by enveloping DBM in perichondrium for 3 weeks, could adequately close the punch hole. When DBM was seeded with isolated chondrocytes in vitro before implantation in the defect, a highly fragmented graft, with some islets of viable cells was seen. To promote an efficient and reliable evaluation of cartilage grafts a semi-quantitative grading system was developed. Items such as quality, quantity and integrity of the cartilage graft were included in a histomorphological grading system to provide information about the properties of a specific cartilage graft. To validate the grading system, all conditions were scored by two independent observers. An excellent reliability (R = 0.96) was seen between the observers. In summary, the rabbit pinna punch-hole model is a reliable and efficient method for first evaluation of cartilage grafts. The results can be easily analyzed using a semi-quantitative grading system.

Pediatric otorhinolaryngology in Europe.

Nowadays Europe encompasses more than 30 countries. These countries differ in climate, in culture, in population density, in history, in socio-economic system and in the organization of medical care. Despite these differences there is a general trend of unification in politics, in industry and in science. In the field of medicine, medical faculties and professional organizations try to harmonize medical curricula and training programmes for medical specialists.

Efficacy of perichondrium and a trabecular demineralized bone matrix for generating cartilage.

A pedicled auricular perichondrial flap wrapped around trabecular demineralized bovine bone matrix can generate an autologous cartilage graft. In earlier experimental studies, it was demonstrated that this graft could be used for nasal and cricoid reconstruction. It was assumed that the vascularization of the perichondrial flap was obligatory, but it was never proven that the flap should be pedicled. Moreover, for clinical use, the dimensions of the auricle would set restrictions to the size of the graft generated. Therefore, the possibility to generate cartilage with a composite graft of a free perichondrial flap wrapped around demineralized bovine bone matrix, by using young New Zealand White rabbits, was studied. This composite graft was implanted at poorly (subcutaneously in the abdominal wall; n = 12), fairly (subcutaneously in the pinna; n = 12), and well-vascularized sites (quadriceps muscle; n = 12). As a control, trabecular demineralized bovine bone matrix was implanted without perichondrial cover. Half of these grafts (n = 6) were harvested after 3 weeks, and the remaining grafts (n = 6) after 6 weeks of implantation. In histologic sections of these grafts, the incidence of cartilage formation was scored. Furthermore, the amount of newly formed cartilage was calculated by computerized histomorphometry. Trabecular demineralized bovine bone matrix without perichondrial cover demonstrated early resorption; no cartilage or bone was formed. In demineralized bovine bone matrix wrapped in perichondrium, early cartilage formed after 3 weeks at well- and fairly vascularized sites. No cartilage could be detected in grafts placed at a poorly vascularized site after 3 weeks; minimal cartilage formed after 6 weeks. In summary, the highest incidence of cartilage formed when trabecular demineralized bovine bone matrix was wrapped either in a pedicled auricular perichondrial flap or in a free perichondrial flap, which was placed at a well-vascularized site. Second, a significantly higher percentage of the total area of the graft was cartilaginized at well-vascularized sites after 3 weeks. The newly generated cartilage contained collagen type II and proteoglycans with hyaluronic acid binding regions, whereas collagen type I was absent, indicating the presence of hyaline cartilage. This study demonstrates that new cartilage suitable for a graft can be generated by free perichondrial flaps, provided that the site of implantation is well vascularized. Consequently, the size of such a graft is no longer limited to the dimensions of the auricle.

Wound healing of cartilage structures in the head and neck region.

This study was performed to determine the various processes involved in the behaviour of hyaline cartilage during the wound healing period after trauma or surgery of vulnerable structures like the nasal septal cartilage and the cricoid. The results of different procedures (perpendicular and parallel to the cartilage surface) in young and young-adult animals were analyzed: septal incision at different locations (young-old), cricoid split (young-old), suturing cartilage, closing defects with autologous cartilage (young), biomaterials (young) and newly engineered cartilage in 4- and 24-week-old rabbits (series of ten animals). Cartilage of the young rabbit and child have similar hyaline cartilage with a varying distribution in thickness. Thinner areas are more susceptible to malformations. Incisions through younger cartilage give rise to some new cartilage formation covered by a new layer of perichondrium: through older, differentiated cartilage the incision causes superficial but permanent necrosis. Edges of cut cartilage mostly do heal by formation of fibrous junctions. This forms a weak spot, sensitive to deviations. The same fate goes for the healing between the autologous graft and the surrounding pre-existent cartilage. Trauma parallel to the surface, leads to inconsistent quantity of neocartilage. With ageing the wound healing and regenerative capacities decrease. In general, biomaterials are less accepted by the surrounding tissues and would impede further growth. Only newly engineered, and thus less differentiated (younger) cartilage of hyaline nature, appeared to be well accepted at the interface with the edges of a cartilage defect. There are indications that the release of growth factors might play a role in cartilage wound healing. In the child as well as the adult, wound healing of hyaline cartilage structures is incomplete, and surgery remains 'experimental' surgery. The clinical implications of gradual loss of the regenerative capacity of hyaline cartilage should be further investigated.

The immediate effects of local trauma on the shape of the cricoid cartilage.

Injury-induced abnormal development of the cricoid ring has been demonstrated in previous growth studies. In this study we focused on the immediate effects of various types of lesions to the cricoid, eliminating the influence of inserting muscles. In isolated, vital cricoids (cricoid explants) the anterior arch was split, creating a small gap between the cut ends. Previous injury to the internal surface of the cricoid ring resulted in a three to four fold increase of the diameter of the gap, actually widening the interrupted cricoid. On the contrary, injuring the external surface of the cricoid cartilage prior to anterior cricoid split, leads to an overlap of the cut edges, and a narrowing of the ring. These injury-specific changes in shape of the cricoid ring are ascribed to the release of interlocked stresses, present in the cartilage. It is suggested that the demonstrated methods to change the shape of the cricoid ring in a predictable way, are relevant for the treatment of patients with cricoid malformation.

Induction in vivo of cartilage grafts for craniofacial reconstruction.

In the craniofacial region, defects of cartilage structures are preferably reconstructed with autologous cartilage. Donor-site morbidity related to the creation of a new defect elsewhere, and a lack of growth potential of the graft--mandatory in children--have stimulated investigators to find other ways to generate new "extra" cartilage. Several biomaterials have been tested as a matrix for the ingrowth of (peri)chondroblasts in experimental animals. In young (growing) rabbits we have developed a process of heterotopic cartilage induction with the use of a demineralized (bovine) bone matrix which is enfolded in a pedicled flap of ear perichondrium for at least three weeks. During this period the demineralized matrix is colonized by macrophages and polymorphonuclear cells which start a process of complete biodegradation of the material. Simultaneously, the collagen matrix is invaded by mesenchymal cells, originating from the perichondrium and differentiating into chondroblasts and later, into chondrocytes forming the intercellular substance. The developing, very young cartilage could be demonstrated as collagen type II, thus, hyaline cartilage. When applied with its adherent perichondrium as a graft, it merges easily with the more matured host cartilage and even appears to be capable of further growth. Therefore, it seems suitable for the reconstruction of a cartilaginous defect in growing cartilaginous structures like the nasal septum or the larynx.

Ultrasound in the diagnosis of cervical tuberculous adenitis.

Ultrasound (US) of cervical tuberculous adenitis (CTA) was demonstrated to produce a characteristic pattern of the affected nodes in the majority of the patients in this study. The contribution of US to the diagnosis and assessment of CTA is evaluated. It is concluded that, since the other diagnostic tests for CTA are not reliable and/or time-consuming, the demonstration of nodal calcifications, conglomerate nodal masses and spread into the subcutaneous tissues at US in patients with elusive cervical masses may result in earlier recognition of CTA.

Psychosocial and physical correlates of survival and recurrence in patients with head and neck carcinoma: results of a 6-year longitudinal study.

BACKGROUND: Studies that have examined correlations between psychosocial factors and survival in cancer patients do not permit any definitive conclusions. To the authors' knowledge, to date no study has examined the relation between medical as well as quality of life variables and survival in head and neck carcinoma patients. The current study focused on the complex interactions among psychosocial, medical, behavioral, and demographic variables as they relate to prognosis in these patients. METHODS: A total of 133 consecutive head and neck carcinoma patients were included in a prospective study at pretreatment. In addition to clinical variables, psychosocial and physical functioning was assessed by means of a self-report questionnaire. RESULTS: During the observation period 57 patients died whereas 76 were still alive at 6 years after treatment. Results of the multivariate survival analysis indicated that patients without head and neck metastasis had a better prognosis than patients with positive cervical lymph nodes. Pretreatment smoking showed a negative correlation with overall survival. Patients who were more physically self-efficacious (i.e., higher perceived physical abilities) were more likely to survive and less likely to develop a recurrence. In addition, patients who expressed intense psychosocial complaints prior to treatment had a better prognosis than had those who did not express such negative feelings. CONCLUSIONS: The current findings linking physical self-efficacy and prognosis are promising, but clinical trials are necessary to examine the direct and indirect mediational pathways of the variables that underlie physical efficacy and influence survival and recurrence. Also, the negative correlation between pretreatment smoking and survival suggests a need for increased efforts to address smoking in newly diagnosed patients.

Growth dynamics of the cricoid cartilage and subglottic injury. An autoradiographic and histometric study in the rabbit.

Earlier studies in young growing rabbits have suggested that post-traumatic developmental deformities of the cricoid might play a role in failing treatment in children with similar injuries. Specific patterns of malformations in the animals occurred preferentially at the anterior side of the cricoid ring. In this study, the growth dynamics of the cricoid were studied by histometry and autoradiography. Results indicated that (1) the cell/matrix ratio remains unchanged from 4 to 24 weeks of age, with both tissue components thus contributing equally to growth of the cricoid; (2) mitoses occur in cartilage and perichondrium, indicating interstitial as well as appositional growth; (3) mitotic activity is mainly restricted to the first 4 weeks of life, while cell hypertrophy is thereafter the dominant feature; (4) the highest degree of mitotic activity and cell hypertrophy is found in the anterior half of the cricoid ring which therefore can be considered as a growth center. This center might play a role in the development of trauma-induced deformation in the anterior part of the cricoid ring.

Management of infantile subglottic hemangioma: laser vaporization, submucous resection, intubation, or intralesional steroids?

The infantile subglottic hemangioma can be treated in various ways. The results of the treatment used in the Sophia Children's Hospital, intralesional steroids and intubation (IS + I), are discussed and compared with the results of other current treatment methods: CO2 laser vaporization, submucous resection and intubation alone. A total of 18 infants were treated for subglottic hemangioma in our hospital: ten with IS + I alone, five were first treated with systemic therapy and later with IS + I alone and three with various therapies. IS + I was effective in 14 of the 15 patients, one patient was lost from follow up. The remaining three infants were treated with (combinations of) various therapies, because IS + I failed or was not tried. Two patients were finally cured, one still has a tracheotomy. Of other current therapies, CO2 laser vaporization is reported to be effective. In all 30% of the infants treated in Boston Children's Hospital with CO2 laser needed a tracheotomy. Moreover subglottic stenosis is a serious complication. Submucous resection is often successful. It may be complicated by subglottic stenosis and in some cases, depending on the localization of the hemangioma, it may be contraindicated. Intubation alone is less effective than intubation combined with intralesional steroids. Management of subglottic hemangioma in Sophia Children's Hospital is primarily intralesional steroids and intubation and secondarily submucous resection or tracheotomy. CO2 laser vaporization is seldom applied because of the risk of subglottic stenosis.

Growth characteristics of the human nasal septum.

Using a specially designed algorithm for the measurement of the surface area of shapes with highly irregular contours, growth curves were developed for post-natal septal growth in humans using post-mortem specimens of a study population of 30 cases, distributed over the age range from birth to 62 years. From the results a rapid growth phase for the total septum is evident immediately after birth, lasting until the second year of life. Then, a gradual deceleration of growth is recognized with a plateau eventually being reached at the age of 36 years. Mathematical analysis of the growth curve shows that the curve for the total septum is the sum of two separate mathematical equations, representing the cartilaginous and bony contribution, respectively. It is demonstrated that the cartilaginous septum reaches adult dimensions (lateral surface area) at the age of two years. Subsequent growth of the septum is due to expansion of the perpendicular plate, i.e. the bony parts of the septum.

Acquired laryngeal stenosis in infants and children treated by laryngofissure and stenting.

Thirty young patients with acquired laryngeal stenosis were treated by means of a laryngofissure and stenting. The age distribution suggested two subgroups: infants aged 0-2 years (n = 24), and children aged 6-16 years (n = 6). The causes of the stenosis and the treatment results were different in these subgroups. Treatment resulted in successful decannulation in 22 of 24 infants, and in 5 of 6 children. Treatment included a re-operation in two patients. In 1 patient the therapy failed, and 2 patients died after fatal complications. Decannulation rate, duration of the tracheotomy, and the number of re-operations compare favorably to the results of other centers. The longer duration of stenting, and the high mortality rate may be considered disadvantages.

Rehabilitation outcomes of long-term survivors treated for head and neck cancer.

BACKGROUND: Little is known about the rehabilitation outcomes of long-term survivors following treatment for head and neck cancer. There are, for example, no studies on physical and psychosocial rehabilitation outcomes of T1 glottic larynx carcinoma, despite the fact that these form the majority of head and neck cancer sites. Thus, this investigation afforded a unique opportunity for examining similarities and differences among T1 glottic larynx patients, laryngectomy patients, and those who had surgery for cancer of the oral cavity and/or oropharynx along a variety of physical and psychosocial dimensions. METHODS: To describe the impact of these three types of head and neck cancer and their treatment on the physical and psychosocial functioning of long-term survivors, a self-report questionnaire was completed by 110 patients treated between 2 and 6 years previously in a major cancer center. RESULTS: Data indicate that a higher percentage of patients treated with laryngectomy or commando procedures still experience severe psychosocial distress between 2 and 6 years after their last treatment than do patients treated with radiotherapy for a T1 carcinoma of the glottic larynx. Psychosocial and physical complaints are still reported by many laryngectomy patients, apparently the result of problems in effective communication with others. Many commando procedure patients experience problems with respect to food intake, and with disfigurement and its consequences. T1 larynx patients mainly experience a considerable number of physical complaints. The greater the time that had elapsed since treatment, the fewer the psychosocial problems associated with head and neck tumors. Open discussion of the illness in the family, social support, and perceptions of adequate information from the specialist are the most important predictors of positive rehabilitation outcomes. CONCLUSIONS: This study indicates that T1 larynx patients report many physical complaints even though several years had elapsed since treatment. Also, laryngectomy patients may need psychosocial guidance for a longer posttreatment period and that health care personnel must involve the partner as much as possible in all communications. Commando procedure patients in particular feel hindered by their disfigurement and its consequences. Future research with respect to validation of the specific head and neck modules is needed.