Removal of Airway Foreign Body in a Premature Neonate.

OBJECTIVE: Airway foreign bodies are the leading cause of infantile deaths and fourth among preschool children. Airway foreign bodies in extremely premature neonates represent a rare but potentially lethal entity. There are very few reports in the literature describing the treatment of such a condition in premature neonates. The objectives of this report are to describe the safe removal of an airway foreign body in an extremely premature infant using urologic instruments in a trans-endotracheal tube fashion and to review the literature for other techniques that have proven safe and effective, thereby adding technical options for future cases. METHODS: We reviewed the case reported and reviewed pertinent literature. RESULTS: A 2-week old, ex-24 3/7-week, 820-g pre-mature infant was intubated with a 2.5 endotracheal tube. After intubation, a 2-cm foreign body was discovered in the distal trachea by chest x-ray. The child's respiratory status continuously deteriorated with increasing oxygen and positive pressure requirements. While remaining intubated, the child underwent direct suspension laryngoscopy, the ventilator circuitry was disconnected, and the object was successfully removed using a 1.2 mm rigid ureteroscope and 1.1 mm grasping forceps through the 2.5 endotracheal tube. CONCLUSION: This case report demonstrates the effectiveness of using a 1.2 mm ureteroscope and 1.2 mm urologic graspers to extract an airway foreign body from an extremely premature neonate through an endotracheal tube without paralyzing the patient. This method provides a safe and effective means of visualizing and, if necessary, manipulating the airway in a population prone to respiratory complications.

Injection Laryngoplasty for the Treatment of Type 1 Laryngeal Clefts: A Single Institution Experience.

OBJECTIVE: Standards for treatment of laryngeal clefts remain poorly defined. There are no large case series that report the efficacy of injection laryngoplasty (IL) in the treatment of pediatric Type 1 laryngeal clefts (LC-1). The objective of this study is to measure the effect of IL in young children with LC-1. METHODS: A retrospective case series of 130 patients was completed over 3 years at a at a single institution included patients aged 1 month to 8 years, diagnosed with aspiration and penetration issues during swallowing based on a Videofluoroscopic Swallow Study (VFSS). Patients underwent surgical evaluation and intervention using carboxymethylcellulose gel injection. Collected data points included age in months at time of first injection, gender, race, pre- and post-operation VFSS scores, number of injections, co-morbidities and post-operative complications. VFSS scores were evaluated pre- and post-operatively to assess efficacy of intervention. A secondary outcome was efficacy in patients with aspiration compared to those with penetration alone. RESULTS: This study included 77 male and 53 female patients. Sixty-two patients (48%) demonstrated a significant post-operative improvement in their swallowing function (P < .05). There were no statistical differences in age, number of injections, or the volume of the first injection. Patients that showed a post-operative improvement in swallowing function were on average 5 months older and had more severe aspiration and penetration compared to those who did not demonstrate a post-operative benefit and underwent less injections. The volume of injection did not appear to play a role in the success rate. CONCLUSION: Injecting the inter-arytenoid area in patients with LC-1 appears to confer some benefit to close to half of our patient population. Successful procedures seemed to occur in patients with more severe aspiration and penetration and older age.

Dexamethasone Use in the Treatment of Pediatric Deep Neck Space Infections.

OBJECTIVES: Assess the outcome of Intravenous (IV) dexamethasone in the treatment of pediatric deep neck space infections (DNSI) in combination with IV antibiotics. METHODS: Retrospective chart review of pediatric patients admitted for a DNSI from March 2014 to June 2016. Patient characteristics including demographics, abscess type, antibiotic, dexamethasone, surgery, culture, and length of stay (LOS) were obtained. Patients treated with antibiotics alone versus antibiotics and dexamethasone were compared. Primary outcome measures were rate of surgical drainage and LOS. RESULTS: Overall 153 patients with DNSI were identified, including 62 lateral neck, 18 parapharyngeal, 40 peritonsillar, 32 retropharyngeal, and 1 submandibular. All patients received antibiotics. Dexamethasone was used in 35% of patients. The rate of surgical drainage in the dexamethasone and non-dexamethasone group was 36% and 53% respectively (P = .043). LOS was shorter for the dexamethasone group (2.9 days) compared to the non-dexamethasone group (3.8 days) but was non-significant, P-value-.09. The most common microorganisms cultured were MRSA (25), MSSA (11), and Streptococcus pyogenes (10). CONCLUSION: Dexamethasone use was associated with a decreased rate of surgical drainage in pediatric patients with DNSI. Further prospective study is needed to determine the role of dexamethasone in treatment.

Traumatic tracheal injury in children: a case series supporting conservative management.

OBJECTIVES: Injuries to the tracheobronchial region are rare, but have the potential for rapid progression and can become life-threatening. Etiologies of non-penetrating tracheobronchial injuries include blunt cervical trauma, endotracheal intubation, and other iatrogenic causes. Several options for treatment ranging from conservative to surgical exist, but no single treatment has been implemented with consensus. While early surgical repair was once considered the cornerstone of therapy, evidence supporting conservative treatment continues to gain strength. METHODS: All pediatric patients who suffered from non-penetrating injuries to the tracheobronchial tree who were treated by the Otolaryngology Service at a tertiary children's hospital from May 2012 through March 2014 were recorded. A total of 8 patients were identified. The cases were collected from the patients treated by the Otolaryngology Department based on retrospective review. The available electronic medical records were reviewed for each patient. Data including type of injury, endoscopic assessment of injury, treatment received, and follow-up were collected. RESULTS: The ages ranged from 2 to 15 years old, with a mean of 9.25 years old. Six of the eight patients had injuries related to endotracheal intubation. Each patient was taken to the operating suite for diagnostic direct laryngoscopy and bronchoscopy, and treated with initial conservative management. All but one of the patients was treated with endotracheal intubation, and the average length of intubation was 11.71 days. All of the injuries healed spontaneously without requiring initial open surgery. Five patients (62.5%) developed some degree of tracheal stenosis. Three patients (37.5%) required further surgery; one received a tracheostomy and two patients required balloon dilation. CONCLUSIONS: This case series is the largest to date documenting the outcomes of conservative treatment of non-penetrating traumatic tracheal injuries in children. By using initial conservative therapy, we were able to avoid open surgical procedures in many of our patients. We believe that this case series provides further support for conservative management for children with tracheobronchial injuries.

Use of fiberoptic endoscopic evaluation of swallowing (FEES) in the management of psychogenic dysphagia in children.

OBJECTIVES: To describe the use of fiberoptic endoscopic evaluation of swallowing (FEES) as an adjunct in the management of children presenting with psychogenic dysphagia, defined as food avoidance and excessive fear of eating without identifiable anatomic or functional swallowing abnormalities. METHODS: Case series of patients presenting to the otolaryngology clinic of a tertiary pediatric teaching hospital between 2007 and 2008 that were evaluated and managed with the utilization of FEES. The outcomes measured were age, gender, duration of symptoms, findings of FEES, additional work-up and resolution of symptoms at follow-up. RESULTS: Five patients (4 males, 1 female) with ages ranging from 5 to 13 years old (mean=8.6). The median duration of symptoms before presentation was 3 weeks. Four families described refusal of solids starting after choking episode and variable estimated weight loss (mean 2.8kg). One child presented with vague complaints of intermittent odynophagia and food refusal. Fiberoptic endoscopic evaluation of swallowing was performed on all patients. No abnormalities of the oropharyngeal swallow were appreciated. Additional management included different combinations of modified barium swallow study, esophagastroduodenoscopy (EGD), upper GI series, antibiotics, and psychotherapy. Mean follow-up with clinic visit was 4.2 months. Three of the five children reported complete resolution of symptoms after FEES at follow-up visit. CONCLUSION: Fiberoptic endoscopic evaluation of swallowing can be a useful management tool in children with psychogenic dysphagia as it provides direct visualization of the oropharyngeal swallowing mechanism. This can be used to provide visual reassure and biofeedback to patients and parents. Additional workup should be decided on an individual basis.