Cartilage grafts--present status.

Cartilage grafts have been in use for almost a century and have proved their usefulness. Many questions about immunology, survival, growth, and role of perichondrium are still debated. We are presenting a review of the literature and of our experimental work on cartilage grafts. Ear cartilage was transplanted from 28 young New Zealand rabbits subcutaneously in the chest walls. The grafts were divided into 1) bare cartilage, 2) perichondrium, 3) cartilage covered with perichondrium on one side, and 4) cartilage covered with perichondrium on both sides. The grafts were measured in length and weight before transplantation, and at 2 and 4 months after transplantation; they were compared to a control piece of cartilage tagged in situ. Histologic examination was performed on all retrieved grafts. Transplanted cartilage survival was good in over 75% of cases; however, cartilage production from perichondrium was minimal and no growth was noticed in any of the grafts.

Projected societal needs in pediatric otolaryngology.

With the recent increase in pediatric otolaryngology fellowship training programs, fellows are being trained in record numbers and there is concern about the possibility that the supply of these physicians will soon exceed societal needs. This study was conducted to determine the number of fellowship-trained pediatric otolaryngologists that would meet the needs of society and when this need will be met. Information was collected from national organizations and from a survey of fellowship training programs. A hospital-based practitioner model was used to predict societal needs based on the anticipated changes in patient care, mainly managed-care capitated systems. The projected societal need is 382 pediatric otolaryngologists. If current fellowship training levels continue, this need will be met in just over 7 years.

Use of stents in laryngotracheal reconstruction in children: indications, technical considerations, and complications.

The keys to successful outcome in surgical repair of laryngotracheal stenosis in children are choice of surgical procedure, including possible need for stenting; choice of type and length of stent; and duration of stenting. Choosing the appropriate method for stenting requires considering consistency of stenosis, altered anatomy, size, location, and stability of grafts when used for surgical repair and host tissue healing factors. Possible stents that can be used include endotracheal tubes, Silastic sheet rolls, Montgomery T-tubes, and laryngeal stents. This study investigates the effectiveness of the Aboulker stent, an increasingly popular stent for use in children. Indications and associated technical considerations for using the stent in 18 cases are reviewed. Postoperative care and follow-up, directed against infection and towards securing the stent in its original location, and management of complications are discussed.

Branchial anomalies: a review of 52 cases.

Fifty-two patients with branchial anomalies (BA) treated at the Children's National Medical Center between 1983 and 1993 were reviewed to determine the incidence of different types of anomalies and to analyze the authors' method of diagnosis and management. First BA was seen in 25%, second in 40%, third in 8%, and fourth in 2%. In 25%, the origin of the anomaly was undetermined. Our incidence of first BA was significantly higher than the incidence reported in other series. Of the anomalies, sinuses were more common than cysts or fistulae. Sinuses tend to present at an earlier age than cysts, which take time to enlarge and present clinically. Repeated incision and drainage and incomplete excisions were frequently seen with first, third, and fourth anomalies due to misdiagnosis. Recent trend has been to utilize radiographic studies more frequently, and they have been found to be helpful in guiding surgical therapy, particularly with the more complicated cases.

Airway obstruction in the Pierre Robin sequence.

Airway obstruction and feeding difficulties vary among patients with Pierre Robin sequence (PRS). Treatment is challenging and the appropriate management may not be readily identified, leading to delay in securing the airway. A retrospective review of 90 children with PRS was done to identify subgroups at a higher risk of developing severe airway obstruction using oxygen and apnea monitoring, sleep studies, and response to treatment. Patients with isolated PRS (group I, 27 patients) and Stickler syndrome (group II, 32 patients) do not suffer from debilitating airway and feeding difficulties when compared to those with unique syndromes (group III, 16 patients) and recognized named syndromes (group IV, 15 patients). Feeding difficulties were universal with the severity proportional to airway obstruction. Aggressive intervention should be considered early in group III and IV patients.

Pneumomediastinum and pneumothorax from blunt cervical trauma in children.

Minor blunt cervical injuries in children are relatively common occurrences leading to serious sequelae in only rare circumstances, yet sufficient impact of even a seemingly minor event may lead to a significant posterior tracheal wall laceration, resulting in pneumomediastinum with or without pneumothorax. Three cases demonstrate how the mechanism of injury does not always match either the severity of initial presentation or the consequent necessary level of emergent management. Pneumomediastinum without pneumothorax often can be treated conservatively; however, the onset of massive pneumomediastinum and pneumothorax may necessitate both tracheotomy and tube thoracostomy as initial treatment.

Value of CT scan in the diagnosis of temporal bone diseases in children.

CT scan of the temporal bone has become a frequently ordered test for diagnosis of temporal bone pathology. We retrospectively examined our experience with CT scans of the temporal bones in 124 consecutive children from January 1983 to September 1984 in an attempt to assess its usefulness in diagnosis and treatment of ear disease in children. Patients were divided into six categories according to their pre-scan diagnosis, (trauma, congenital aural atresia, dizziness, facial nerve paralysis, middle ear disease, congenital sensorineural hearing loss) and CT findings were compared to data found by physical examination, by otologic studies such as audiogram and BSER, by other x-ray studies and ultimately compared to findings at surgery when applicable. CT was found to be instrumental in diagnosing middle ear disease; gave necessary preoperative information in children with aural atresia; delineated most temporal bone fractures; ruled out gross inflammatory, neoplastic, or traumatic etiologies in dizzy patients and in facial nerve abnormalities; and provided anatomic information about the inner ear in patients with sensorineural hearing loss. In our group of patients with sensorineural hearing loss, a 6.8% incidence of anatomic malformations was found by CT. However, CT had major limitations in stapes and oval window areas, especially in cases of perilymph fistulas. CT use was also limited in children because of the difficulty in achieving projections that require active patient cooperation.

Vocal quality of decannulated children following laryngeal reconstruction.

Laryngotracheal reconstruction with expansion surgery is a reliable method for treatment of laryngotracheal stenosis in children. It allows for decannulation of the patient and restoration of vocal communication. Previous information regarding vocal quality in these patients has been scant. Sixteen children who underwent successful laryngotracheal reconstruction were evaluated using a standardized voice assessment during each of the following: phoneme prolongation, counting, storytelling, and spontaneous conversation. Interjudge ratings were obtained to establish reliability. The location and severity of the laryngotracheal stenosis and the method of treatment were reviewed. Twelve children have a functional voice compared to six preoperatively. Overall, vocal parameters suggested a particular pattern consisting of a lower than optimal pitch and a restricted pitch range. Laryngotracheal reconstruction does make oral communication possible for children who would otherwise have persistent tracheotomy. However, vocal quality appears to be disturbed in most of the patients.

Periorbital hematoma secondary to sinusitis in a child.

Periorbital abscess secondary to sinusitis is a well-recognized entity in children. However, subperiosteal hematoma is extremely rare and has been reported in only four adult patients. This article presents the case of a 4-year-old girl with sinusitis, proptosis, and decreased visual acuity. Surgical exploration of the orbit revealed the presence of a large organizing subperiosteal hematoma that was drained. The presence of a periorbital hematoma should be suspected in patients with acute onset of proptosis and findings of a periorbital mass and sinusitis on computed tomographic scan.

Treatment of laryngotracheal stenosis with anterior and posterior cartilage grafts. A report of 41 children.

Forty-one tracheotomy-dependent children with moderate and severe laryngotracheal stenosis (Cotton grades III and IV) underwent laryngotracheal reconstruction with simultaneous use of costal cartilage grafts in the anterior and posterior subglottis and posterior glottis. The indications for this procedure are the presence of stenosis in the posterior part of the glottis, subglottis, or both in combination with anterior subglottic or upper tracheal narrowing. Other indications are the presence of circumferential subglottic stenosis, bilateral subglottic shelves, or total subglottic obstruction. The complications of this procedure included pneumothorax (one patient) and granulation tissue formation (five patients). There were two deaths unrelated to the reconstructive procedure. This technique offers an excellent opportunity for repair of laryngotracheal stenosis with a better than 90% tracheotomy decannulation rate after a single procedure within a short period after removal of the stent.

Quincke's edema, revisited.

Angioneurotic edema involving the uvula is sometimes referred to as Quincke's edema. The term angioneurotic edema describes several closely related diseases manifested by recurrent, acute edema of the skin or mucosa. We report a case of uvular edema secondary to food allergy, treated successfully with steroids. A short review of angioneurotic edema and its management is also presented.

In vitro regulation of expression of cartilage-derived morphogenetic proteins by growth hormone and insulinlike growth factor 1 in the bovine cricoid chondrocyte.

OBJECTIVES: To delineate the endogenous growth factors that regulate cricoid cartilage growth at the molecular level. Specifically, to attempt to establish the presence of cartilage-derived morphogenetic proteins (CDMPs), cartilage-specific members of the bone morphogenetic protein family, in newborn bovine cricoid chondrocytes and to assess the expression of these endogenous growth factors with the addition of exogenous growth hormone or insulinlike growth factor 1 in an in vitro chondrocyte culture model. METHODS AND DESIGN: Basic science molecular biologic research methods, including high-density monolayer and explant chondrocyte cultures with extraction of messenger RNA and quantitation via Northern blot hybridization via radiolabeled complementary DNA probes. SETTING: Intramural basic science research laboratory. RESULTS: Both CDMP-1 and CDMP-2 were found in newborn cricoid chondrocytes. Addition of exogenous growth hormone did not appear to influence the expression of CDMP-1 or CDMP-2. Addition of exogenous insulinlike growth factor 1 appeared to down-regulate the expression of CDMP-1 but had no effect on the expression of CDMP-2. No major differences in CDMP level of expression were noted between high-density monolayer cultures vs explant cultures. No tissue specificity differences were noted in regulation of CDMPs between cricoid and articular chondrocytes. CONCLUSIONS: Our preliminary studies indicate the presence of endogenous morphogenetic proteins in newborn bovine cricoid chondrocytes. These novel polypeptide hormones (CDMP-1 and CDMP-2) have not been previously reported in laryngeal cartilage chondrocytes. Change in level of transcription of these morphogenetic proteins under various in vitro conditions suggests that these proteins are subject to regulation and/or play a regulatory role in cricoid chondrocyte growth and differentiation. Further experimentation is needed to confirm these findings.

Pitfalls in laryngotracheal reconstruction.

OBJECTIVE: To determine the causes of laryngotracheal reconstruction (LTR) failures. DESIGN: Retrospective chart review. SETTING: Tertiary care children's hospital. PATIENTS: Seventeen pediatric patients who underwent revision LTR from October 1, 1986, to December 31, 1998. INTERVENTION: Laryngotracheal reconstruction. MAIN OUTCOME MEASURE: Decannulation. RESULTS: Seventeen patients required a total of 42 LTRs for decannulation. There were 17 primary LTRs and 25 revision LTRs. The primary LTRs were done either at our or other institutions. Two patients died after initial LTR failed, one because of tracheotomy tube plugging and the other because of a severe respiratory syncytial virus pneumonia. All 15 remaining patients have been decannulated. There were 27 failed LTRs with 17 being primary and 10 revision LTR failures. In 3 of the 27 failed procedures, no obvious causes for failure could be found. In the remaining 24 procedures, 1 or more factors that contributed to LTR failure could be found. Poor preoperative evaluation with subsequent failure to address the airway lesion was seen in 6 procedures. Intraoperative reasons for LTR failure included inappropriate choice of graft in 2 procedures; inappropriate stent in 7; inappropriate stent length in 1; and inappropriate duration of stent in 8. In 6 procedures, the airway abnormalities identified at endoscopy were not adequately addressed at LTR. Postoperative factors for failure were poor follow-up in 2, anterior suprastomal collapse in 2, and slipped or broken stent in 2. Other factors that contributed to LTR failures included intractable gastroesophageal reflux disease in 1 procedure and keloid formation in 5. CONCLUSIONS: Although some LTRs may fail secondary to factors that are not under the surgeon's control, many LTR failures can be avoided by accurate preoperative and intraoperative assessment of the stenosis, correct choice of surgical procedure, and close postoperative monitoring.

Tonsillectomy in children under 3 years of age.

A retrospective study was performed on 190 children younger than 3 years who underwent tonsillectomy either alone or in combination with other surgical procedures at the Children's National Medical Center, Washington, DC, over a 5-year period. The average age was 2 years 4 months and average weight was 12.8 kg. The most common indication for surgery was upper airway obstruction with apnea. One hundred sixty-two of 190 patients were discharged on the day following surgery. Complications were seen in 20 (10.5%) patients, 16 requiring prolongation of hospital stay and 4 requiring readmission. However, apart from one child with cerebral palsy who had multiple post-operative complications, no other child required reintubation, blood transfusion, or return to the operating room. It is concluded that age should not be a factor in determining whether or not to proceed with a tonsillectomy.

Balancing pediatric otolaryngology training for fellows and residents at a children's hospital.

OBJECTIVE: To determine the feasibility of providing surgical, endoscopic, and patient contact experience of high educational value at a children's hospital sufficient for adequately training contemporaneously both residents in otolaryngology-head and neck surgery and fellows in pediatric otolaryngology. DESIGN: Retrospective review of operating room case logs and assignment of cases based on arbitrary perception of inherent case complexity and skill and experience that are required to manage the case. SETTING: Tertiary care children's hospital located in a major metropolitan area. MAIN OUTCOME MEASURES: (1) Volume of surgical and endoscopic cases assigned retrospectively to junior resident, senior resident, or fellow. (2) Score on newly developed self-assessment skill list in pediatric otolaryngology. RESULTS: During 1 year, there were 3224 surgical and endoscopic procedures performed in the operating room. Of the total number of procedures, only 44 (1.4%) were designated as being exclusively assigned for hands-on experience to a fellow, but 380 (11.8%) were appropriate for both a senior resident and a fellow and therefore were apportioned in an alternating fashion. A self-assessment instrument has been developed to assess competency and comfort in the management of otolaryngic disorders, both surgical and nonsurgical, in children. CONCLUSIONS: The volume and assortment of surgical and endoscopy cases at a tertiary care children's hospital can provide the basis for a rich, practical hands-on experience for residents and fellows. Since few surgical or endoscopic cases require pediatric fellowship training for mastery, becoming a pediatric otolaryngologist depends on acquiring skills and competence that exceed the technical skills acquired in the operating room.

External fixation using microplates after laryngotracheal expansion surgery. An animal study.

Management of severe laryngotracheal stenosis requires treatment with open laryngeal surgical approaches. Performing the necessary anterior, and possibly posterior, incisions to expand the cricoid and tracheal rings causes instability of the segments. Placing an intraluminal stent has several disadvantages, ranging from injury of healthy tissue to airway obstruction. The availability of an external stent would avoid many of these complications. We performed expansion laryngeal surgery in dogs and explored the use of microplates for external fixation and determined the surgical outcome if no fixation is used. The results show that microplates are very effective in maintaining external fixation and that a need for placing an intraluminal stent when a posterior cricoid split is performed exists.

An in vitro model for studying growth and effect of trauma and external agents on the cricoid at the cellular level.

Over the past several years it has become evident that expansion laryngotracheal surgery is effective in the treatment of laryngotracheal stenosis. Several clinical and animal studies have been performed to study the process of laryngotracheal stenosis and its treatment. However, there are still many questions that cannot be addressed by currently used clinical and animal research. Further indepth study of the behavior of the subglottis at the cellular level is necessary. We present an in vitro model for studying chondrocyte metabolism of the bovine cricoid. Cartilage was successfully grown in an explant culture system, and it was shown that the chondrocytes were metabolically active and responded to external agents. This model will serve to study the mechanism of growth and effects of trauma and external agents on the cricoid at the cellular level.

Laryngeal reconstruction in children. Assessment of vocal quality.

During the past decade, the outcome of laryngotracheal reconstruction in children has improved substantially regarding airway patency. Now that we feel comfortable with airway results, attention should be directed toward vocal quality. The aims of this article are to present our evaluation process, which has been developed during the past 3 years, and our assessment of results. Six patients who underwent successful laryngotracheal reconstruction and could be examined preoperatively and postoperatively were studied. Information about disease and reconstruction techniques was recorded. Vocal quality assessment was done using psychoacoustic evaluation and objective techniques, including acoustic analysis. Children offer a specific challenge, especially when their chronological or developmental age is younger than 3 years. Objective assessment still lacks the ability of using cooperative patients, and adequate samples for acoustic analysis are difficult to obtain and standardize. Preoperative abnormalities continued to persist postoperatively. Laryngotracheal reconstruction is instrumental in making oral communication possible, but the vocal quality is disturbed in most patients.

The effect of gastroesophageal reflux on laryngotracheal reconstruction.

OBJECTIVES: To determine the need for preoperative evaluation for gastroesophageal reflux disease (GERD) in all children undergoing laryngotracheal reconstruction (LTR) and to assess the effect of GERD on the outcome of LTR. DESIGN: Prospective, single-blind observational study. SETTING: Tertiary care children's hospital. PATIENTS: Seventy-four pediatric patients with laryngotracheal stenosis who underwent LTR at the Children's National Medical Center, Washington, DC, from October 1, 1986, through August 31, 1994. INTERVENTION: Evaluation for and treatment of GERD, LTR, endoscopy, and removal of granulation tissue. MAIN OUTCOME MEASURES: Successful decannulation and number of endoscopies required to remove laryngeal and tracheal granulation tissue. RESULTS: Seventy-four patients underwent 82 LTRs. The senior surgeon was blinded to the status of GERD evaluation and treatment. Four groups were identified: 37 patients (40 LTRs) with no preoperative evaluation for GERD; 10 patients (11 LTRs) with normal findings on preoperative evaluation for GERD; seven patients (nine LTRs) with abnormal findings on preoperative evaluation for GERD but who failed to receive appropriate treatment; and 20 patients (22 LTRs) with abnormal findings on preoperative evaluation for GERD who received appropriate therapy. Severity and extent of stenosis as determined by multicentricity of stenosis, type of repair, and duration of stent were similar in the four groups. The effect of GERD and its treatment on the outcome of LTR was measured by the number of endoscopies necessary for removal of granulation tissue following reconstruction and successful decannulation. Statistical analyses indicate that (1) all children do not require preoperative evaluation for GERD; (2) neither the presence of GERD nor its treatment are major factors in determining the outcome of LTR. CONCLUSION: Preoperative evaluation for GERD and its treatment do not favorably affect the outcome of LTR.

Subglossopalatal membrane.

A newborn who experienced respiratory distress just after birth had an oral web that extended from the floor of the mouth anterior to the tongue up to the hard palate. The membrane was slit in the midline to facilitate air exchange. The patient did well without intubation, and the web was resected. To our knowledge, this is the second case of subglossopalatal membrane to be reported. Embryologic and anatomic considerations, along with a review of the literature, are presented.