Mediastinitis associated with foreign body erosion of the esophagus in children.

OBJECTIVE: Timely and experienced intervention for esophageal foreign bodies generally allows for removal with minimal morbidity. However, esophageal foreign bodies present a risk for esophageal perforation and subsequent mediastinitis, especially if the diagnosis of the foreign body is delayed. Although much has been written about the management of esophageal foreign bodies and their complications, little has been mentioned in recent literature about the specific complication of mediastinitis. This review was performed to examine our experience with this uncommon complication of esophageal foreign bodies. METHODS: A retrospective review of the esophageal foreign body database at Children's Hospital of Wisconsin from 1987 to 1997 was performed to identify patients with esophageal foreign bodies and subsequent mediastinitis. RESULTS: Four patients with esophageal perforation with associated mediastinitis secondary to retained esophageal foreign bodies were identified. Three of the four patients were treated with conservative measures consisting of foreign body removal, intravenous antibiotics and discontinuing of oral nutrition. These patients all achieved resolution of their mediastinitis and esophageal perforation with subsequent return to normal diets and no significant morbidity. One patient, with vascular erosion, required aggressive, invasive therapy. CONCLUSION: From review of this limited number of patients, in the absence of major vascular erosion, conservative methods of treating children with foreign body esophageal perforation and subsequent mediastinitis appears to be effective.

Laryngotracheal reconstruction in canines: fixation of autologous costochondral grafts using polylactic and polyglycolic acid miniplates.

OBJECTIVE: To examine the feasibility of a new method of laryngotracheal reconstruction (LTR) that uses a bioabsorbable plating system consisting of polylactic and polyglycolic acid and provides some advantages over currently used methods. DESIGN AND INTERVENTIONS: Anterior subglottic stenosis was created in 10 beagles that then underwent LTR using an autologous costochondral graft. External laryngotracheal framework and cartilage grafts were secured using a sheet and screws made from a copolymer composed of polylactic and polyglycolic acid. Animals were humanely killed at 40, 60, and 90 days, and specimens were submitted for pathological examination. Histologic analysis included evaluation for inflammatory reaction, polylactic and polyglycolic acid incorporation into cartilage, cartilage necrosis, cartilage remodeling, and graft epithelialization. RESULTS: All animals underwent LTR after creation of a subglottic stenosis without episodes of airway compromise. After LTR, all airways were returned to prestenosis diameter without significant complication, and all animals were immediately extubated after surgery without difficulty. After the animals were killed, distraction of the stenotic cricoid area was demonstrated in 100% of the cases. Significant necrosis was noted in 2 of 10 grafts grossly; however, histologic analysis demonstrated significant areas of viable cartilage, areas of cartilage remodeling, and good epithelialization despite graft necrosis. Complete epithelialization of grafts was noted in the other 8 specimens. CONCLUSIONS: Using a canine model, we demonstrated a bioabsorbable plating system that offers an effective method for LTR. This model has the advantages of providing external support to the operated laryngeal and tracheal framework, elimination of the difficulties of suture placement, and potential future failure while offering rigid external fixation of a cartilage graft.

Posttransplantation lymphoproliferative disease in children: otolaryngologic manifestations and management.

BACKGROUND: Posttransplantation lymphoproliferative disease (PTLD) is associated with Epstein-Barr virus (EBV) infection after solid organ and bone marrow transplantation. METHODS: We did a retrospective analysis of cases with a diagnosis of PTLD at Children's Hospital of Wisconsin. RESULTS: Ten patients were identified. Seven of 10 cases (70%) were associated with bone marrow transplantation and 3 with solid organ transplantation. Three patients (30%) died of PTLD. The average time to development of PTLD after transplantation was 120 days. CONCLUSIONS: Otolaryngologic symptoms and findings are often the first manifestations of PTLD. Associated findings in this series included tonsillar necrosis, tonsillitis, airway obstruction, lymphadenitis, sinusitis, and otitis media. Diagnosis generally requires pathologic evaluation of tonsillar or adenoid tissue. Surgical intervention may also be important for relief of airway obstruction when present. Prompt recognition, diagnosis, and intervention with reduction in immunosuppression and antiviral therapy are essential to reduce the mortality of PTLD.

A prospective evaluation of the prevalence of submucous cleft palate in patients with isolated cleft lip versus controls.

Although there is an established relationship between cleft lip and overt cleft palate, the relationship between isolated cleft lip and submucous cleft palate has not been investigated. To test the hypothesis that patients with isolated cleft lip have a greater association with submucous cleft palate, a double-armed prospective trial was designed. A study group of 25 consecutive children presenting with an isolated cleft lip, with or without extension through the alveolus but not involving the secondary palate, was compared with a control group of 25 children with no known facial clefts. Eligible patients were examined for the presence of physical criteria associated with classic submucous cleft palate, namely, (1) bifid uvula, (2) absence of the posterior nasal spine, and (3) zona pellucida. Nasoendoscopy was subsequently performed just after induction of general anesthesia, and the findings were correlated with digital palpation of the palatal muscles. Patients who did not satisfy all three physical criteria and in whom nasoendoscopy was distinctly abnormal relative to the control group were classified as having occult submucous cleft palate. Classic submucous cleft palate was found in three study group patients (12 percent), all of whom had flattening or a midline depression of the posterior palate and musculus uvulae on nasoendoscopy and palpable diastasis of the palatal muscles under general anesthesia. An additional six study group patients (24 percent) had similar nasoendoscopic criteria and palpable diastasis of the palatal muscles; they were classified as having occult submucous cleft palate. No submucous cleft palate was identified in the control group. Seventeen patients in the study group had an alveolar cleft with a 53 percent (9 of 17) prevalence of submucous cleft palate. In the present study, classic submucous cleft palate in association with isolated cleft lip was 150 to 600 times the reported prevalence in the general population. All children with an isolated cleft lip should undergo peroral examination and speech/resonance assessment no later than the age of 3 years. Any child with an isolated cleft lip with velopharyngeal inadequacy or before an adenoidectomy should be assessed by flexible nasal endoscopy to avoid missing an occult submucous cleft palate.

Avoidance of primary post-tonsillectomy hemorrhage in a teaching program.

OBJECTIVE: To determine the incidence of primary post-tonsillectomy hemorrhage in a teaching institution by using a uniform technique, including a 3-minute relaxation of retraction before case termination and the use of bismuth subgallate. DESIGN: Case series. SETTING: Tertiary care academic pediatric center. PATIENTS: A 7-year retrospective study was performed by using the medical records of 1286 children without a bleeding abnormality who underwent tonsillectomy (with or without adenoidectomy). A uniform technique, proposed to reduce hemorrhage, was used for 705 children and was not used for 581 children. RESULTS: No episodes of primary hemorrhage (onset < or = 24 hours after surgery) occurred, and the incidence of delayed hemorrhage (onset >24 hours after surgery) was 1.1% in the study group. The primary hemorrhage rate of the study group was significantly lower (P = .007) than the rate for the reference group (0.0% vs 1.0%), as was the total hemorrhage rate (1.1% vs 4.1%) and the delayed hemorrhage rate (1.1% vs 3.1%). CONCLUSION: A uniform technique including the use of bismuth subgallate and reassessment of the tonsillar fossae after a 3-minute observation period reduces the incidence of primary tonsillar hemorrhage in a teaching institution setting.

Identification and assessment of velopharyngeal inadequacy.

PURPOSE: To review current literature with respect to the diagnosis and assessment of velopharyngeal inadequacy (VPI), including present knowledge about the most common causes of VPI. METHODS: Data sources include published reports over the past 20 years derived from computerized databases and bibliographies of pertinent articles and books. Indexing terms used were "velopharyngeal incompetence," "velopharyngeal inadequacy." "velopharyngeal insufficiency." CONCLUSION: VPI is most commonly associated with cleft palate, submucous cleft palate, and following adenoidectomy. The otolaryngologist can prevent the latter by preoperative identification of physical stigmata associated with VPI. Perceptual assessment is the criterion standard for diagnosis of VPI. Multiview videofluorography and flexible nasal endoscopy provide the best direct assessments to help plan and direct the optimal treatment of VPI.

Changes in deglutition following tonsillectomy in neurologically impaired children.

Tonsillectomy for improvement of dysphagia in children is well recognized, but its effects upon deglutition in the neurologically impaired child have not been described. A review was performed of pre- and post-operative oral-pharyngeal motility (OPM) studies obtained on 15 children (aged 1-10 years; mean 4.6 years) with neurologically-based dysphagia who underwent tonsillectomy for upper airway obstruction (13) or recurrent tonsillitis (2). Each OPM study was rated independently by two trained observers for the presence or absence of 13 features of deglutition. Subjects served as their own control in comparative analysis. There was a mean improvement of 4.33 features of deglutition (mode: 4, range: -1(-)+7) following tonsillectomy. Of 10 children with pre-existing laryngeal penetration or aspiration, two had partial resolution and five had complete resolution following surgery. Post-operatively, two children developed new laryngeal penetration with one also having aspiration. The inter-observer reliability for the OPM study interpretation was 0.90. We conclude that tonsillectomy has a role in the neurologically impaired child with dysphagia, but a pre-operative OPM study is indicated to identify silent aspiration and to aid in necessary counseling for the possibility of a deterioration of deglutition following surgery.

Submucous cleft palate: diagnostic methods and outcomes of surgical treatment.

The following statements summarize our interpretation of the literature regarding submucous cleft palate: Incidence and Diagnosis of Submucous Cleft Palate 1. In surveys of classic stigmata of submucous cleft palate among the general population, the incidence has been reported to be 0.02 to 0.08 percent. In the larger of these series, the incidence of velopharyngeal inadequacy among patients identified to have submucous cleft palate was 1 to 9. The incidence of occult submucous cleft palate is not known, since these patients will only be detected during the evaluation of patients who present with velopharyngeal inadequacy. 2. The diagnosis of submucous cleft palate is made by identification of the classic stigmata on physical examination. The diagnosis of occult submucous cleft palate is only pursued if the patient has velopharyngeal inadequacy. 3. For consistency in evaluating and reporting data, patients with an overt cleft of the secondary palate that extends beyond the uvula should be reported as having a cleft palate, and not a submucous cleft palate, even if a submucous cleft exists in a portion of the palate anterior to the overt cleft. 4. The true incidence of otitis media with effusion in the presence of submucous cleft palate has yet to be determined using a prospective study. Surgical Treatment of Velopharyngeal Inadequacy in Patients with Submucous Cleft Palate 1. The technique that has most consistently been documented to result in a significant correction of velopharyngeal inadequacy is the pharyngeal flap. There is recent evidence from one large center supporting the efficacy of the Furlow Z-plasty in selected patients with submucous cleft palate. Both these procedures appear to be most effective in patients with good lateral pharyngeal wall motion. 2. If a pharyngeal flap is performed as the primary procedure to act as an obturator against which the lateral pharyngeal walls appose for closure, we do not see the need for adjunctive palatal procedures. The dynamic component of velopharyngeal competence following such a pharyngeal flap consists of lateral wall motion, which is not enhanced by further surgical manipulation of the palate. However, a pharyngeal flap may be performed as an adjunctive procedure to a palatal pushback in order to provide lining for the resultant defect in the nasal mucosa. 3. The present literature does not support "prophylactic" operations on patients who present with the physical stigmata of submucous cleft palate prior to reaching an age at which it can be demonstrated by perceptual speech assessment that velopharyngeal inadequacy remained refractory to speech therapy. A significant number of patients will never develop velopharyngeal inadequacy; therefore, surgery would be unnecessary. In addition, objective data regarding the outcomes of different surgical techniques cannot be gathered if patients with submucous cleft palate are operated on without having had velopharyngeal inadequacy documented prior to those operations. 4. In order to objectively compare the outcomes of different surgical techniques, any future studies should be prospective and utilize uniform means of assessment. As minimum criteria, these would include preoperative and postoperative perceptual speech assessments performed by a trained speech pathologist and preoperative nasopharyngoscopy and multiview videofluoroscopy. The latter two studies should be repeated postoperatively only in those patients who have persistent velopharyngeal inadequacy.

Modified orticochea pharyngoplasty for treatment of unilateral velopharyngeal incompetence.

Unilateral nasopharyngeal paralysis is a relatively rare cause of velopharyngeal incompetence. Few therapeutic modalities for this problem have been described. A modification of the orticochea sphincter pharyngoplasty was developed using only a unilateral flap for treatment of the symptoms of hypernasality and nasal reflux. This preliminary report summarizes the operative approach and the successful outcomes in 2 patients.

Gastroesophageal reflux complicating choanal atresia repair.

Four infants with bilateral congenital choanal atresia (CCA) underwent transpalatal (3) or transnasal (1) repairs. Postoperatively all four infants experienced gastroesophageal reflux (GER) with intermittent nasal reflux. GER was documented by GER radionuclide scanning in one patient and by dual nasopharyngeal and esophageal pH probe studies in the remaining three patients. The infants with documented GER required prolonged stenting and dilations for choanal restenosis and granulations. The literature emphasizes the importance of the technical repair for prevention of these complications; GER can be a significant complicating factor.

Pediatric laryngeal granular cell tumor.

Granular cell tumor of the larynx is an uncommon, benign tumor which has rarely been described in the pediatric population. Fewer than 10 cases in children under the age of 10 years have been reported. This paper describes two pediatric patients: An eight-year-old boy with a seven-year history of hoarseness due to an anterior subglottic tumor, and an 11-year-old boy with a one-year history of hoarseness due to a left true vocal cord tumor. Subglottic involvement by laryngeal granular cell tumor is rare in adults, but has been seen in half of the reported cases in the pediatric population. The clinical course of granular cell tumor and its pathology are reviewed.

Non-Hodgkin's lymphoma of the head and neck: the University of Iowa experience.

The evaluation of a patient with a mass in the head and neck may require the consideration of lymphoma in the process of differential diagnosis. Non-Hodgkin's lymphoma is a well-described heterogeneous group of lymphoid malignancies characterized by a natural history ranging from indolent to aggressive growth. Little has been written, however, concerning the specific features of this disease in the head and neck. Between 1974 and 1984, 287 patients were treated for non-Hodgkin's lymphoma presenting in the head and neck. A multivariant analysis of these cases forms the basis of this report. All case material was reviewed and classified according to the working formulation of the National Cancer Institute and the Ann Arbor Classification System for lymphomas. Sites of initial presentation, methods of diagnosis, choice of therapy and subsequent response to treatment were related to the manifestations of non-Hodgkin's lymphoma in the head and neck. Of particular interest to the head and neck surgeon is the constellation of presenting signs and symptoms which point one to the possibility of non-Hodgkin's lymphoma.