Intubation techniques of the difficult airway.

Visualization and intubation of the larynx in the normal infant may be difficult, especially in a newborn who has a large tongue in relation to the size of the oral cavity and an oval epiglottis. There are a number of congenital and acquired conditions that virtually guarantee that establishment of an airway will be difficult; therefore the pediatric physicians should be equipped with and capable of using a wide range of instruments and techniques. This article will focus on the techniques available for handling the difficult airway and will emphasize a new instrument.

Croup syndrome: historical perspective.

The management of acute croup syndrome has undergone very interesting changes in the past century. Initially a number of conditions were thought to be synonymous with croup, but with identification of the bacterial and viral etiology these have been separated into different clinical entities: viral croup which is very common and frequently self-limited; bacterial tracheitis, a condition which is infrequently encountered and which may be a complication of viral croup; and epiglottitis or supraglottitis, a disease that has been identified as most frequently due to a specific organism, H. influenzae. The management of the child with airway obstruction has also changed. Before the past decade virtually all children with epiglottitis were treated with tracheotomy and currently very few children are thus treated. Intubation has been showed to be a safe procedure in these cases. There still exists some controversy regarding the treatment of the child with laryngotracheobronchitis. In the vast majority of cases medical management has been successful and in the remainder there is controversy regarding the use of intubation or tracheotomy.

The impact of otitis media.

Otitis media is one of the most worldwide prevalent diseases that affects children. The socioeconomic costs may exceed 3.5 billion dollars a year in the United States alone in direct and indirect costs. If a vaccine can be developed that will decrease 1% of the illness this would be significant in this country and probably even more valuable in less developed countries.

Controversy over tubes and adenoidectomy.

Dr. Bluestone then summarized the panelists' discussion by stating that there is now evidence that myringotomy alone for chronic otitis media with effusion has some efficacy but is probably no better than watching the child and not performing surgery. He also stated there are now some data to show that myringotomy and tube insertion for chronic otitis media with effusion appear to be more beneficial than either watching a child over a long period of time or performing myringotomy alone. However, the panelists made a plea that each child should be individualized on the basis of the duration of the effusion, the child's response to medication, the time of the year, distance from health care providers and other factors. Dr. Gates stressed that hearing loss was an important factor, but if hearing loss is a deciding factor, then serial audiograms or at least some assessment of hearing in the clinician's office should be performed. He also stated that there is now evidence that adenoidectomy is effective in certain children, but there is still an 80% recurrence rate and a 15% rate of failure in which children require repeat surgery. Dr. Bluestone suggested that parents and the child (if old enough) should be informed of what is known about the risks, costs and benefits of these surgical procedures. He recommended the clinician discuss with the parents the pros and cons of performing or not performing surgery, including the complications and sequelae of otitis media and also of tube insertion.(ABSTRACT TRUNCATED AT 250 WORDS)

Nasal glioma.

Six cases of nasal gliomas, which are rare ectopic rests of neural tissue found at the root of the nose, are presented. It is important to distinguish nasal tumors from basofrontal encephaloceles to avoid inadvertent exposure of the brain during the surgical removal of mass lesions. Because of their related embryologic origins, the distinction between nasal gliomas and basofrontal encephaloceles may not be clear clinically. Nasal gliomas may be treated by several surgical specialties, and only a proper awareness of their relatonship to encephaloceles can assure the selection of a flexible and adequate surgical approach. This paper emphasizes the salient clinical characteristics of nasal gliomas, their clinical distinction form and embryologic relationship to encephaloceles, and the options for treatment.

Cerebrospinal fluid fistula: the identification and management in pediatric temporal bone fractures.

Cerebrospinal fluid (CSF) fistula represents a potentially lethal complication and requires a high index of suspicion to make the diagnosis. A 12-year retrospective study of pediatric basilar skull fractures identified 147 patients with temporal bone fractures, of which 37 patients exhibited evidence of CSF fistula. The diagnosis is made from a combination of clinical, radiographic, and chemical evaluation. The evolution of diagnostic techniques are reviewed, and the more recent and sensitive tests, such as beta-2 transferrin, are emphasized. Treatment of CSF fistula is nonsurgical in most cases. Surgical exploration and mastoid obliteration were required in two patients, and the indications for surgical treatment are explored. The use of antibiotic prophylaxis is controversial and not routinely indicated.

The compleat otolaryngologist: Burton Alexander Randall.

The practicing otolaryngologist and resident is the beneficiary of a highly organized educational system which has evolved over the past 100 years. A number of social, scientific and technical advances were involved in the evolution of these training programs; however, one of the most important developments was the emergence of the Clinician Educator Concept. Burton Alexander Randall was prominent in the profession in the late nineteenth century and early twentieth century and is an example of the clinician-teacher who participated in the development of otorhinolaryngologic instruction. His unpublished memoirs, recently made available, illustrate the difficulties in obtaining appropriate training, organizing clinical services, and establishing professional relationships. These interesting documents provide insight into the present and illustrate that although there have been great technical advances, some problems in interpersonal relationships remain the same.

Adam Politzer, otology and the Centennial Exhibition of 1876.

The Centennial Exhibition of 1876 was held in Philadelphia. Among the exhibits was a collection of temporal bone dissections produced by Adam Politzer of Vienna. This exhibit included both normal and pathological temporal bones, and emphasized the relationship of the tympanic membrane to the middle ear, external canal and bony labyrinth. At the close of the Centennial Exhibition the collection was purchased by the College of Physicians of Philadelphia. This collection and the congress associated with the Centennial had a tangible effect on the otology in this country.

The role of tympanocentesis in the management of infants with sepsis.

Tympanocentesis is a procedure that can identify pathogenic organisms in otitis media. However, the clinical value of this diagnostic method in the management of infants who have sepsis has not been previously reported. Although otitis media is a significant source of sepsis in infants, tympanocentesis is not routinely employed in the work-up of infants with sepsis who have abnormal otoscopic findings. Charts of 40 consecutive infants who had sepsis and were undergoing tympanocentesis as part of their emergency room work-up were reviewed. Results of middle-ear aspirations from these infants, the bacteriology of middle-ear effusions, and the role of this information in their clinical management is presented. In 80% of these patients, clinical management was directly affected by tympanocentesis data. Tympanocentesis is a safe, effective diagnostic and therapeutic procedure with which otolaryngologists can provide important bacteriologic information to the pediatricians who are managing infants with sepsis.

Acute management of laser-ignited intratracheal explosion.

The laser-ignited airway explosion is a shocking emergency. Techniques available for prevention of an airway fire minimize the risk, but they are not applicable in all circumstances. The severity of the patient's injury depends on the duration and intensity of the burn. Prompt, appropriate management is facilitated if the operating team has previously discussed and "rehearsed" this potential disaster. The distal airway burn produced by an ignited endotracheal tube differs from an inhalation burn in character and severity. The anatomic and respiratory effects occurring subsequent to the laser-induced burn are examined. Emergency care requires immediate elimination of the fire, removal of the tube and any foreign body or debris, and usually a tracheostomy. A program of medical and endoscopic management is suggested.

Management of facial palsy caused by birth trauma.

We present a newborn with a unilateral complete facial palsy caused by birth trauma, and discuss the differential diagnosis, pathophysiology, and management of this common, usually benign, condition. This child made a rapid, complete, spontaneous recovery despite a severe initial injury. Surgical exploration of the facial nerve should be considered only for infants with complete paralysis, clinically and electrophysiologically, who demonstrate no improvement by 5 weeks of age.

Nasal surgery in children with cystic fibrosis: complications and risk management.

Children with cystic fibrosis (CF) are predisposed to pansinusitis and nasal polyposis and, therefore, require frequent surgery by otolaryngologists. These children are at risk to have complications following surgery, both locally, at the surgical site, as well as systemically from their underlying pulmonary disease. A 20-year retrospective study of children (average census 219 per year) revealed 39 children developed nasal polyps and these children required 85 nasal polypectomies. No major complications occurred and only three minor complications (fever, minor bleeding) were noted. Over 95% of our CF children were able to return home in less than 48 hours, and extensive hospital stays appeared not to be required.

Function of the Eustachian tube related to surgical management of acquired aural cholesteatoma in children.

A group of 12 children with acquired cholesteatoma had the ventilatory function of the Eustachian tube assessed by the inflation-deflation technique. All had varying degrees of functional rather than mechanical obstruction of the Eustachian tube. In these children, the pathogenesis of acquired cholesteatoma appeared to be the result of the following sequence of events: functional Eustachian tube obstruction, high negative middle ear pressure, atelectasis of the tympanic membrane-middle ear, a retraction pocket in either the posterosuperior or attic portion of the tympanic membrane, and adhesive otitis media. Tympanoplasty in these children was not successful. It is suggested that when the middle ear-mastoidectomy cavity is allowed to remain open, then the bony portion of the Eustachian tube should be surgically closed to prevent postoperative reflux of nasopharyngeal secretions.

Should granulomas be excised in children with long-term tracheotomy?

We reviewed 265 rigid bronchoscopies performed in 50 children with tracheotomy-dependent subglottic stenosis (25 congenital, 25 acquired). Granulomas developed in 40 children (80%) and were unrelated to age, sex, race, gastroesophageal reflux, tracheotomy duration, or type of stenosis. The incidence of small to medium, large, and obstructing granulomas at endoscopy was 28%, 6%, and 0%, respectively. Compared with a baseline finding of no granuloma at preceding bronchoscopy, the odds of granuloma recurrence were 3.0 after an unexcised granuloma (95% confidence interval [CI], 1.1 to 8.4), 4.1 after granuloma excision (95% CI, 1.4 to 11.9), and 7.3 after expansion surgery (95% CI, 1.1 to 49.2). Considering the low incidence of large or obstructing granulomas, and the failure of granuloma excision to diminish recurrence, we do not recommend interval excision of nonobstructing granulomas in children with stable tracheotomies.

Revolutionary inventions in the 20th century. The history of endoscopy.

Today, the wide variety of modern endoscopes allows routine diagnostic examinations. Precise observation is possible because of excellent optical and light transmission. Surgery can be performed while viewing a television screen, and video documentation and intraoperative photography are possible with outstanding quality. The invention of a rod-lens optical system by Harold H. Hopkins, PhD, in 1959 and the addition of fiberoptic light transmission by Karl Storz in 1960 marked a breakthrough in modern endoscopy. This article summarizes an interview with the instrument maker, Karl Storz.

Otolaryngologic findings in whistling face syndrome.

Craniocarpotarsal dysplasia or whistling face syndrome is rare with only 60 cases having been reported in the literature. More than 60 anatomic anomalies of the head, hands, and feet, in addition to the face, have been noted. Although the literature contains numerous case reports describing in detail the various features and abnormalities of the syndrome, the otolaryngologic findings in these patients have yet to be summarized. We present two additional cases in a mother and daughter with an extended follow-up period of 30 and 17 years, respectively, and summarize the otolaryngologic findings in all previously reported cases of this rare syndrome. Also, the principal clinical features and associated features are described.

Otitis media and hearing loss in Turner syndrome.

Twenty-two phenotypic females with Turner syndrome underwent prospective otologic evaluation including a standard history, physical examination, audiogram, and tympanogram. Eight of these patients had computed tomography of the temporal bones. Eighty-two percent of the patients had a history of chronic or recurrent ear infections. Eleven patients (50%) had previous myringotomy and tube placement and 4 (16%) had undergone tympanoplasty or tympanomastoidectomy for sequelae of otitis media. Ten patients (45%) had middle ear effusions evident on examination. Sixteen patients (73%) had hearing loss in at least one ear at the time of examination. Sensorineural losses were evident in 37% of patients. No malformations of the otic capsule were noted on computed tomography. The high prevalence of both hearing loss and otitis media in Turner syndrome warrants otologic and audiologic assessment of patients with this chromosomal anomaly.

Otologic manifestations of Langerhans' cell histiocytosis.

Eighteen of 62 children diagnosed with Langerhans' cell histiocytosis at the Children's Hospital of Pittsburgh (Pa) between 1970 and 1986 demonstrated ear and temporal bone involvement. In six children, such otologic disease was their sole presenting manifestation. Common signs and symptoms included aural discharge, postauricular swelling, and conductive hearing loss. The otologic findings in these children, if not investigated properly, could easily be attributed to acute or chronic infectious ear disease. Computed tomography with contrast enhancement proved to be particularly valuable as a diagnostic study because of its clear delineation of both osseous and soft-tissue temporal bone involvement. Computed tomographic findings could also be used to enhance local treatment by guiding surgical biopsy and curettage procedures or defining low-dose radiation therapy portals. Eleven of these 18 children with otologic Langerhans' cell histiocytosis additionally required chemotherapy due to the systemic nature of their disease.

Evolution of pediatric otolaryngology.

A historical overview of the evolution of the field of pediatric otolaryngology is presented in this article. The author recounts his own experiences in the field, and details the development of this rapidly expanding specialty.

Clinical guideline development for otitis media: a report on methodology.

Clinical guideline development is a major emphasis of recent health policy efforts. Interest in clinical guidelines is the result of multiple factors, including economic pressures and the desire to achieve a baseline level of practice in clinical settings. Guidelines have always been of fundamental importance in medicine. This article will discuss the place clinical guidelines have in contemporary practice and the difficulties encountered in the process of developing a meaningful guideline for managing otitis media with effusion.