Adenotonsillectomy Normalizes Hormones and Urinary Electrolytes in Children With Nocturnal Enuresis and Sleep-Disordered Breathing.

OBJECTIVE: To assess (1) plasma levels of antidiuretic hormone (ADH) and brain natriuretic peptide (BNP) and urinary levels of electrolytes in children with sleep disordered breathing (SDB), with or without nocturnal enuresis (NE), and (2) the effect of adenotonsillectomy (T&A) on urinary electrolytes and the secretion of ADH and BNP in children with NE and SDB. We previously reported post-T&A improvements in plasma levels of BNP and ADH in children with SDB and NE. However, the differences in plasma concentration of these hormones in SDB children with and without NE, and their relationships with urinary electrolytes, have not yet been addressed. METHODS: This prospective study compared concentrations of urinary electrolytes and plasma ADH and BNP in (1) children with SDB and NE (study group) and an age- and sex-matched control group of children with SDB without NE, and (2) the study group before and 1-month after T&A. RESULTS: Compared with the control group (n = 31), the study group (n = 37) exhibited significantly lower ADH (P = .04) and higher BNP (P = .009) plasma levels. The differences in urinary electrolytes were not significant. Post-T&A, the study group showed significantly decreased BNP (P = .018), urinary sodium-to-creatinine ratio (P = .02), and urinary calcium-to-creatinine ratio (P = .007) compared with the pre-T&A values. Post-T&A changes in urinary calcium were significantly correlated with changes in sodium excretion (P = .002) and in plasma levels of BNP (P <.001). CONCLUSION: The presence of NE is associated with altered ADH and BNP levels in children with SDB. T&A led to normalization of ADH and BNP, probably through a calcium- and sodium-dependent mechanism.

Adenotonsillectomy improves quality of life in children with sleep-disordered breathing regardless of nocturnal enuresis outcome.

BACKGROUND: Nocturnal enuresis (NE) and sleep-disordered breathing (SDB) have both been associated with impaired health-related quality of life (HRQoL). The following were investigated: (1) whether tonsillectomy and/or adenoidectomy (T&A) significantly affect the HRQoL in children with NE and SDB, and 2) differences in HRQoL between children with NE persistence versus resolution post-T&A. METHODS: This was a prospective study comparing the HRQoL of children with SDB and NE (study group) pre- and 4 weeks post-T&A, and the HRQoL of children with SDB without NE (control group) (independent t-tests). HRQol was assessed using the Obstructive Sleep Apnea Quality of Life 18 questionnaire (OSAS-18), a validated measure containing five subscales that combine to create a total score. Individual items were scored on a Likert-type scale ranging from 1 (none of the time) to 7 (all of the time). Symptoms of SDB were evaluated using the validated Pediatric Sleep Questionnaire (PSQ). Mixed ANOVA was conducted to evaluate changes in the measures between the wet and dry children post-T&A. Pre- and post-T&A change scores were calculated for both the PSQ and the OSAS-18. RESULTS: There were 30 children in the study group (18 male, mean age 9.07 years, SD 2.19), and 30 age-matched controls (16 male). There were no statistically significant differences between the two groups in regards to OSAS-18 total, PSQ total, BMI, diagnosis of snoring or OSAS on sleep study, or race. Overall, OSAS-18 and PSQ scores significantly improved in all children post-surgery (p < 0.001; p < 0.001, respectively), with no significant differences between dry and wet children post-T&A. The correlation between the pre- and post-T&A change scores on the OSAS-18 and PSQ was significant (r(29) = 0.58, p = 0.001), suggesting that a reduction in SDB symptoms post T&A is related to improved HRQoL. CONCLUSIONS: T&A significantly improved HRQoL in all children with SDB and NE, regardless of NE outcomes. These findings support recommendations for T&A in children with SDB with or without NE.

Complete second branchial cleft anomaly presenting as a fistula and a tonsillar cyst: an interesting congenital anomaly.

Branchial cleft anomalies make up 30% of all pediatric neck masses, but complete second branchial cleft anomalies are extremely rare. We report an unusual case of a complete second branchial cleft anomaly that presented as a draining neck fistula and a tonsillar cyst in an otherwise healthy 3-month-old girl. At the age of 7 months, the patient had been experiencing feeding difficulties, and there was increasing concern about the risk of persistent infections. At that point, the anomaly was excised in its entirety. Our suspicion that the patient had a complete second branchial cleft anomaly was confirmed by imaging, surgical excision, and histopathologic analysis.

Treatment of inflammatory myofibroblastic tumor of the subglottis with KTP laser: a case report.

Although inflammatory myofibroblastic tumors (IMTs) are seen in the lower respiratory tract in the pediatric population, few cases occurring in the larynx have been reported in the literature. Treatment of choice is complete surgical excision because of risk of recurrence. We describe a case of pediatric subglottic IMT presenting with progressive hoarseness and symptoms of persistent reactive airway treated with potassium titanyl phosphate laser. We also enumerate the number of pediatric cases of IMT that occur in the larynx and subglottis compared with those which occur in the upper respiratory tract, specifically the trachea and bronchi. To the best of our knowledge, this is the first reported case of respiratory tract IMT excision using a potassium titanyl phosphate laser and the second reported case of a pediatric laryngeal IMT showing anaplastic lymphoma kinase-1 immunoreactivity.

Sleep architecture parameters that predict postoperative resolution of nocturnal enuresis in children with obstructive sleep apnea.

OBJECTIVES: We performed a prospective cohort study in a pediatric tertiary care center to determine whether preoperative sleep architecture is associated with complete resolution of nocturnal enuresis (NE) after adenotonsillectomy. METHODS: Thirty-seven pediatric patients with primary NE who underwent adenotonsillectomy for obstructive sleep apnea (OSA) were evaluated. Preoperative polysomnograms, as well as preoperative and postoperative reports of NE, were recorded. We performed chi2 analysis, Fisher's exact test (for p values), and t-tests to evaluate the impact of multiple demographic characteristics on sleep architecture, comparing children with resolved NE to those with unresolved NE after adenotonsillectomy. RESULTS: The patients' mean age was 8.0 years (SD, 2.32 years). All children had presurgical primary NE. No age or gender differences were identified between children with resolved NE and those with unresolved NE. After surgery, more than half of the participants had resolution of NE. A higher percentage of boys had unresolved NE (chi2 = 3.63; p = 0.06). Improvement of NE was identified in children with a higher obstructive apnea-hypopnea index and more desaturation events. Eleven of the 12 children with prolonged stage 2 sleep reported resolution of NE (p = 0.001). Children with an obstructive apnea-hypopnea index of greater than 10 had a significantly greater rate of resolution of NE (p = 0.01). Logistic regression demonstrated that an elevated body mass index and the interaction of severe OSA and prolonged stage 2 sleep predicted resolution of NE. All 10 children with severe OSA and an abnormal total time spent in stage 2 sleep had resolution of NE. CONCLUSIONS: Adenotonsillectomy is a treatment option for children with OSA and NE. Postoperative resolution of NE was seen in 51.4% of patients who underwent adenotonsillectomy. The children with both severe OSA and prolonged stage 2 sleep were 3.4 times as likely to have postoperative resolution of NE. These results suggest that there are significant differences in preoperative sleep architecture between children whose NE resolves after adenotonsillectomy and those whose NE does not resolve.

Submucosal resection of a microcystic oropharyngeal lymphatic malformation using radiofrequency ablation.

Lymphatic malformations (LMs) are uncommon congenital anomalies noted to have a prevalence of 1 per 5000 births and comprise roughly 6% of all pediatric soft tissue lesions. Recently radiofrequency ablation has been described as a surgical option for the treatment microcystic LMs in the oral cavity, more specifically the tongue. The following case describes the use of radiofrequency ablation for the submucosal removal of a large obstructing pharyngeal LM in a 4-year-old female. The mucosal sparing approach and surgical method of extirpation are discussed in detail. To the authors' knowledge this is the first description of a submucosal coblation technique being used as treatment for pharyngeal LMs.

Enuretic children with obstructive sleep apnea syndrome: should they see otolaryngology first?

OBJECTIVES: To study: (1) the prevalence of diurnal urinary incontinence (DI) and nocturnal enuresis (NE) in children with obstructive sleep apnea syndrome (OSAS) who underwent surgery for their upper airway symptoms, (2) the postoperative rate of enuresis resolution, and (3) factors that may predict lack of improvement post surgery. PATIENTS AND METHODS: An observational, pilot study of children 5-18 years of age with OSAS and NE who underwent tonsillectomy and/or adenoidectomy (T&A) between 2008 and 2010 was performed. Study consisted of a phone interview and chart review. Severity of NE and DI, frequency, arousal and sleeping disturbances were assessed pre and post T&A. Factors associated with failure to respond were analyzed using a logistic regression model. RESULTS: Among the 417 children who underwent T&A, 101 (24%) had NE (61 males, mean age 7.8 ± 2.5 years), and of these 24 had associated DI (6%). Mean postoperative follow-up was 11.7 months. Of the 49 whose NE responded to T&A (49%), 30 resolved within 1 month postoperatively. DI resolved in 4 children (17%). There was a statistically significant difference between responders and non-responders regarding the presence of prematurity, obesity, family history of NE, type of enuresis, enuresis severity, and ability to be easily aroused. CONCLUSION: NE was present in about one fourth of children with OSAS undergoing surgery, and resolved in about half. Lower response rate was associated with prematurity, obesity, family history of NE, presence of non-monosymptomatic NE, severe NE preoperatively, and arousal difficulties.

NUT midline carcinoma mimicking tonsillitis in an eight-year-old girl.

We review a unique case of NUT midline carcinoma that presented in a young girl with an initial diagnosis of tonsillar abscess. We stress the importance of assaying poorly differentiated carcinomas in young patients for the t(15;19) translocation. Our patient presented with tonsillar enlargement and cervical lymphadenopathy mimicking acute tonsillitis. The clinical suspicion for malignancy arose after an aspirate from the tonsil did not yield any pus, and biopsy of a cervical lymph node demonstrated undifferentiated carcinoma. Further analysis by fluorescence in situ hybridization was positive for rearrangements in both BRD4 and NUT genes consistent with NUT carcinoma. In addition, fluorodeoxyglucose-positron emission tomography (FDG-PET) revealed a very high standard uptake value in both the primary tumor and metastatic foci, suggesting that FDG-PET could be a useful tool in the staging and follow-up of NUT midline carcinoma.

Pediatric total tonsillectomy using coblation compared to conventional electrosurgery: a prospective, controlled single-blind study.

OBJECTIVE: Postoperative recovery after tonsillectomy using Coblation excision (CES) was compared with conventional electrosurgery (ES). STUDY DESIGN AND SETTING: Patients aged 3 to 12 years from 3 clinical sites were randomly assigned and blinded to receive tonsillectomy using CES (n = 44) or ES (n = 45). RESULTS: Operative parameters did not differ between groups. Return to normal diet, activity, and pain-free status were similar, although fewer CES patients contacted the physician regarding postoperative complications (33% vs 54%; p = 0.081), experienced nausea (35% vs 62%, p = 0.013), or had localized site-specific swelling (p < 0.05) during the 2 weeks after surgery. In addition, CES children tended to discontinue prescription narcotics 1 day earlier than ES patients (7 vs 8 days, p = 0.071) and took one half as many daily doses. More CES than ES parents rated the postoperative experience as 'better than expected' (79% vs 60%, p = 0.055). CONCLUSION AND SIGNIFICANCE: Children who received CES tonsillectomy appeared to experience a better quality postoperative course, with no detriment to operative benefits of conventional electrosurgery.

Airway management in mucopolysaccharide storage disorders.

Mucopolysaccharidoses (MPS), a group of disorders caused by a genetic disruption, create a special challenge for the otolaryngologist. With the rare types of MPS IV and MPS 1 S, a skilled practitioner is required to abate airway management complications. The erratic deposits of mucopolysaccharides throughout the trachea should be taken into account when decisions to stent the airway are made. Proper management requires to provide an airway that is custom-made to meet the patient's needs. This is a case-by-case presentation of 3 patients with MPS who presented to the Children's Hospital of Michigan with progressive respiratory embarrassment. Discussed are the various issues revolving around our ability to provide proper airway management, from intubation to tracheostomy tube placement.

Esophagoscopy for removal of foreign bodies in the pediatric population.

A retrospective chart review of children who had rigid esophagoscopy for potential foreign body ingestion from 1998 to 2001 was conducted at Children's Hospital of Michigan Detroit. All pediatric patients less than 11 years of age who presented with suspected foreign body ingestion in a hospital setting over a 4-year period were retrospectively studied. Patient characteristics noted included age, sex and clinical presentation. Pre-operative radiographic findings, esophagoscopy findings, clinical presentations and types of foreign bodies were recorded. A history compatible with foreign body ingestion dictates diagnostic endoscopy with or without radiographic confirmation, and an acceptable rate of performing esophagoscopy without finding a foreign body was found to be 6.2%.