Imaging findings of a hibernoma of the neck.

Hibernoma is an uncommon benign fatty tumor that arises from the vestiges of fetal brown fat. We present a case report of a hibernoma of the neck in an asymptomatic 19-year-old girl and describe the important imaging findings. Computed tomography (CT) shows a well defined hypodense mass with septations. Magnetic resonance imaging (MRI) shows intermediate T1 and bright T2 signal of the mass and also demonstrates the characteristic marked contrast enhancement.

Surgical treatment of cervicofacial nontuberculous mycobacterial adenitis in children.

Fifteen children with nontuberculous mycobacterial adenitis of the head and neck underwent surgical treatment between July 1991 and July 1994. Fine-needle aspiration for biopsy and culture allowed early diagnosis in nine children. Positive cultures grew Mycobacterium avium-intracellulare complex in 12 children and M. chelonei in one child. Total excision was performed in 10 cases with combinations of lymphadenectomy and salivary gland excision. Curettage was used to successfully treat five children. One patient required local flap coverage for primary wound repair. Two patients required more than one surgical procedure. Our approach to early diagnosis and surgical treatment of cervicofacial nontuberculous mycobacterial adenitis is presented.

Acquired maxillary sinus hypoplasia: a consequence of endoscopic sinus surgery?

The effects of functional endoscopic sinus surgery (FESS) on sinus and midfacial development remain unclear. The authors report five children who, at a median age of 30 months, underwent FESS for refractory sinusitis. Three of the children had cystic fibrosis, and two had asthma. Preoperative computed tomographic (CT) scanning showed symmetric maxillary sinus development with varying degrees of mucosal disease. At a mean of 42 months after surgery, CT scans were obtained to evaluate recurrent symptoms in the five children. The scans showed unilateral maxillary hypoplasia in four children and bilateral maxillary sinus hypoplasia in one child. No child had clinically apparent facial asymmetry or midfacial hypoplasia. The authors also discuss the factors involved in maxillary sinus pneumatization, the possible effects of sinus surgery on sinus development, and the clinical implications of "acquired" maxillary sinus hypoplasia.

Functional laryngeal dyskinesia in children and adults.

OBJECTIVE: Functional laryngeal dyskinesia (FLD) is characterized by signs and symptoms of airway obstruction without anatomic basis. Failure to recognize its features often leads to inappropriate diagnostic studies and therapies. A systematic approach is presented for the recognition and management of patients with this disorder. DESIGN: A retrospective case series at a large, urban tertiary care academic hospital. METHODS: Retrospective review of charts of adults and children diagnosed with FLD between 1979 and 1996. Presenting symptoms and signs of FLD were categorized and methods of diagnosis were recorded. Therapeutic interventions and resolution of FLD at follow-up were also analyzed. RESULTS: Ten patients were identified with FLD, seven females and three males, with mean age of 25.9 years at diagnosis (range, 10-59 y). Patients were hospitalized a mean of three times (range, 1 to 6 admissions) before FLD was correctly diagnosed. Nine patients were receiving treatment for asthma prior to diagnosis. Flow volume loops most often showed a fixed extrathoracic inspiratory. Arterial blood gas and radiographic data were essentially normal. The most useful diagnostic test was fiberoptic laryngoscopy, which showed abnormal adduction of the vocal cords on inspiration in the nine patients in this series who underwent laryngoscopy. CONCLUSIONS: The authors' experience with FLD shows that its early recognition is associated with fewer interventions and their accompanying risks. A high degree of suspicion is required in these patients, who are often young and well educated. They present with stridor that may disappear while they are asleep or after distraction techniques.

Bilateral parotid enlargement in HIV-seropositive patients.

Bilateral enlargement of the parotid glands has been noted in five patients who are seropositive for antibody to the human immunodeficiency virus. A characteristic cystic appearance has been noted in these lesions on clinical and radiographic examination. A benign lymphoepithelial infiltrate with cystic degeneration is found in parotid specimens from these patients. The presence of human immunodeficiency virus ribonucleic acid in inflammatory cells infiltrating the parotid specimen was confirmed by an in situ hybridization technique. The clinical manifestations of sicca syndrome were not present nor were opportunistic infections diagnostic for the acquired immunodeficiency syndrome.

Surgery for cervicofacial nontuberculous mycobacterial adenitis in children: an update.

OBJECTIVE: To assess optimal surgical treatment with excision or curettage techniques in children with cervicofacial nontuberculous mycobacterial (NTM) adenitis. DESIGN: Retrospective case series. SETTING: Tertiary university-based pediatric referral center. PATIENTS: Patients younger than 18 years diagnosed as having cervicofacial NTM adenitis by positive mycobacterial cultures or stains, or by histopathologic evaluation. INTERVENTIONS: Fine-needle aspiration biopsy for diagnosis, surgical excision and/or curettage of head and neck lesions for treatment. MAIN OUTCOME MEASURES: Number of procedures per patient, complications, resolution of mass. RESULTS: A total of 32 surgical procedures were performed in 25 children with cervicofacial NTM adenitis (mean, 1.3 procedures per patient; range, 1-3): 19 excisional and 13 curettage procedures. The 14 children who had excision as an initial procedure required no additional surgery. Of 11 children who had curettage as an initial procedure, 6 (55%) required additional procedures. Three of these children had additional surgery as planned staged procedures. Excisional surgery after initial curettage (5 patients) was simplified by initial debridement and secondary healing. No complications of curettage were noted. Transient marginal mandibular nerve weakness was seen in 4 patients who had excision. Fourteen of 16 fine-needle aspiration biopsy specimens were diagnostic for NTM adenitis. CONCLUSIONS: Cervicofacial NTM adenitis can be treated with excision or curettage. Excision remains the treatment of choice because of the high cure rate with a single procedure. We now consider curettage as a staged procedure for lesions in proximity to the facial nerve or with extensive skin necrosis, with initial curettage simplifying subsequent excision and wound closure. Preoperative counseling should include discussion of planned or unplanned revision surgery after curettage. Fine-needle aspiration biopsy allows early diagnosis of NTM adenitis.

Pediatric flexible fiberoptic bronchoscopy through the laryngeal mask airway.

OBJECTIVE: To determine the usefulness and safety of the laryngeal mask airway (LMA) as an adjunct to pediatric flexible fiberoptic bronchoscopy (FOB). DESIGN: A case-series retrospective study. SETTING: Pediatric otolaryngology tertiary referral center, outpatient and inpatient operating suites. PATIENTS: Retrospective review of charts of children who had FOB performed with the use of LMA by the pediatric otolaryngology service. The patients were ages 3 months to 18 years with respiratory symptoms requiring FOB for diagnosis. INTERVENTIONS: Use of LMA to support airway during FOB with spontaneous ventilation with the patients under general anesthesia. MAIN OUTCOME MEASURES: Ability to perform airway evaluation with FOB and LMA; number and type of complications. RESULTS: Seventeen patients, ages 3 months to 18 years (median age, 39 months) underwent FOB with use of LMA. In 2 patients use of LMA failed-1 from airway obstruction with LMA in place, which required intubation, and another who could not have LMA appropriately placed. Fifteen patients underwent uncomplicated FOB through the LMA. None of these 15 patients required unplanned endotracheal intubation. Two patients with mandibular hypoplasia required LMA use for airway evaluation when the glottis could not be visualized at direct laryngoscopy. CONCLUSIONS: The LMA is a safe and effective adjunct to pediatric FOB. Laryngeal mask airway use for FOB allows evaluation of the airway during spontaneous ventilation without an endotracheal tube or a face mask. Larger fiberoptic scopes can be used through the LMA compared with pediatric FOB performed through the nose or through an endotracheal tube.

Fine-needle aspiration biopsy of cervicofacial masses in children.

OBJECTIVE: To show the usefulness of fine-needle aspiration biopsy (FNAB) in the diagnosis of cervicofacial masses in children. DESIGN: Case series. SETTING: Pediatric otolaryngology referral center, ambulatory and hospitalized patients. PATIENTS: Seventeen pediatric (age, < 18 years) patients with cervicofacial masses. INTERVENTION: Fine-needle aspiration biopsy. OUTCOME MEASURES: Cytologic diagnosis, resolution of mass, and need for further surgical diagnosis or treatment. RESULTS: Following FNAB, 10 patients underwent open surgery; in seven, the surgery was indicated based on FNAB diagnosis; in three, surgery provided diagnoses where FNAB was insufficient. Based on FNAB data, seven patients were observed without surgery. CONCLUSIONS: Fine-needle aspiration biopsy is a useful early step in diagnosing cervicofacial masses in children.

A simple method for closure of tracheocutaneous fistula in children.

OBJECTIVE: To review the results of a simple technique of closure of persistent tracheocutaneous fistula (TCF) in children. DESIGN: Retrospective case series. SETTING: Tertiary pediatric otolaryngology referral center. PATIENTS: Children (age, < 18 years) who underwent repair of TCF from July 1, 1991, to August 31, 1996. INTERVENTIONS: Surgical closure of persistent TCF using multilayered closure of de-epithelialized local tissue. Tracheal dissection was not performed. A thermal hemostatic scalpel was used in some cases to assist in de-epithelialization and provide hemostasis without electrocautery near the airway. MAIN OUTCOME MEASURES: Success of closure and number and types of complications. RESULTS: Nine procedures were performed in 8 children. Seven (88%) of 8 primary procedures were successful, but early recurrent TCF developed in 1 patient. Revision surgery using an identical surgical technique, but maintaining endotracheal intubation for 48 hours, was successful in this patient. No complications occurred. CONCLUSIONS: This procedure is a simple, reliable method for closure of TCF in children.

Latex allergy: an update for the otolaryngologist.

OBJECTIVE: To describe the clinical manifestations of latex allergy in otolaryngology patients. DESIGN: Descriptive case series. SETTING: Tertiary academic otolaryngology practice. PATIENTS: Otolaryngology patients with documented allergic reactions to latex during surgery and confirmatory laboratory test results for latex allergy. MAIN OUTCOME MEASURES: Clinical description of latex reactions; identification of risk factors for latex allergy. RESULTS: We describe 3 patients, 2 children and 1 young adult, with severe latex allergy manifested by intraoperative cardiorespiratory changes and confirmed by positive latex-specific IgE test results. A 9-year-old boy with a tracheotomy and a history of multiple procedures for laryngeal stenosis developed a rash and unexplained bronchospasm during an open laryngeal procedure. Surgery was aborted, and subsequent surgery was performed uneventfully 4 weeks later using a latex-safe environment. A 13-year-old boy with recurrent respiratory papillomatosis and a ventriculoperitoneal shunt had sudden unexplained arterial oxygen desaturation and a rash during laser endoscopy. He was then treated successfully using latex-safe protocols. A 23-year-old man with a parotid malignancy developed unexplained hypotension and ventilatory difficulties in the operating room during preparation for surgery. He responded to medical treatment for anaphylaxis. CONCLUSION: The otolaryngologist should share in the increased awareness of latex allergy. Our patients who have had multiple surgical procedures or who are exposed to latex on a long-term basis may be at increased risk. Latex allergy should be considered when unexplained cardiorespiratory compromise occurs during surgery.

Polysomnography in the evaluation of readiness for decannulation in children.

OBJECTIVE: To determine whether polysomnography is useful in the evaluation of readiness for decannulation in children with long-term tracheotomy. DESIGN: Descriptive, retrospective case series. SETTING: Tertiary care pediatric center, pediatric sleep disorders laboratory, and pediatric otolaryngology referral center. PATIENTS: Children (younger than 18 years) with tracheotomy undergoing polysomnography to assess their dependence on tracheotomy. INTERVENTION: Polysomnography in all patients; endoscopy and decannulation in those judged clinically ready. MAIN OUTCOME MEASURES: Success of decannulation. RESULTS: Thirteen of 16 patients with favorable polysomnographic data were successfully decannulated. CONCLUSION: Polysomnography is a useful supplement to airway endoscopy in the evaluation of readiness for decannulation in children with long-term tracheotomy and dynamic airway issues.

Ectopic cervical thymic tissue: diagnosis by fine needle aspiration.

Cervical thymic masses are congenital lesions that result from aberrant thymic migration during embryogenesis. Although most of these masses are asymptomatic, they may cause debilitating symptoms secondary to encroachment on adjacent aerodigestive structures. Preoperative diagnosis of ectopic thymic tissue is rare; most cases are clinically misinterpreted as branchial cleft remnants or cystic hygromas. Definitive diagnosis has relied on histopathologic examination in nearly all reported cases. However, the invasiveness of open incisional or excisional biopsy carries the risk of surgical and anesthetic complications. Inadvertent surgical thymectomy may result in cell-mediated immune deficiencies in infants and young children. The utility of fine needle aspiration is gaining wider acceptance in the diagnostic evaluation of neck masses. We describe an infant with an asymptomatic cervical thymic mass diagnosed by fine needle aspiration.

Differential diagnosis of dysphagia in children.

Dysphagia in children often presents a difficult diagnostic challenge. A systematic approach in each individual can help with diagnosis and treatment. An overview of the differential diagnosis and the diagnostic and treatment options available is provided.

Stridor in infants and children: ambulatory evaluation and operative diagnosis.

The presence of stridor in the young child suggests a congenital or acquired abnormality of the large diameter airways. The diagnostic evaluation of the stridulous child is discussed. Emphasis is placed on those outpatient examination techniques and radiographic studies which can define the nature of the offending airway lesion(s).

Lightwand intubation of infants and children.

STUDY OBJECTIVE: To examine factors contributing to successful lightwand (lighted stylet) intubation of infants and children. DESIGN: Prospective observational study. SETTING: University hospital. PATIENTS: 125 children under age 10 years presenting for elective surgery. INTERVENTIONS: Prototype lightwands specifically designed for pediatric patients were used. Intubations were done by anesthesia residents with little or no prior lightwand experience. All attempts were recorded on videotape. In a subgroup of 14 patients, an endoscopic view of the lightwand was also recorded with a flexible nasopharyngoscope. MEASUREMENTS AND MAIN RESULTS: 125 patients with a mean age of 3.0 years (+/- 2.4 years SD; range: 3 weeks to 9 years) were enrolled. 83.2% were intubated using the lightwand, including 75.5% (34 of 45) of infants weighing less than 10 kg. Of the 21 failed intubations, 8 were due to an inappropriately large endotracheal tube, as recognized during direct laryngoscopy; 4 were due to other reasons discussed; and 9 (persistent vallecular or esophageal entry) could not be explained from videotape analysis. Factors contributing to successful intubation included: (1) use of a shoulder roll and slight head extension; (2) conscientious alignment of airway axes; (3) anterior jaw lift to elevate the epiglottis; and (4) gentle handling of the lightwand to avoid displacing soft tissue. Inability to advance the lightwand despite correct glow is caused by entrapment in the vallecula, hang up of the lightwand on the aryepiglottic folds, subglottic narrowing, or vocal cord closure. CONCLUSIONS: Lightwand intubation in children uses both tactile and visual cues regarding the location of the endotracheal tube tip. Attention to detail results in a high level of success among novice users of the pediatric lightwand. Endoscopic and external videotaping gave us a means of monitoring the progress of mechanical skills among novice users.