Modified Minerva Cervical Thoracic Orthosis for Postoperative Management of Cricotracheal Resection.

The worst complication of cricotracheal resection (CTR) is anastomotic dehiscence, and to limit it, postoperative management at Michigan Medicine included the use of a modified Minerva cervical-thoracic orthosis (MMCTO). To date, there has been no analysis of the risks and benefits of the brace's use following CTR. We analyze this with our retrospective study. A search with the keywords "cricotracheal resection" and "laryngotracheal reconstruction" was performed in the Electronic Medical Record Search Engine to identify patients retrospectively. The Statistical Package for Social Sciences was used for analysis; t test, χ2, and Fisher exact tests were used to analyze data. Fifteen males and 13 females with a median age of 4 years were identified, and almost 2/3 had a supra- and/or infrahyoid release performed. Postoperatively, 12 had a Grillo stitch and an MMCTO for a mean of 7 days. Most had no complications, but the most common complications were agitation due to brace discomfort and skin irritation. The worst complication was stroke. Our MMCTO's design allowed for better head and neck control with relative comfortability, and most patients had no complications with its short-term use. Our modification may be useful adjunct in the postoperative management.

Inhalational injury and the larynx: A review.

OBJECTIVE: To review and discuss the existing research on the pathophysiology, impact and management of inhalational injury on the larynx and lower respiratory tract. DATA SOURCES: A literature search was conducted on the PubMed, MedLine, Embase, Web of Science and Google Scholar databases based on the keywords "airway burn", "inhalational injury" and "larynx". REVIEW METHODS: Inclusion criteria included English language studies containing original and review data on airway injury. Data was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. CONCLUSIONS: Abnormal laryngeal and lower airway findings are common in burns patients and the incidence tends to increase with severity of the burns. Most patients with abnormal findings remain dysphonic decades after the initial injury. Larynx, the inlet to the airway, is exposed to the most intense thermal damage and highest concentration of chemical in inhalational injury. Airway injury is common and may result in long term morbidity. Healing of this tissue architecture is prolonged and different from cutaneous burn. Many patients receive prolonged intubation for medical complications that arise due to the burn injury. The degree of subglottic damage, however, is more extensive and occurs sooner compared with those without inhalational injuries. IMPLICATIONS FOR PRACTICE: With advances in acute medical and surgical management of burn and inhalational injury, airway injury is an important secondary outcome with lasting impact. Awareness of these potential complications and early involvement of medical and allied health team are important steps in improving patient care. A multi-disciplinary approach to management will optimise the short and long-term morbidity management and ultimately our patients' quality of life.

Massive Macroglossia After Posterior Cranial Fossa Surgery: A Case Report.

A 16-year-old boy with Chiari 1 malformation presented for an elective suboccipital craniectomy and C1 laminectomy. His intraoperative course was uneventful. At the conclusion of the procedure, he met extubation criteria and followed commands. After extubation, he developed progressive upper airway obstruction and became obtunded. He was reintubated via videolaryngoscopy, which showed edema not only to the tongue, but also to the posterior pharynx and blisters over the vocal folds and epiglottis. The patient was transferred to the pediatric intensive care unit intubated and sedated. This report describes the clinical course of his massive macroglossia and discusses short- and long-term management.

Treatment of extensive post tonsillectomy oropharyngeal stenosis secondary to fibromatosis.

Aggressive fibromatosis is an uncommon, benign tumor of fibroblastic origin with high potential for local invasion. Less than a quarter of these lesions are located in the head and neck, and although extremely rare, associations have been demonstrated with physical trauma. We describe a unique case of oropharyngeal fibromatosis with traumaticetiology, managed successfully with surgical excision of the lesion with negative surgical margins. A 5-year old patient was found to have an aggressive fibromatosis causing oropharyngeal stenosis following tonsillectomy. We demonstrate that surgical resection with a clear margin allowed for alleviation of stenosis without recurrences reported since the procedure.

Laryngotracheal reconstruction and swallowing: A review.

OBJECTIVES: Significant advances in laryngotracheal reconstruction over the last few decades have revolutionised the management of paediatric patients with complex congenital or acquired airway stenosis. The primary aim of laryngotracheal reconstruction has focused primarily on airway and surgery specific outcomes, often at the expense of voice, as well as swallowing function, which are all intricately related. There is currently a paucity of data on swallowing outcome. The goal of this paper is to review and discuss the existing research on the impact of laryngotracheal on swallowing. METHODS: Narrative review. RESULTS: Successful and safe oral feeding in children requires a highly complex and integrated sensorimotor system for proper timing and coordination, beginning with a well-coordinated suck-swallow-breathe sequence in infancy. Factors to consider include the normal laryngeal anatomy, nutrition as a stimulus and the development of feeding skills on swallowing, the underlying aetiology and other risk factors, LTR procedures and their adjuncts. All these impact on the children's growth. Swallow assessments and rehabilitation is therefore an important part of the post-operative care. CONCLUSIONS: As airway reconstructive surgeries have improved in airway and surgery specific outcomes, swallowing function is an important secondary outcome that impacts on the children's and their families' life. Management in a multi-disciplinary manner will optimise the outcome and improve their quality of life.

Clinical characterization of novel chromosome 22q13 microdeletions.

INTRODUCTION: The advent of chromosome microarray analysis (CMA) for evaluation of patients with multiple congenital anomalies has made it possible to define chromosomal imbalances with greater precision and resolutions significantly smaller than possible by standard G-banded chromosome analysis. We describe two patients with novel chromosomal anomalies involving chromosome 22q13, a locus also associated with Phelan-McDermid syndrome (PMS). OBJECTIVE: We aim to characterize the novel phenotypic and genotypic findings of two patients with 22q13 microdeletions, distinct from PMS, comparing and contrasting with features of PMS. RESULTS: Case 1 is a 4-year-old boy with global developmental delay, esotropia, moderate aortic root dilation, genu valgum, and in-toeing gait. MRI brain for evaluation of neonatal hypotonia revealed a left cerebellopontine angle arachnoid cyst. He referred on newborn hearing screening, and diagnostic auditory brainstem response (ABR) showed left profound retrocochlear hearing loss. Surgical intervention for the arachnoid cyst was deferred, with spontaneous resolution at age two years without hearing recovery. CMA revealed a novel, de novo 5.1 Mb microdeletion of 22q13.31q13.33 not involving SHANK3, a gene typically deleted in PMS. Case 2 is a 6-year-old girl with some features also seen in patients with PMS but also several atypical features. She has a complex chromosomal rearrangement including a 5.3 Mb 22q13 microdeletion (not including SHANK3) and de novo 2.1 Mb gain of 22q11. CONCLUSION: As diagnostic sensitivity improves, smaller chromosomal imbalances will be detectable related to milder or different phenotypes. We present two patients with novel deletions of chromosome 22q13 associated with multiple congenital anomalies and features distinct from PMS.

Computer-Aided Design and 3-Dimensional Printing for Costal Cartilage Simulation of Airway Graft Carving.

Autologous cartilage grafting during open airway reconstruction is a complex skill instrumental to the success of the operation. Most trainees lack adequate opportunities to develop proficiency in this skill. We hypothesized that 3-dimensional (3D) printing and computer-aided design can be used to create a high-fidelity simulator for developing skills carving costal cartilage grafts for airway reconstruction. The rapid manufacturing and low cost of the simulator allow deployment in locations lacking expert instructors or cadaveric dissection, such as medical missions and Third World countries. In this blinded, prospective observational study, resident trainees completed a physical simulator exercise using a 3D-printed costal cartilage grafting tool. Participant assessment was performed using a Likert scale questionnaire, and airway grafts were assessed by a blinded expert surgeon. Most participants found this to be a very relevant training tool and highly rated the level of realism of the simulation tool.

Successful conservative management of a rare complication of tracheostomy; extensive posterior tracheal false pouch.

INTRODUCTION: With the advent of improved neonatal and pediatric intensive care management, tracheostomy is increasingly performed in children requiring prolonged ventilation. Even though tracheostomy is generally a safe procedure, there remains mortality and morbidity associated with it. OBJECTIVE: We report a rare complication of a tracheostomy tube resulting in extensive erosion and posterior tracheal false pouch secondary to a large tracheostomy tube and high positive end expiratory pressure in a 12-month-old infant. This was managed successfully with conservative treatment. RESULTS: A former 34-week premature infant was transferred to our pediatrics intensive care unit (PICU) with recurrent episodes of cardiopulmonary arrests due to suspected severe tracheobronchomalacia. The patient has bronchopulomonary dysplasia, severe restrictive lung disease and thoracic insufficiency from skeletal dysplasia requiring tracheostomy tube (TT) at two-month-old and mechanical ventilation. The 3.5 NEO TT was gradually upsized to a 5. The PEEP setting at transfer was 18cmH2O. The direct laryngoscopy and bronchoscopy showed moderate tracheomalacia at the innominate artery with a false pouch in the posterior tracheal wall that was 1.1cm below the tracheostomy stoma. A multi-disciplinary discussion including otolaryngology, PICU, Pulmonary Medicine, and Pediatric Surgery decided on conservative management. The false pouch healed and she was transferred back to referring PICU after a 46-day. CONCLUSION: Tracheal wall erosion resulting in a pouch formation is a rare complication, but it should be considered in patients with long term tracheostomy with difficulty ventilation and oxygenation with positional change. DLB is a useful tool in its diagnosis and conservative management can be successful.

Spontaneous cutaneous extrusion of a parotid gland sialolith.

Parotid gland sialolithiasis is an uncommon condition that can cause pain and recurrent infection in affected patients. Migration of a stone through a fistula is a rare but possible complication of untreated sialolithiasis. We present a case of parotid gland sialolithiasis in a 63-year-old woman with recurrent episodes of parotitis and facial pain, which resolved through spontaneous extrusion of the stone (11 mm) through a cutaneous fistula while awaiting surgery. Management is typically conservative or surgical, depending on the location and size of the stone, and the clinical presentation.

Surgical management of chronic salivary aspiration.

AIM OF THE STUDY: Sialorrhoea and chronic salivary aspiration are a major problem in many neurologically impaired children causing embarrassment, skin issues and recurrent lower respiratory tract infections (LRTI). The aim of this study was to assess the efficacy of salivary gland surgery in the treatment of chronic salivary aspiration in such children. OBJECTIVES: To compare admission rates for LRTI per annum before and after surgical intervention. METHODS: Retrospective review of all patients who underwent salivary management surgery for chronic aspiration under Princess Margaret Hospital's (PMH) Otolaryngology department from 2006 until 2013. RESULTS: Twelve patients were included in this review. Their ages ranged from 3 to 21 years (mean=11.4). Their genders were equally distributed. Two patients had underlying congenital disorders; one had an acquired brain injury, while the majority (n=9, 75%) had cerebral palsy secondary to a sustained perinatal injury. Most patients (n=11, 91.7%) had bilateral submandibular gland excision and parotid duct ligation as a primary procedure. One patient had a laryngotracheal separation. Two patients went on to have a second procedure. The mean follow up time was five years. Using Wilcoxon Signed-Rank test we showed that the median rate of admission per annum for LRTI pre-operatively was 1.0. This was reduced to 0.5 post-operatively, which was statistically significant (p≤0.05). CONCLUSIONS: We hypothesize that the combination of bilateral submandibular gland excision and bilateral parotid duct ligation is effective in reducing admissions with aspiration pneumonia in neurologically impaired children, and therefore improves the quality of life in these patients.

Cholesteatoma in cleft lip and palate: a population-based follow-up study of children after ventilation tubes.

OBJECTIVES/HYPOTHESIS: To investigate the association of cleft conditions and the development of secondary cholesteatoma following middle ear ventilation tube insertion (MEVTI) in children. STUDY DESIGN: A retrospective cohort study of all children born after 1980 who underwent at least one MEVTI in a Western Australian hospital from 1980 to 2009 using administrative health data. METHODS: The timing and number of MEVTIs, adenoidectomy, type of cleft conditions and cholesteatoma were identified along with demographic variables. Flexible parametric proportional hazards models and hazard functions using age as a time scale were used to estimate the relative rate of developing cholesteatoma. RESULTS: There were 56,949 children who underwent at least one MEVTI during the study period. There were 869 (1.5%) children who also had a diagnosis of a cleft condition. Overall, 594 (1.0%) children developed a secondary cholesteatoma. After taking length of follow-up into account, 6.9% (95% confidence interval [CI], 5.0-9.6) of children with cleft conditions developed cholesteatoma by 18 years of age compared to 1.5% (95% CI, 1.3-1.6) of children without cleft conditions. After adjusting for demographic and clinical variables, children with cleft conditions developed cholesteatoma 7.5 (95% CI, 3.8-18.2) times faster after first MEVTI compared to children without cleft conditions, although by the third MEVTI this difference was no longer statistically significant (P = .257). The rate of developing cholesteatoma in 2005 to 2009 was 0.5 (95% CI, 0.3-0.8) times that of 1980 to 1990. CONCLUSIONS: Children with cleft conditions are at increased risk of developing cholesteatoma compared to other children who had one or two MEVTIs, although the overall rate of cholesteatoma is declining.

Split thickness skin graft removal from free flaps: indications and technique.

A variety of methods are commonly used in plastic surgery for skin defect reconstruction. Split skin graft (SSG) is the most commonly used method in the soft tissue defects reconstructive ladder to achieve coverage. One of the most distressing postoperative problem associated with SSG is donor site pain because of the healing process and the stimulation of nociceptive fibers, which is proportional to the size of the harvested area. In the "bowtie scar" method, we describe a technique harvesting the SSG in addition to a gracilis-free flap. The bowtie scar method is an efficient and economical use of donor tissue from the gracilis-free flap. It allows for rapid healing, minimal scarring, and improved cosmesis.

Air embolism in gastroscopy.

Endoscopy of the upper gastrointestinal tract (GIT) is a common medical examination. One of the rare but serious, albeit fatal complications of gastroscopy is venous air embolism. We performed a literature search with the keywords "air embolism", "gastroscopy", and "endoscopy". There were 14 cases of air embolism associated with gastroscopy. The median age was 66 years old (range 4 months-80 years old). The main presenting symptoms were neurological (n=9) and respiratory compromise (n=7). The main investigation used for diagnosis were CT (n=10) and ECHO (n=6). The main risk factor identified was mucosal breach (n=9). Hyperbaric oxygen therapy was used in four cases. The mortality rate is 57.1%. Air embolism is a very rare complication and is often overlooked. Rapid diagnosis is vital for successful treatment. It should be considered in any patient with sudden onset of severe cardiopulmonary and/or neurologic decompensation during gastroscopy.