Utility of two-stage laryngotracheal reconstruction in the management of subglottic stenosis in adults.

OBJECTIVES: We examined a retrospective case series to evaluate the utility of two-stage laryngotracheal reconstruction (LTR) in the management of subglottic stenosis (SGS) in adults. Operative correction of SGS with LTR has been practiced successfully in the pediatric population. However, in the adult population, cricotracheal resection has been a more common alternative. METHODS: We reviewed the medical records at the Wayne State University Department of Otolaryngology-Head and Neck Surgery. We included all adult patients with SGS who underwent LTR and completed the recommended procedures between December 24, 2003, and October 1,2010. RESULTS: Twelve of the 14 patients identified were decannulated (86%). Of the 12 decannulated patients, 1 required a salvage operation, eventually achieving decannulation after cricotracheal resection. Therefore, although our overall decannulation rate was 86%, the rate with LTR alone was 79%. The majority of our patients (71%) had high-grade (grade III or IV) stenosis. CONCLUSIONS: We conclude that LTR is a viable option for adult patients with SGS. In children, LTR is a relatively safe and often-performed procedure. With use of modern techniques, it has the potential to be applicable to adults, as well. It has the added benefit of avoiding the pitfalls and complications associated with cricotracheal resection.

Systematic review of endoscopic airway findings in children with gastroesophageal reflux disease.

OBJECTIVES: We performed a systematic review of published literature correlating findings on endoscopic evaluation of the larynx and trachea in the pediatric population with the incidence of gastroesophageal reflux disease. METHODS: Eight articles were identified through a structured PubMed search of English-language literature using the key terms laryngopharyngeal reflux, extraesophageal reflux, and gastroesophageal reflux. A systematic review was performed relating the presence of reflux in the pediatric population to findings on endoscopic airway evaluation. A covariant analysis was performed, and each study was weighted according to the number of available samples in that study as a fraction of the total. Overall odds ratios and confidence intervals were computed for each endoscopic finding on the basis of the documented absence or presence of gastroesophageal reflux disease. RESULTS: A correlation was seen between the endoscopic findings and the presence of reflux. CONCLUSIONS: Arytenoid, postglottic, and vocal fold edema and erythema, lingual tonsil hypertrophy, laryngomalacia, and subglottic stenosis are among the endoscopic findings most frequently identified in patients with gastroesophageal reflux disease. Certain findings commonly encountered on endoscopic evaluation of the larynx and trachea in children who present with respiratory symptoms do indeed demonstrate a correlation with the presence of laryngopharyngeal reflux disease and may indicate the need for antireflux therapy.

Biofilms and chronic otitis media: an initial exploration into the role of biofilms in the pathogenesis of chronic otitis media.

PURPOSE: The aim of the study was to compare the extent of biofilm infection in percentage of mucosal surface area of adenoids removed from children with otitis media with effusion (OME) vs those with recurrent acute otitis media (RAOM) and obstructive sleep apnea (OSA). MATERIALS AND METHODS: Comparative microanatomical investigation of adenoid mucosa using scanning electron microscopy obtained from 30 children with OME, RAOM, and OSA was used in this study. Seventeen males and 13 females ranging in age from 9 months to 10 years were included in this study. Percentage of biofilm surface area involvement was the main measure. RESULTS: Adenoids removed from patients with OME had moderately dense mature biofilms covering the mucosal surface with a mean of 27.7% of their mucosal surface covered with mature biofilms. These results were distinct from results obtained from patients diagnosed with RAOM and OSA with means of 97.6% and 0.10% of their mucosal surfaces covered with mature biofilms, respectively. These differences were statistically significant at P < .0001. CONCLUSIONS: Adenoids removed from patients with OME were characterized by distinctly different percentage of biofilm mucosal surface area coverage, with significantly more biofilm presence than OSA patients but significantly less biofilm presence than RAOM patients. Although previous investigations have supported a dominant role of nasopharyngeal biofilms in RAOM pathogenesis, these results suggest nasopharyngeal biofilms may play a different role in the pathogenesis of OME and that this clinical entity may be more multifactorial in nature.

Demonstration of nasopharyngeal and middle ear mucosal biofilms in an animal model of acute otitis media.

OBJECTIVES: We performed this study to determine the role of nasopharyngeal and middle ear (ME) biofilms in acute otitis media (AOM). METHODS: Sixty female 6-month-old chinchillas, free of ME disease, were utilized. Experimental animals were inoculated with influenza A followed by Streptococcus pneumoniae 7 days later. Control animals were inoculated with Sorensen's phosphate buffer. Daily otoscopy and tympanometry was performed, and the animals were painlessly sacrificed on days 1, 2, 5, 8, and 14. All mucosae were harvested and prepared for scanning electron microscopy. RESULTS: The ME inflammation, initially detected on day 2 after bacterial inoculation, peaked on day 8. Eight percent of the dually inoculated chinchillas displayed type B tympanograms, and 40% displayed type C. Otoscopic evaluation of tympanic membrane inflammation was rated from 0 to 4 (0 = normal and 4 = severe drainage and/or inflammation) according to an otoscopic grading system. Ten percent of the experimental chinchillas had a grade 2 score, 20% had grade 3, and 6.7% had grade 4. The controls demonstrated no abnormal tympanometric or otoscopic findings. Scanning electron microscopic imaging showed dense biofilms on 83% of the nasopharynges and 67% of the MEs on day 8 in the experimental animals. All animals with ME biofilms had biofilms in the nasopharynx. The controls did not demonstrate biofilm formation. CONCLUSIONS: The study parallels the natural pathogenesis of AOM in humans. The demonstration of mucosal biofilms in both the nasopharynx (58%) and the ME (47%) of animals with ME inflammation and/or infection lends further support to the importance of mucosal biofilms in the pathogenesis of AOM.

Biofilm density in the pediatric nasopharynx: recurrent acute otitis media versus obstructive sleep apnea.

OBJECTIVES: We compared the biofilm surface density of adenoids removed from children with recurrent acute otitis media (RAOM) to that of adenoids removed from children with a diagnosis of obstructive sleep apnea (OSA). METHODS: We performed a comparative microanatomic study of adenoid mucosa using scanning electron microscopy in patients with diagnoses of RAOM and OSA (27 female and 41 male; age range, 3 months to 15 years). RESULTS: The adenoids removed from patients with RAOM had dense, mature biofilms covering nearly their entire mucosal surfaces. More specifically, the adenoids removed from patients with RAOM had an average of 93.53% of their mucosal surface covered, versus an average of 1.01% coverage on the adenoids removed from patients with OSA. These differences were statistically significant (p < 0.0001). CONCLUSIONS: The adenoids removed from patients with RAOM had almost their entire mucosal surface covered with biofilms, versus scant coverage for patients with OSA. Recurrent acute otitis media is notoriously resistant to antibiotic treatment, and aspirates of middle ear fluid repeatedly yield negative cultures. It is these properties that have led biofilms to become increasingly implicated in the pathogenesis of RAOM. Thus, the resistance of biofilms to antimicrobials, together with their planktonic shedding of organisms, may be an important mechanism in the development of RAOM.

Craniocervical necrotizing fasciitis with and without thoracic extension: management strategies and outcome.

OBJECTIVE: First objective was to review cases of craniocervical necrotizing fasciitis (CCNF) at Wayne State University/Detroit Medical Center (Detroit, MI) for the last 18 years. Second was to analyze patients with and without thoracic extension for contributing factors. METHODS: Retrospective review of 660 patients with necrotizing fasciitis treated at WSU/DMC from January 1989 to January 2007 was conducted. Data regarding source/extent of infection, presenting signs/symptoms, computed tomography, microbiology, antibiotics, comorbidities, number/type of operations, hyperbaric oxygen (HBO) therapy, hospital duration, complications, and overall outcome were compared/analyzed between patients with and without thoracic extension. RESULTS: Twenty patients with CCNF for the past 18 years met the inclusion criteria. Ten patients had thoracic extension, and 10 patients did not have. Individuals in the thoracic extension group were likely to be older, had increased comorbidity, required more surgical debridement, experienced increased postoperative complications, and had lower overall survival. Three patients with thoracic extension underwent HBO therapy and 66% survived. CONCLUSION: This is the largest single institutional review of CCNF comparing patients with and without thoracic extension. Patients with thoracic extension have a poorer outcome as follows: 60% (6/10) survival vs 100% (10/10) for those without thoracic extension (P < .05). The CCNF patients without thoracic extension treated at our institution all survived after prompt medical and surgical intervention. Overall survival of CCNF patients without thoracic extension may be attributed to rigorous wound care, broad spectrum intravenous antibiotics, aggressive surgical debridement, and vigilant care in surgical intensive care unit. The HBO therapy should be included if the patient can tolerate it.

Correlating the clinical course of recurrent croup with endoscopic findings: a retrospective observational study.

OBJECTIVES: We sought to correlate endoscopic findings with the clinical course of recurrent croup. METHODS: Children were classified as having recurrent croup if they had had 2 or more episodes of barky cough, inspiratory stridor, and hoarseness. All study participants underwent direct laryngoscopy and bronchoscopy and were started on an antireflux regimen. A telephone questionnaire assessed the child's symptoms and treatment response. RESULTS: Forty-seven children with recurrent croup were seen in our otolaryngology outpatient clinic. Demographics included a male-to-female ratio of 1.6 to 1 and an age range of 1 month to 11 years (median, 20 months). Thirty patients (63.8%) had a medical history of asthma, and 10 (21.3%) came with a prior diagnosis of gastroesophageal reflux. Gastroesophageal reflux-related laryngopharyngeal changes were seen during direct laryngoscopy and bronchoscopy in 87.2%. Of those with survey follow-up, 87.5% had improvement of respiratory symptoms after a 6- to 9-month course of antireflux medications. This finding was further reflected in a decreased number and duration of episodes (p < .0001). CONCLUSIONS: The underlying narrowing process of recurrent croup can be attributed to gastroesophageal reflux and should be considered in any child with persistent barky cough, inspiratory stridor, and hoarseness. To confirm the diagnosis, diagnostic methods should be correlated with symptom progression after treatment initiation.

Pediatric chronic rhinosinusitis: a retrospective review.

PURPOSE: Chronic rhinosinusitis (CRS) is a major cause of morbidity in the pediatric population and a difficult entity to treat with a poorly defined pathophysiology and diagnostic criteria. Functional endoscopic sinus surgery (FESS) has proven to be effective for these patients, but concerns remain regarding its possible interference with facial growth. Recently, stepwise treatment protocols, which include maxillary sinus irrigation followed by long-term intravenous (IV) antibiotics, have been demonstrated to be effective alternatives to FESS. However, long-term IV therapy is inconvenient and not without complications. The purpose of this study is to review one institution's experience in treating medically refractory pediatric CRS, specifically to describe the epidemiology of the affected population and estimate the success of a stepped treatment protocol using long-term double oral antibiotic therapy for its treatment. MATERIALS AND METHODS: A retrospective review of the medical records of 23 patients who received treatment. RESULTS: Mean age was 2.3 years. Clinical resolution was achieved in 96% of patients and in 78% without the use of IV antibiotics. Four patients who required IV antibiotics subsequently tested positive for immune deficiency. Long-term resolution rate was 78% overall and 86% for those that did not require IV antibiotics. No complications were reported, and no patients required FESS. CONCLUSIONS: A stepwise protocol that includes concurrent adenoidectomy and bilateral maxillary sinus irrigation followed by long-term double oral antibiotic therapy is safe and effective for the treatment of pediatric CRS. Patients with immunodeficiency may require long-term IV therapy to achieve symptom resolution.

Biofilm surface area in the pediatric nasopharynx: Chronic rhinosinusitis vs obstructive sleep apnea.

OBJECTIVE: To compare the percentage of mucosal surface area of adenoids infected with biofilms removed from children with chronic rhinosinusitis (CRS) vs children with obstructive sleep apnea (OSA). DESIGN: Comparative microanatomical investigation of adenoid mucosa from patients with CRS and OSA using scanning electron microscopy. SETTING: University-affiliated hospitals and ambulatory surgery center. PATIENTS: Four girls and 12 boys ranging in age from 3 months to 10 years. MAIN OUTCOME MEASURE: Measurements of biofilm coverage of the entire adenoidal surface. RESULTS: Adenoids removed from patients with CRS had dense mature biofilms covering the mucosal surface; they had a mean of 94.9% of their mucosal surface covered with mature biofilms, compared with a mean of 1.9% coverage on the adenoids removed from patients with OSA. This difference was statistically significant at P < .001. CONCLUSIONS: Adenoids removed from patients with CRS had almost their entire mucosal surface covered with biofilms vs scant coverage for patients with OSA. Biofilms in the nasopharynx of children with CRS may act as a chronic reservoir for bacterial pathogens resistant to standard antibiotics. The mechanical debridement of the nasopharyngeal biofilms may explain the observed clinical benefit associated with adenoidectomy in this subset of pediatric patients.

Identification of Helicobacter pylori biofilms in human gastric mucosa.

The purpose of this study was to use endoscopically directed biopsies and scanning electron microscopy (SEM) to document the existence of Helicobacter pylori biofilms in human gastric mucosa. Patients underwent flexible esophagogastroduodenoscopies with three gastric mucosal biopsies. Rapid urease testing was performed to determine the presence or absence of H pylori. Urease-positive and urease-negative control specimens were imaged with SEM to obtain detailed images of gastric mucosa for the identification of biofilm colonies. Samples were obtained from patients who underwent esophagogastroduodenoscopies. Eleven were found to be H pylori positive and nine were H pylori negative. These were imaged at 500x and 1000x with electron microscopy. Dense, mature biofilms were present and attached to the cell surface of H pylori-positive specimens and were absent in urease-negative controls. Photomicrographs were obtained. Biofilms are complex microbiological ecosystems where sessile bacteria surround themselves in a protective matrix. This lifestyle affords protection, allows for growth in hostile environments, and alters host physiology. Many have hypothesized that H pylori infections resulting in gastric ulcers may be a manifestation of biofilms. Our investigation is the first to photographically document the existence of H pylori biofilms on human gastric mucosa. This elucidation of the ecology and pathophysiology of the mucosa of the organism is important to our understanding of a potential mechanism of this organism's resistance to current therapy and how to better eradicate it in the future.

Presence and density of Helicobacter pylori biofilms in human gastric mucosa in patients with peptic ulcer disease.

Our purpose was to use endoscopically directed biopsies and scanning electron microscopy to quantify Helicobacter pylori biofilm density on the surface of human gastric mucosa in urease-positive and -negative patients. Participating patients underwent flexible esophago-gastro-duodenoscopies coupled with gastric mucosal biopsies. Rapid urease testing was performed on all specimens to determine the presence of H. pylori, followed by scanning electron microscopy to identify the existence of biofilms. Samples were then analyzed using Carnoy Image Analysis Software to determine percent biofilm coverage of the total surface area. These data were compared to control specimens that were urease negative. Of the patients who tested urease positive for H. pylori, the average percent of total surface area covered by biofilms was 97.3%. Those testing negative had an average surface area coverage of only 1.64%. These differences were determined to be statistically significant at the 0.0001 level. This study demonstrates that compared with controls, urease-positive specimens have significant biofilm formation, whereas urease-negative specimens have little to none. This was reflected in the significantly increased biofilm surface density in urease positive specimens compared with urease-negative controls.

Temperature-controlled radiofrequency treatment of tonsillar hypertrophy for reduction of upper airway obstruction in pediatric patients.

OBJECTIVES: To determine if temperature-controlled radiofrequency (TCRF) tonsil reduction and adenoidectomy (TCRF&A) and conventional tonsillectomy and adenoidectomy (T&A) are statistically similar in outcome and to compare morbidity between TCRF&A and conventional T&A. DESIGN: Randomized control trial. SETTING: Tertiary care children's hospital. PARTICIPANTS: The study population comprised 23 patients aged 2.6 to 12.5 years with symptoms of obstructive sleep apnea, hypertrophic tonsils with no other areas of upper airway obstruction with the exception of hypertrophic adenoids, and a body mass index (calculated as weight in kilograms divided by the square of height in meters) of less than 30. INTERVENTION: Temperature-controlled radiofrequency tonsil reduction (mean +/- SD, 12.6 +/- 1.5 ablations per patient and 994.68 +/- 91.88 J per insertion) and adenoidectomy or traditional bovie T&A. MAIN OUTCOME MEASURES: Primary outcomes were respiratory distress index and total volume reduction. Secondary outcomes include postoperative pain, daytime sleepiness, speech and swallowing problems, weight and diet, narcotic use, and analogue snoring scale. RESULTS: The respiratory distress index difference for TCRF&A was 5.63 vs 6.56 for standard T&A. On postoperative day 1 for the 13 patients who underwent TCRF&A, 0 reported severe pain, 11 (85%) had mild to moderate pain, and 2 (15%) had no pain. In the 10 patients who underwent standard T&A, 1 (10%) had severe pain and 9 (90%) had mild to moderate pain. By postoperative week 1, all TCRF&A patients experienced mild or no pain, whereas 1 (10%) of the standard T&A patients still had moderate pain. Mean visual analogue snore scores (0-10) 4 weeks after surgery were less than 1 for both groups. The mean +/- SD weight loss at postoperative week 1 for TCRF tonsil reduction patients was 1.0 +/- 3.5 lb (0.45 +/- 1.58 kg) vs 4.6 +/- 3.9 lb (2.07 +/- 1.76 kg) for standard T&A patients. Return to normal diet at postoperative week 1 occurred in 11 TCRF&A patients (85%) and 0 standard T&A patients. CONCLUSIONS: The respiratory distress indexes were similar for TCRF&A patients and standard T&A patients. In addition, there were similar analog snoring scales, decreased pain, and weight loss.

Identification of adenoid biofilms in chronic rhinosinusitis.

OBJECTIVE: To compare the percent mucosal surface area of adenoids removed from children with chronic rhinosinusitis (CRS) and those with obstructive sleep apnea (OSA) infected with biofilms. DESIGN: Comparative micro-anatomic investigation of adenoid mucosa using scanning electron microscopy from patients with CRS and OSA. SUBJECTS: 4 females and 12 males ranging from 3 months to 10 years of age. RESULTS: Adenoids removed from patients with CRS had dense mature biofilms covering the mucosal surface. More specifically, adenoids removed from patients with CRS had an average of 94.9% of their mucosal surface covered with mature biofilms vs. an average of 1.9% coverage on the adenoids removed from patients with OSA. These differences were statistically significant at the p<0.001 level. CONCLUSIONS: It is well established that adenoidectomy is useful in the treatment of CRS resistant to antibiotics. Adenoids removed from patients with CRS had almost their entire mucosal surface covered with biofilms vs. scant coverage for patients with OSA (p<0.001). Decreased metabolic activity, decreased growth rate, and transmission of resistance genes all contribute to the antibiotic resistant nature of the biofilms. These metabolically sessile communities shed planktonic microorganisms on an intermittent basis. Therefore biofilms in the nasopharynx of children with CRS may act as a chronic reservoir for bacterial pathogens resistant to standard antibiotics. Also, the mechanical debridement of the nasopharyngeal biofilms may explain the observed clinical benefit associated with adenoidectomy in this subset of pediatric patients.

Methicillin-resistant Staphylococcus aureus otorrhea after tympanostomy tube placement.

OBJECTIVE: To compare a retrospective cohort of nonhospitalized children with methicillin-resistant Staphylococcus aureus (MRSA) otorrhea with those with methicillin-sensitive S aureus (MSSA) otorrhea to determine the risk factors predisposing to MRSA otorrhea and the treatments used. DESIGN: Retrospective case-controlled series. SETTING: Tertiary pediatric care facility. PATIENTS: Seventeen children with MRSA otorrhea after bilateral myringotomy with tympanostomy tube insertion (BM&T) and 19 age- and sex-matched control subjects who demonstrated MSSA otorrhea. The average age at culture in MRSA patients was 52 months; in MSSA patients, 54 months. There were 8 boys and 3 girls in the MRSA group and 8 boys and 4 girls in the MSSA group. INTERVENTIONS: Oral, topical, and intravenous antimicrobial agents. MAIN OUTCOME MEASURES: Antibiotic exposure and history of otitis media and routine antibiotic administration (topical, oral, or intravenous). RESULTS: The following findings were statistically significant (P < or = .06, Mann-Whitney test): (1) longer duration of antibiotic treatment after BM&T for patients with MRSA vs those with MSSA; (2) increased number of episodes of acute otitis media before BM&T in patients with MRSA vs those with MSSA; and (3) increased number of courses of antibiotics after BM&T in patients with MRSA vs those with MSSA. CONCLUSIONS: Methicillin-resistant S aureus otorrhea is commonly seen as a community-acquired infection in otherwise healthy pediatric outpatients. Risk factors for development of MRSA otorrhea include the number of episodes of acute otitis media before BM&T and number of treatment courses and duration of antibiotic therapy after BM&T.

Tissue engineering of autologous cartilage grafts in three-dimensional in vitro macroaggregate culture system.

In the field of tissue engineering, techniques have been described to generate cartilage tissue with isolated chondrocytes and bioresorbable or nonbioresorbable biomaterials serving as three-dimensional cell carriers. In spite of successful cartilage engineering, problems of uneven degradation of biomaterial, and unforeseeable cell-biomaterial interactions remain. This study represents a novel technique to engineer cartilage by an in vitro macroaggregate culture system without the use of biomaterials. Human nasoseptal or auricular chondrocytes were enzymatically isolated and amplified in conventional monolayer culture before the cells were seeded into a cell culture insert with a track-etched membrane and cultured in vitro for 3 weeks. The new cartilage formed within the in vitro macroaggregates was analyzed by histology (toluidine blue, von Kossa-safranin O staining), and immunohistochemistry (collagen types I, II, V, VI, and X and elastin). The total glycosaminoglycan (GAG) content of native and engineered auricular as well as nasal cartilage was assayed colorimetrically in a safranin O assay. The biomechanical properties of engineered cartilage were determined by biphasic indentation assay. After 3 weeks of in vitro culture, nasoseptal and auricular chondrocytes synthesized new cartilage with the typical appearance of hyaline nasal cartilage and elastic auricular cartilage. Immunohistochemical staining of cartilage samples showed a characteristic pattern of staining for collagen antibodies that varied in location and intensity. In all samples, intense staining for cartilage-specific collagen types I, II, and X was observed. By the use of von Kossa-safranin O staining a few positive patches-a possible sign of beginning mineralization within the engineered cartilages-were detected. The unique pattern for nasoseptal cartilage is intense staining for type V collagen, whereas auricular cartilage is only weakly positive for collagen types V and VI. Engineered nasal and auricular macroaggregates were negative for anti-elastin antibody (interterritorially). The measurement of total GAG content demonstrated higher GAG content for reformed nasoseptal cartilage compared with elastic auricular cartilage. However, the total GAG content of engineered macroaggregates was lower than that of native cartilage. In spite of the mechanical stability of the auricular macroaggregates, there was no equilibrium of indentation. The histomorphological and immunohistochemical results demonstrate successful cartilage engineering without the use of biomaterials, and identify characteristics unique to hyaline as well as elastic cartilage. The GAG content of engineered cartilage was lower than in native cartilage and the biomechanical properties were not determinable by indentation assay. This study illustrates a novel in vitro macroaggregate culture system as a promising technique for tissue engineering of cartilage grafts. Further long-term in vitro and in vivo studies must be done before this method can be applied to reconstructive surgery of the nose or auricle.

Presentation, diagnosis, and management of deep-neck abscesses in infants.

OBJECTIVE: To clarify the presenting signs and symptoms, clinical course, pathogenic organisms, and management of deep-neck-space abscesses in infants. DESIGN: Retrospective chart review. SETTING: Tertiary care academic children's hospital. PATIENTS: Records of 25 patients 9 months or younger with deep-neck-space abscesses from July 1989 through May 1999 were reviewed. MAIN OUTCOME MEASURE: Resolution of abscess. RESULTS: Presenting symptoms included neck mass, 92% (n = 23); fever, 60% (n = 15); and dysphagia and/or poor intake by mouth, 36% (n = 9). Overall, patients were symptomatic for a mean duration of 3.8 days before presenting to the hospital; 21 of 22 evaluated patients had elevated white blood cell counts. Imaging included 68% computed tomographic scan (n = 17) and 44% plain radiographs (n = 11). On the basis of radiology and operative findings, locations of the abscesses were as follows: anterior triangle, 8; parapharyngeal, 5; posterior triangle, retropharyngeal, and undefined, 3 each; submandibular, 2; and parotid, 1. Of 17 scanned patients, 13 had some degree of airway compromise evident on computed tomography. All were treated with incision and drainage, 3 of 25 intraorally and 22 of 25 externally. Pus was identified in all 25; 20 of these grew Staphylococcus aureus, 1 grew group A Streptococcus, and 4 grew no organism. All patients received intravenous antibiotics for a mean of 4.8 days and oral antibiotics for a mean of 11 days. Only 1 patient required a second procedure. CONCLUSIONS: Deep-neck-space abscesses in infants are rapidly progressive, often cause airway compromise, and usually present with fever and neck mass. The most common pathogen is S aureus. Patients are effectively treated with incision and drainage coupled with intravenous followed by oral antibiotics.

Age-, site-, and time-specific differences in pediatric deep neck abscesses.

OBJECTIVE: To clarify presentations, organisms, and locations of deep neck abscesses in children. DESIGN: Retrospective review. SETTING: Tertiary children's hospital. The study population comprised 169 patients younger than 19 years who were surgically treated for deep neck abscesses between 1989 and 1999. MAIN OUTCOME MEASURE: Resolution of abscess. RESULTS: Neck mass (91%), fever (86%), cervical adenopathy (83%), poor oral intake (66%), and neck stiffness (59%) were common in all ages. Patients younger than 4 years, compared with patients 4 years or older, presented with agitation (50% vs 14%), cough (35% vs 14%), drooling (27% vs 12%), lethargy (46% vs 33%), oropharyngeal abnormalities (45% vs 60%), respiratory distress (5% vs 2%), retractions (5% vs 2%), rhinorrhea (53% vs 15%), stridor (4% vs 2%), and trismus (14% vs 53%). Children younger than 1 year were infected with Staphylococcus aureus (79%) vs group A streptococcus (6%). Children 1 year or older were infected with group A streptococcus (29%) vs S aureus (16%). Retropharyngeal or parapharyngeal regions were involved in children 1 year or older (49%) vs younger than 1 year (21%). Anterior or posterior triangles and submandibular or submental regions were involved in 39% and 36%, respectively, of children younger than 1 year vs 30% and 23%, respectively, of children 1 year or older. Retropharyngeal and parapharyngeal abscesses yielded group A streptococcus (34%) vs S aureus (11%). Anterior and posterior triangle abscesses yielded S aureus (35%) vs group A streptococcus (19%), as did submandibular and submental abscesses (42% vs 19%). CONCLUSIONS: Abscesses in children younger than 1 year affected anterior or posterior triangles and submandibular or submental regions, yielding S aureus. Abscesses in children 1 year or older affected retropharyngeal or parapharyngeal regions, yielding group A streptococcus.

Value of rigid bronchoscopy in the management of critically ill children with acute lung collapse.

OBJECTIVE: To describe the potential uses of a rigid bronchoscopy in pediatric patients, as well as explaining the advantage of a rigid bronchoscopy versus a flexible bronchoscopy in pediatric patients with acute lung collapse. DESIGN: Case report. SETTING: Pediatric intensive care unit. PATIENT: A 16-month-old male infant with a 5-day history of cough, congestion, and "wheezing" that progressively worsened. INTERVENTIONS: A rigid bronchoscopy. MEASUREMENTS AND MAIN RESULTS: The evolution of the patient's acute lobar collapse to his final discharge is described. This includes the initial presentation, primary methods employed to improve the patient's condition, the use of a rigid bronchoscopy in removing a mucous plug, and the patient's results up to his final discharge. CONCLUSION: This report demonstrates the value of rigid bronchoscopy in pediatric patients with severe atelectasis and pneumonia. Although bronchoscopy may not be indicated as an initial procedure to remove respiratory tract secretions, it may provide a beneficial option in cases where less invasive methods prove ineffective in removing secretions and mucous plugs.

Incidence of gastroesophageal reflux disease and positive maxillary antral cultures in children with symptoms of chronic rhinosinusitis.

OBJECTIVES: Studies have shown that gastroesophageal reflux disease occurs more frequently than expected in children with chronic rhinosinusitis. The objective of this study is to further understand the relationship of pediatric chronic rhinosinusitis and gastroesophageal reflux disease in children with symptoms of rhinorrhea, nasal congestion, and chronic cough. METHODS: A retrospective chart review of 63 children, ages 6 months to 10 years old with rhinorrhea, nasal congestion, and chronic cough. The patients underwent maxillary cultures, adenoidectomy, and distal third esophageal biopsies. Children with esophageal biopsies showing esophagitis were classified as positive for gastroesophageal reflux disease, and maxillary antral swabs growing a high density of bacteria were classified as positive for chronic rhinosinusitis. RESULTS: Six months to 5 years old children (n=43), 6 (14%) had simultaneous positive maxillary antral cultures and positive esophageal biopsies, 11 (26%) had positive esophageal biopsies alone, 23 (53%) had positive maxillary antral cultures alone, and 3 (7%) had neither. Six to 10 years old children (n=20), 9 (45%) had simultaneous positive maxillary antral cultures and positive esophageal biopsies, 1 (5%) patient had positive esophageal biopsies alone, 3 (15%) patients had positive maxillary antral cultures alone, and 7 (35%) patients had neither. Twenty-seven (42%) of the patients from the whole study had gastroesophageal reflux positive biopsies. The younger children were statistically likely to have chronic rhinosinusitis and gastroesophageal reflux disease independently of each other (p=0.0002). A direct group comparison found the younger group to have independent chronic rhinosinusitis and gastroesophageal reflux disease and the older group to have simultaneous chronic rhinosinusitis and gastroesophageal reflux disease (p=0.0006). CONCLUSION: In children with the presenting symptoms of rhinorrhea, nasal congestion, and chronic cough, younger children tend to have either chronic rhinosinusitis or gastroesophageal reflux disease, whereas older children tend to have a more complicated etiology of chronic rhinosinusitis and gastroesophageal reflux disease or other. In all of these patients gastroesophageal reflux disease plays an important role, as over 40% of all patients had gastroesophageal positive biopsies.

Demonstration of the role of an implantable bioscaffold in airway reconstruction: a pilot study utilizing an animal model.

INTRODUCTION: Laryngotracheal reconstruction is a common procedure to repair subglottic stenosis. Despite a success rate upwards of 85%, this procedure has significant morbidity associated with it, specifically with the site of the graft harvest and recurrence of stenosis. We propose that a recently described cellular bioscaffold xenograft may be useful in reducing these complications. METHODS AND MATERIALS: 10 Sprague Dawley rats were divided into 2 groups of 5. One group underwent incision through the cricoid and the first two tracheal rings followed by primary closure (G1); the second group underwent incision through the cricoid and the first two tracheal rings followed by placement of the xenograft (G2); additionally, a specimen was harvested from an animal which did not undergo any surgical procedure to compare to the two surgical groups. Specimen harvest occurred on post-operative days 1, 7, 14, 21, and 28. RESULTS: 6 of 10 animals provided usable data. All animals receiving the xenograft survived until the time of specimen harvest. Only 1 animal undergoing primary closure survived beyond post-operative day one. On histology review, the xenograft animals showed a progressive decrease in fibrosis relative to the animals that underwent primary closure. On POD 28, restoration of the respiratory epithelium and intact basement membrane was noted in the xenograft group. CONCLUSION: We believe that this pilot study shows the potential of utilizing bio-implantable biomaterials, specifically a cellular bioscaffold which encourages the ingrowth of native tissue instead of fibrosis. Histologic analysis shows that use of the xenograft can initiate the proliferation of native tissues decreasing the amount of fibrosis present post-operatively, although significant further analysis is needed before definitively concluding that this approach is superior to utilization of a graft.