Cannabis induced thermal epiglottitis in a pediatric patient.

Acute epiglottitis is an airway emergency presenting with edema and inflammation of the epiglottis and aryepiglottic folds [1]. Infectious and other non-infectious etiologies may cause significant airway injury presenting with similar clinical symptoms and radiographic findings [1]. While many causes of thermal epiglottitis have been described in the pediatric and young adult population, we describe an unusual case of an adolescent patient with cannabis induced thermal epiglottitis. A 17-year-old previously healthy, vaccinated adolescent male presented to the pediatric emergency department with dysphagia, odynophagia, drooling, and muffled voice with fever, tachypnea, and leukocytosis. Lateral plain film imaging and computed tomography (CT) scan showed significant edema of the epiglottitis. Urinary drug screen in the emergency department was positive for benzodiazepine, opiates, and cannabinoids. Transnasal flexible laryngoscopy and direct laryngoscopy demonstrated significant erythema, edema, and copious secretions. Culture of the epiglottis culture showed normal oropharyngeal flora. The patient was diagnosed with thermal induced epiglottitis secondary to cannabinoid use based on positive substance use history, urinary drug screen, and negative bacterial cultures. Clinicians must consider thermal injury of the epiglottitis due to substance use, specifically marijuana in vaccinated adolescent patients presenting with positive substance use history, progressive dysphagia, odynophagia, and drooling with a muffled voice. It is essential to obtain a thorough history and physical examination and urinary drug screen in the pediatric emergency department since the clinical and radiographic findings are similar in epiglottitis due to infectious and non-infectious etiologies. Prompt management with intubation should occur to protect and maintain airway integrity.

Bilateral parotitis as the initial presentation of childhood sarcoidosis.

The differential diagnosis of bilateral parotid gland enlargement in children includes infectious, inflammatory, and neoplastic disorders. We present the case of a 13-year-old male who presented with a 5-week history of bilateral parotid swelling. On exam, both parotid glands were nontender, smooth, and diffusely enlarged. He had slightly elevated inflammatory markers, but other lab results were normal. A neck CT revealed symmetric enlargement of the parotid, submandibular, and sublingual glands. A chest CT revealed scattered peripheral pulmonary nodules and bilateral hilar adenopathy. A parotid gland biopsy showed multiple noncaseating granulomas with multinucleated giant cells surrounded by lymphocytes, consistent with the diagnosis of sarcoidosis. Special stains for acid-fast and fungal organisms were negative. Using this illustrative case, we discuss the differential diagnosis of bilateral salivary gland enlargement in children and review the etiology, diagnosis, clinical manifestations, and treatment of pediatric sarcoidosis.

Disk battery ingestion: case series with assessment of clinical and financial impact of a preventable disease.

BACKGROUND: Commonly, foreign objects are incidentally ingested and pass harmlessly through the gastrointestinal tract; however, disk batteries present exceptional risk. In 2009, the American Association of Poison Control Centers listed disk batteries as the number 1 cause of fatal ingestions in children younger than 5 years. Lithium batteries are the most dangerous, and they are rapidly rising in use by manufacturers. Paralleling that rise, there has been a 6.7-fold increase in major or fatal outcomes between 1985 and 2009. This study describes the variability in patient presentations, the courses of patients' evaluations, and the clinical and financial consequences of disk battery ingestion. METHODS: In this retrospective study, cases from 2001 to 2011 were reviewed for details of care for disk battery ingestions including presentation and management details. Cost of care information from our patients' records was compared with that of national averages on esophageal foreign bodies using the Healthcare Cost and Utilization Project's Kids' Inpatient Database. RESULTS: Six cases are presented. The patients' age averaged 1.85 years. Presentations varied with respect to symptoms, time course, and steps in treatment. Mean length of stay was 9.0 days, and mean cost was $14,994. CONCLUSIONS: Emergency medicine physicians, otolaryngologists, radiologists, gastroenterologists, and pediatric surgeons may be able to mitigate, albeit not entirely prevent, potential serious complications in patients with disk battery ingestions by proper diagnosis and timely treatment. Recommendations for management are presented, which highlight the need for emergent removal of any battery that is lodged and close follow-up of these patients once they are out of the hospital.

Loeys-Dietz syndrome presenting as respiratory distress due to pulmonary artery dilation.

Loeys-Dietz syndrome (LDS) is an autosomal dominant connective tissue condition with clinical features that may include ocular hypertelorism, cleft palate, craniosynostosis, and vascular dilation and tortuosity. Here we describe a patient with LDS confirmed by genetic analysis (R528H mutation of TGFBR2) who presented at 3 months of age in respiratory distress of unknown origin. In addition to expressing several of the classic findings of LDS, including a novel finding of squamosal suture craniosynostosis, CT angiography revealed aortic dilation at the sinus of valsalva, pulmonary artery dilation that extrinsically compressed the right mainstem bronchus causing bronchomalacia, and an apical herniation of the right lung. This is the first documentation of concomitant airway and pulmonary findings in a patient with LDS. We suggest that (1) vascular abnormalities be considered as a cause of unexplained respiratory distress in a patient with LDS, and (2) pediatric patients exhibiting any of the physical findings listed above be evaluated for LDS with particular attention paid to vascular, airway, and/or pulmonary malformations.

Detection of group A Streptococcus in tonsils from pediatric patients reveals high rate of asymptomatic streptococcal carriage.

BACKGROUND: Group A Streptococcus (GAS) causes acute tonsillopharyngitis in children, and approximately 20% of this population are chronic carriers of GAS. Antibacterial therapy has previously been shown to be insufficient at clearing GAS carriage. Bacterial biofilms are a surface-attached bacterial community that is encased in a matrix of extracellular polymeric substances. Biofilms have been shown to provide a protective niche against the immune response and antibiotic treatments, and are often associated with recurrent or chronic bacterial infections. The objective of this study was to test the hypothesis that GAS is present within tonsil tissue at the time of tonsillectomy. METHODS: Blinded immunofluorescent and histological methods were employed to evaluate palatine tonsils from children undergoing routine tonsillectomy for adenotonsillar hypertrophy or recurrent GAS tonsillopharyngitis. RESULTS: Immunofluorescence analysis using anti-GAS antibody was positive in 11/30 (37%) children who had tonsillectomy for adenotonsillar hypertrophy and in 10/30 (33%) children who had tonsillectomy for recurrent GAS pharyngitis. Fluorescent microscopy with anti-GAS and anti-cytokeratin 8 & 18 antibodies revealed GAS was localized to the tonsillar reticulated crypts. Scanning electron microscopy identified 3-dimensional communities of cocci similar in size and morphology to GAS. The characteristics of these communities are similar to GAS biofilms from in vivo animal models. CONCLUSION: Our study revealed the presence of GAS within the tonsillar reticulated crypts of approximately one-third of children who underwent tonsillectomy for either adenotonsillar hypertrophy or recurrent GAS tonsillopharyngitis at the Wake Forest School of Medicine. TRIAL REGISTRATION: The tissue collected was normally discarded tissue and no patient identifiers were collected. Thus, no subjects were formally enrolled.

One third of middle ear effusions from children undergoing tympanostomy tube placement had multiple bacterial pathogens.

BACKGROUND: Because previous studies have indicated that otitis media may be a polymicrobial disease, we prospectively analyzed middle ear effusions of children undergoing tympanostomy tube placement with multiplex polymerase chain reaction for four otopathogens. METHODS: Middle ear effusions from 207 children undergoing routine tympanostomy tube placement were collected and were classified by the surgeon as acute otitis media (AOM) for purulent effusions and as otitis media with effusion (OME) for non-purulent effusions. DNA was isolated from these samples and analyzed with multiplex polymerase chain reaction for Haemophilus influenzae, Streptococcus pneumoniae, Alloiococcus otitidis, and Moraxella catarrhalis. RESULTS: 119 (57%) of 207 patients were PCR positive for at least one of these four organisms. 36 (30%) of the positive samples indicated the presence of more than one bacterial species. Patient samples were further separated into 2 groups based on clinical presentation at the time of surgery. Samples were categorized as acute otitis media (AOM) if pus was observed behind the tympanic membrane. If no pus was present, samples were categorized as otitis media with effusion (OME). Bacteria were identified in most of the children with AOM (87%) and half the children with OME (51%, p < 0.001). A single bacterial organism was detected in middle ear effusions from children with AOM more often than those with OME (74% versus 33%, p < 0.001). Haemophilus influenzae was the predominant single organism and caused 58% of all AOM in this study. Alloiococcus otitidis and Moraxella catarrhalis were more frequently identified in middle ear effusions than Streptococcus pneumoniae. CONCLUSIONS: Haemophilus influenzae, Streptococcus pneumoniae, Alloiococcus otitidis, and Moraxella catarrhalis were identified in the middle ear effusions of some patients with otitis media. Overall, we found AOM is predominantly a single organism infection and most commonly from Haemophilus influenzae. In contrast, OME infections had a more equal distribution of single organisms, polymicrobial entities, and non-bacterial agents.

The Hunter-MacDonald syndrome with expanded phenotype including risk of meningioma: an update and review.

Hunter-MacDonald syndrome (HMS) is a rare, autosomal dominant skeletal dysplasia with multiple malformations. The skeletal manifestations of HMS include short stature, scoliosis, epiphyseal dysplasia with early osteoarthritis leading to joint replacement, prominent humeral insertions for the deltoids, camptodactyly, subluxation of the thumbs, and malformed feet. Craniofacial manifestations include normal head circumference, tall forehead, bitemporal narrowing, ptosis, short palpebral fissures, and short philtrum. Decreased hearing acuity, transient cranial nerve palsies, congenital heart defects, and meningioma are also reported. Herein, we present two cases, and, through review of the manifestations of HMS in affected and at-risk family members, we have observed that predisposition to brain tumor is a cardinal feature of this condition.

Superiorly-based turnover skin flap: Pediatric tracheocutaneous fistula closure.

OBJECTIVE: To present a novel superiorly-based turnover skin flap for the primary repair of pediatric tracheocutaneous fistula closure, and to determine the efficacy and safety of this tracheocutaneous fistula turnover flap primary closure technique. SUBJECT AND METHODS: This retrospective review analyzed one surgeon's (DJK) pediatric tracheostomy decannulation methods and results, specifically relating to the development of tracheocutaneous fistulas, over a fourteen-year period, from October 2002 through June 2016. The review furthermore examined a turnover flap technique for the primary closure of tracheocutaneous fistulas described herein. RESULTS: Over the period of study, 57 patients were decannulated, of whom 31 (54%) developed a tracheocutaneous fistula. Mean duration of tracheostomy in patients who developed a tracheocutaneous fistula following decannulation was forty-two months compared to thirteen months in patients who did not. Duration of decannulation was an independently significant variable (P < .001) in tracheocutaneous fistula development while gender, age at tracheostomy and age at decannulation were not (P > .05). Of the 31 patients who developed a tracheocutaneous fistula, 30 (97%) elected to pursue tracheocutaneous fistula closure using the turnover flap technique described in this study. Mean time from decannulation to tracheocutaneous fistula repair was 132 days. All tracheocutaneous fistulas were successfully closed. There were no perioperative or postoperative complications and no patient required subsequent hospitalization or surgical revision. CONCLUSIONS: The turnover technique presented is simple, straightforward, reliable, safe, and effective with excellent cosmetic results.

Considerations for the successful decannulation of the pediatric patient: A single surgeon's experience.

OBJECTIVE: To characterize the steps and interventions necessary for successful decannulation of the chronic pediatric tracheostomy patient. METHODS: This retrospective review analyzed one surgeon's (DJK) pediatric tracheostomy decannulation methods and results at a tertiary academic medical center over a thirteen-year period, from October 2002 through November 2015. It also examined which tests and procedures were conducted on patients prior to their successful decannulation. RESULTS: Over the period of study, 46 patients met inclusion criteria for analysis and underwent decannulation after being followed in the clinic or the hospital. One of these patients had to have the tracheostomy tube replaced. In nearly all cases, these patients underwent a systematic progression from tolerance of daytime tracheostomy capping to a capped sleep study, and endoscopic airway evaluation. In recent years, a subset of patients also underwent sleep endoscopy. In nearly all cases, patients spent a single night in the hospital in a non-acute bed at the time of decannulation. Ninety-eight percent (n = 45) of patients were successfully and safely decannulated after having met the milestones that we employ at our institution. CONCLUSIONS: This study serves as a safe, efficient, and resource-prudent protocol for otolaryngologists to follow when considering tracheostomy decannulation in the pediatric population. Sleep endoscopy can play a helpful role in guiding decannulation decisions. Since it is impossible to employ a single rigid protocol of testing prior to decannulating all patients, clinical judgment must always be exercised in individual circumstances.

Resistance of non-typeable Haemophilus influenzae biofilms is independent of biofilm size.

The inflammatory middle ear disease known as otitis media can become chronic or recurrent in some cases due to failure of the antibiotic treatment to clear the bacterial etiological agent. Biofilms are known culprits of antibiotic-resistant infections; however, the mechanisms of resistance for non-typeable Haemophilus influenzae biofilms have not been completely elucidated. In this study, we utilized in vitro static biofilm assays to characterize clinical strain biofilms and addressed the hypothesis that biofilms with greater biomass and/or thickness would be more resistant to antimicrobial-mediated eradication than thinner and/or lower biomass biofilms. Consistent with previous studies, antibiotic concentrations required to eliminate biofilm bacteria tended to be drastically higher than concentrations required to kill planktonic bacteria. The size characterizations of the biofilms formed by the clinical isolates were compared to their minimum biofilm eradication concentrations for four antibiotics. This revealed no correlation between biofilm thickness or biomass and the ability to resist eradication by antibiotics. Therefore, we concluded that biofilm size does not play a role in antibiotic resistance, suggesting that reduction of antibiotic penetration may not be a significant mechanism for antibiotic resistance for this bacterial opportunist.

Endoscopic extended ventriculotomy for congenital saccular cysts of the larynx in infants.

OBJECTIVE: To report a new procedure that has been successful in endoscopically treating congenital saccular cysts of the larynx without the need for a tracheostomy or an external incision. DESIGN: Retrospective chart review of a case series involving 4 patients who underwent a single endoscopic procedure for the treatment of their congenital saccular cysts. SETTING: Two pediatric tertiary care referral centers. PATIENTS: Four pediatric patients aged 1 to 7 weeks. INTERVENTIONS: Three of 4 patients underwent endoscopic extended ventriculotomy for treatment of a congenital laryngeal saccular cyst. The remaining patient had wide unroofing of the cyst through the floor of the vallecula. MAIN OUTCOME MEASURES: The patients were followed up for breathing difficulties, dysphagia, and dysphonia. Routine flexible endoscopy was used to evaluate for recurrence of cysts. RESULTS: All 4 patients were successfully treated with a single endoscopic procedure. None has had a recurrence, and none required tracheostomy. One patient subsequently underwent conservative unilateral epiglottoplasty to remove redundant tissue caused by the cyst. Disease-free follow-up ranged from 2 to 6 years. CONCLUSIONS: The endoscopic extended ventriculotomy procedure allowed successful endoscopic management of congenital saccular cysts of the larynx in 3 of 4 patients. Previously described management strategies for these difficult lesions have involved multiple failed endoscopic procedures or an external approach to the lesion and frequently required tracheostomy. With this procedure, we have avoided both a tracheostomy and an external approach to the lesion, which has minimized morbidity. Use of modern instrumentation and surgical adjuncts such as mitomycin C, as well as the support of the laryngeal framework for the continued patency of the ventriculotomy, has led to successful single-stage management of congenital saccular cysts of the larynx.

Investigation of Postoperative Oral Fluid Intake as a Predictor of Postoperative Emergency Department Visits After Pediatric Tonsillectomy.

IMPORTANCE: This study contributes novel data on the association between oral fluid intake before discharge and adverse outcomes following tonsillectomy in pediatric patients. These data contribute to evidence-based, safe, and cost-effective decision making regarding discharge. OBJECTIVE: To determine whether the quantity of oral fluid intake before discharge is associated with adverse outcomes following tonsillectomy in pediatric patients. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort analysis was conducted using the electronic medical records of 1183 pediatric patients undergoing tonsillectomy between September 24, 2012, and June 5, 2015, at a tertiary care academic medical center. Exclusion criteria included age 18 years or older, overnight admission, and missing data on fluid intake. The final cohort comprised 473 patients. Data analysis was conducted from July 8 to August 23, 2015. EXPOSURES: All patients underwent tonsillectomy by 1 of 7 attending surgeons at our institution. All patients were given intravenous fluids and analgesia in the postanesthesia care unit before being admitted to the pediatric inpatient floor for monitoring before discharge. MAIN OUTCOMES AND MEASURES: The primary outcome measured was presentation to the emergency department within 2 weeks after tonsillectomy with a related complication. We also recorded hospital readmissions and returns to the operating room for related complications. The primary diagnosis was noted for each complication. RESULTS: Among 473 patients (235 male; mean [SD] age, 7.2 [3.5] years), oral fluid intake after tonsillectomy ranged from 0.7 to 66.7 mL/kg, with a mean (SD) intake of 18.2 (10.8) mL/kg. Mean (SD) time to discharge was 6.96 (1.91) hours (range, 1.68-14.25 hours). Overall, 31 patients (6.6%) presented to the emergency department for a related complication after tonsillectomy. No correlation was found between oral fluid intake after tonsillectomy and presentation to the emergency department (odds ratio, 1.03; 95% CI, 0.98-1.08; P = .29). CONCLUSIONS AND RELEVANCE: This study suggests that oral fluid intake before discharge is not predictive of presentation to the emergency department after tonsillectomy within the ranges studied and at this institution. Therefore, discharge criteria based strictly on thresholds for oral fluid intake may be unnecessary. Further study at multiple institutions using a wider range of fluid intake volumes or a large-scale randomized clinical trial is needed before conclusions can be generalized.

Expanding applications for the microdebrider in pediatric endoscopic airway surgery.

OBJECTIVE: The microdebrider has been described for treating laryngeal papillomas, but there are no reports of other uses for this instrument in the pediatric airway. The objective of this article is to describe expanding applications for the microdebrider in pediatric airway surgery. STUDY DESIGN AND SETTING: Retrospective review, tertiary care academic institution. RESULTS: The microdebrider was used in 75 pediatric airway procedures. Twenty-two of these cases involved novel, previously unreported applications of the microdebrider. CONCLUSIONS: The microdebrider can be used safely and effectively for a variety of pediatric airway pathologies, including papillomas, granulations, and stenoses from the larynx to the distal trachea. SIGNIFICANCE: Correct usage of the various tip configurations on the microdebrider has made management of many airway lesions commonly encountered by pediatric otolaryngologists safer, more expedient, and simpler than management by other methods. In our practice, this instrument largely has supplanted the use of the CO(2) laser and some open approaches for pediatric airway lesions.

Otopathogens Detected in Middle Ear Fluid Obtained during Tympanostomy Tube Insertion: Contrasting Purulent and Non-Purulent Effusions.

Otitis media is a prominent disease among children. Previous literature indicates that otitis media is a polymicrobial disease, with Haemophilus influenzae, Streptococcus pneumoniae, Alloiococcus otitidis and Moraxella catarrhalis being the most commonly associated bacterial pathogens. Recent literature suggests that introduction of pneumococcal conjugate vaccines has had an effect on the etiology of otitis media. Using a multiplex PCR procedure, we sought to investigate the presence of the aforementioned bacterial pathogens in middle ear fluid collected from children undergoing routine tympanostomy tube placement at Wake Forest Baptist Medical Center during the period between January 2011 and March 2014. In purulent effusions, one or more bacterial organisms were detected in ~90% of samples. Most often the presence of H. influenzae alone was detected in purulent effusions (32%; 10 of 31). In non-purulent effusions, the most prevalent organism detected was A. otitidis (26%; 63 of 245). Half of the non-purulent effusions had none of these otopathogens detected. In purulent and non-purulent effusions, the overall presence of S. pneumoniae was lower (19%; 6 of 31, and 4%; 9 of 245, respectively) than that of the other pathogens being identified. The ratio of the percentage of each otopathogen identified in purulent vs. non-purulent effusions was >1 for the classic otopathogens but not for A. otitidis.

The otolaryngological manifestations of mitochondrial disease and the risk of neurodegeneration with infection.

OBJECTIVE: To report the nature and extent of hearing loss and other otolaryngological problems in patients with mitochondrial disease, and to document the risk of neurodegeneration with infection. DESIGN: Medical chart review and telephone interview of 40 patients with documented mitochondrial disease. SETTING: An international referral center for the diagnosis and management of mitochondrial disorders. PATIENTS: We describe 40 patients with a definitive diagnosis of mitochondrial disease. Thirty-three (82%) were younger than 15 years. RESULTS: Hearing loss was the most common clinical finding associated with mitochondrial disease. Twenty-eight (80%) of the 35 patients undergoing testing had hearing loss or significant auditory dysfunction. In 20 (57%) of these, brainstem conduction abnormalities were identified. Eight (30%) of the 27 patients had an abnormal number of recurrent upper respiratory tract infections, and 4 (50%) of these had life-threatening or neurodegenerative sequelae. Mitochondrial disease followed an episodic course, with periods of stasis or slow developmental progress, punctuated by neurodegenerative events in 18 (60%) of 30 patients. Intercurrent infection was recognized as a precipitant of neurodegenerative events in 13 (72%) of 18 patients with a history of episodic degeneration. CONCLUSIONS: Children and adults with mitochondrial disorders are at high risk for hearing loss and life-threatening complications of intercurrent infections. A constellation of audiologic abnormalities, multiorgan system involvement, and history of neuromuscular setbacks with infection strongly suggests mitochondrial disease. Knowledge of these features can lead to more rapid diagnosis and improved medical and surgical management for this special group of patients with fundamental defects in bioenergy metabolism.

Vagus nerve stimulator implantation in children.

BACKGROUND: Vagus nerve stimulation was approved in 1997 as an adjunctive treatment of partial-onset seizures refractory to medical therapy. Subsequent to the initial clinical trials, few studies have been published specifically addressing perioperative management issues. OBJECTIVES: To review the operative technique and perioperative management of patients undergoing vagus nerve stimulator implantation and to analyze complications and their management. DESIGN: Retrospective medical record review and survey of patients who underwent implantation. SETTING: A tertiary care pediatric hospital in Kansas City, Mo. PATIENTS: One hundred two patients aged 21 months to 40 years. INTERVENTION: Vagus nerve stimulator implantation and lead placement. MAIN OUTCOME MEASURES: The surgical technique of vagus nerve stimulator implantation is presented in detail. Perioperative complications are enumerated, and strategies for their management are described. A subjective patient survey addresses some quality-of-life issues and the effect on swallowing and voice. RESULTS: One hundred two patients successfully underwent vagus nerve stimulator implantation. Three patients experienced infection of the chest wound holding the generator and required explantation. These 3 patients underwent reimplantation within 2 months after the infection had cleared. Most patients experience some degree of hoarseness when the generator is activated, but this symptom usually does not significantly affect the ability to communicate. Responses to questions regarding quality of life are positive. CONCLUSIONS: Vagus nerve stimulator implantation has a low incidence of serious complications. Quality of life seems to be improved for most patients. Modifications to the surgical procedure must be considered when performing the implantation on a young patient.

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.

Compliance with recommendations for tympanostomy tube follow-up: patient characteristics.

OBJECTIVES: (1) To determine the percentage of otherwise healthy patients achieving "graduation," or postoperative compliance achieving complete problem resolution and discharge from the otolaryngologist's care, after tympanostomy tube placement. (2) To analyze follow-up behaviors and patient characteristics influencing the likelihood of graduation. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary care hospital. SUBJECTS AND METHODS: Analysis of details of tympanostomy tube placements performed from 2004 to 2011 by 2 pediatric otolaryngologists for children aged 0 to 18 years. Exclusion criteria were clearly defined craniofacial anomalies, cleft palates, and other ongoing postoperative care. The remaining study subjects were categorized into 3 groups. Graduation (GRAD) subjects achieved discharge from care with "follow-up pro re nata" status. LOST<2Y subjects had not attended scheduled follow-up in <2 years. LOST≥2Y subjects had no follow-up in ≥2 years. RESULTS: A total of 1454 pediatric subjects were included. GRADs constituted only 25.6% of the subject pool; 22.1% were LOST<2Y, and 52.3% were LOST≥2Y. Statistically significant factors in achieving graduation were total number of follow-up visits, total duration of follow-up, compliance with first postoperative visit, patient age, insurance type, and distance between home and practice. CONCLUSION: Rate of graduation, or postoperative compliance achieving complete problem resolution, of otherwise healthy tympanostomy tube patients is low despite perioperative discussions of the importance of proper follow-up. Higher graduation rates are associated with increasing number of follow-up visits and duration, younger patient age, private insurance, and proximity to the practice. Compliance with attending the first postoperative visit may be an early marker for increased likelihood of graduation.

Surveillance tracheal aspirate cultures do not reliably predict bacteria cultured at the time of an acute respiratory infection in children with tracheostomy tubes.

BACKGROUND: The aim of this study was to characterize the practice of routinely obtaining tracheal aspirate cultures in children with tracheostomy tubes and to analyze the appropriateness of using this information to guide antibiotic selection for treatment of subsequent lower respiratory infections. METHODS: Pediatric otolaryngologists and pulmonologists were surveyed regarding surveillance culture practices. Records of children with tracheostomy tubes from January 1, 2003, through December 31, 2007, were reviewed. Consecutive cultures were compared for similarity of bacteria and antibiotic sensitivity when a clinic culture preceded a culture from when the child was ill and received antibiotics and when a hospital culture preceded a hospital culture from a separate hospitalization. RESULTS: Seventy-nine of 146 pulmonologists and five of 33 otolaryngologists obtained routine surveillance tracheal aspirate cultures (P < .001); 97% of pulmonologists used these cultures to guide subsequent empiric therapy. There were 36 of 170 children with one or more eligible pairs of cultures. Nearly all children had a change in flora in their tracheal cultures. Limiting empiric antibiotic choices to those that would cover microbes isolated in the previous culture likely would not have been effective in covering one or more microbes isolated in the second culture in 56% of pairs with the first culture from hospitalization vs 30% with the first culture from an outpatient setting (P = .15). CONCLUSIONS: This study demonstrated that there are significant changes in bacteria or antibiotic sensitivity between consecutive tracheal cultures in children with tracheostomy tubes. Use of prior tracheal cultures from these children was of limited value for choosing empiric antibiotic therapy in treating acute lower respiratory exacerbations. Surveillance cultures, thus, are an unnecessary burden and expense of care.