A needle holder for vascular and plastic surgery.

A needle holder is described that can be oriented to both the long and transverse axes of the hand, can be used with equal facility in either hand, and because of its narrow configuration is less apt to obscure the operative field.

Lateral sinus thrombosis: a sometimes unexpected diagnosis.

Lateral sinus thrombosis, a frequent complication of ear infections in preantibiotic days, is seldom seen today. When it does occur, it is usually in a patient with a known history of a chronic ear infection. Two patients are described with septic pulmonary emboli from inapparent lateral sinus thrombosis. Lateral sinus thrombosis should be suspected in any patient with chills, fever, neck pain, and septic pulmonary emboli.

Glottic and subglottic stenosis from endotracheal intubation.

As a result of increased use of prolonged endotracheal intubation, complications of intubation are now being seen more often. Stenosis of the airway may develop at the level of the glottic or subglottic larynx, or in the trachea. Discussions of management do not always distinguish clearly between laryngeal stenosis and tracheal stenosis. Yet, these are two separate entities. Discussions of laryngeal stenosis usually deal with subglottic stenosis, with less emphasis on obstruction at the glottic level. Of 20 patients, 14 adults and six children, with stenosis of the larynx secondary to intubation, we were successful in establishing adequate airways in 16. An analysis of these 20 patients leads to the following conclusions: 1. Scarring in the glottic posterior commissure between the arytenoid cartilages is a frequent cause of laryngeal stenosis after intubation. 2. Endoscopic management can be successful in many cases if it is started early enough, and repeated as often as is necessary. The earlier it is begun, the better the results will be. 3. Indwelling stents which are extremely valuable in laryngeal stenosis from external trauma, may not be as useful in stenosis from endotracheal tube trauma.

Schwannomas of the head and neck in children.

Schwannomas are relatively rare tumors that arise from Schwann cells of the sheaths of peripheral nerves. They may be found in any portion of the body. In reported series of schwannomas, the percentage of tumors in the head and neck varies from 16% to 45%. Usually demonstrating slow growth, they often have a history of long duration, and are most often diagnosed in adults. Approximately 10% of schwannomas are diagnosed in patients under 21 years of age. In this paper two children with large schwannomas of the head and neck are reported. In both, the symptoms were of relatively short duration, but physical findings suggested that the tumors had been present much longer. One patient was a 10-year-old female with a schwannoma filling the anterior and posterior triangles of the left side of her neck and extending superiorly to the base of the skull. The tumor intimately involved the vagus, spinal accessory, and hypoglossal nerves. The other patient was a 12-year-old female with a nasal tumor filling the right naris and nasopharynx. Our management of these patients is discussed.

Tracheostomy in infants and young children.

Seventy-three tracheostomies performed in children three years of age and under in a 52-month period are discussed. Thirty-six were under one year of age. Forty-one were performed for upper airway obstruction, 23 for ventilation or suction, and nine for a combination of upper airway obstruction and lower bronchopulmonary disease. Operative complications developed in 10 patients, and postoperative complications in 16. The most common complication was interstitial air; the most deadly was obstruction of the cannula. There were 20 deaths. Sixteen were due to the patients' diseases; four were due to complications of tracheostomy. If serious operative and postoperative complications are avoided, the important factors determining prognosis are the patient's age and the condition for which the tracheostomy was done. The long term results in these patients show this to be true for both survival and duration of tracheostomy.

Avoiding a wrapped endotracheal tube in laser laryngeal surgery: experiences with apneic anesthesia and metal laser-flex endotracheal tubes.

Ninety-one laser laryngeal procedures using the apneic technique of anesthesia were performed in 28 patients between 2 months and 64 years of age. Seventy-two procedures (79%) were performed on children and 19 on adults. There were no complications. Eight laser laryngoscopies were performed using a new metal Laser-Flex endotracheal tube. Obstruction of the endotracheal tube with a mucous plug occurred in one case. The apneic technique described in this paper provides a laser operative field free of an endotracheal tube, virtually eliminating the danger of a laser fire. It is a relatively safe and effective means of performing laser laryngeal surgery. In addition, the Laser-Flex endotracheal tube appears to be an acceptable alternative to a metallic tape-wrapped endotracheal tube.

Cysts of the thyroglossal duct.

Experiences with 53 consecutive patients undergoing surgical excision of thyroglossal duct cysts are reported. Four patients (7.5%) developed recurrent cysts after surgery. Analysis of cases revealed the following factors to contribute to an increased risk of recurrence: young age, skin involvement by the cyst, lobulation of the cyst, rupture of the cyst, and failure to follow the second principle advocated by Sistrunk.

Caustic ingestion: controversies in management. A review of 214 cases.

Two hundred fourteen patients admitted with a history of caustic ingestion are reviewed. Sixty-five had mucosal penetrating burns. Children five years of age and under accounted for 39% of admissions, but only 8% of burns requiring treatment. Adults accounted for 48% of admissions and 81% of burns requiring treatment. Complications associated with mucosal penetrating burns occurred in 31 patients; all but one were due to lye or acids. A three year prospective study evaluating methylprednisolone in the management of caustic burns is reported. This included 24 patients with mucosal penetrating burns due to lye or acids. The results of this study, and this review as a whole, indicate that methylprednisolone is beneficial in moderately severe burns due to lye, but is not indicated for severe burns from liquid lye, or for acid burns.

Acute mastoiditis in children: a review of 54 cases.

Fifty-four children with acute mastoiditis were managed at the Los Angeles County-University of Southern California Medical Center from 1972 through 1982. Our criteria for the diagnosis of acute mastoiditis are acute or subacute otitis media, postauricular swelling and erythema, protrusion of the auricle, and clouding of mastoid air cells on radiographs. Thirty-one (57%) recovered with conservative therapy consisting of early myringotomy and intravenous antibiotic, usually ampicillin. Twenty-three patients were managed surgically. The indication for surgery in each case was the clinical diagnosis of subperiosteal abscess; mastoid radiographs played no part in the decision to operate. Two of the 23 patients managed surgically had only incision and drainage of abscess; simple mastoidectomy was performed on 20 and radical mastoidectomy on one. Etiologic bacteria were cultured in 21 instances, S. pyogenes was cultured in 9, S. pneumoniae was cultured in 6, H. influenzae in 1, enterococci in 1, anaerobes in 2, and M. tuberculosis in 2.

Tracheotomy in infants and young children: the changing perspective 1970-1985.

One hundred fifty-three children 3 years of age or younger who had tracheotomies performed during the past 15 years are reviewed. During this time, short-term endotracheal intubation for airway obstruction from acute infections and long-term intubation for patients on ventilators have replaced early tracheotomy for these conditions. The number of tracheotomies decreased during each of three 5-year periods, from 73 to 55 to 25, respectively. Improvements in medical management resulted in prolonged survival of children with multiple abnormalities and resulted in more prolonged tracheotomies. Early complications occurred in 12% of patients and late complications occurred in 26%. In spite of changes in the indications, basic fundamentals of pediatric tracheotomy management remain unchanged.

Familial vocal cord dysfunction associated with digital anomalies.

Familial vocal cord dysfunction is a rare condition that has been reported in only a few instances. This is a report of identical male twins, both of whom had congenital bilateral abductor vocal cord paresis associated with finger deformities. The vocal cord paresis progressed to paralysis that required tracheotomy, then returned to a slowly resolving paresis during which the vocal cords had uncoordinated motion generally known as synkinesis. Another male sibling and the mother had a history of stridor during infancy and finger deformities. Several other relatives had digital abnormalities, and an infant first cousin with finger abnormalities required a tracheotomy for vocal cord paralysis.

Corticosteroid management of airway hemangiomas: long-term follow-up.

Nine children with airway obstructing hemangiomas were managed with corticosteroid therapy for durations of 6 weeks to 17 months. One patient required a tracheotomy. Steroid therapy improved the airways of the other 8 patients. Therapy was continued for 8 months or longer in 6 patients, none of whom developed life-threatening infections. Examinations 1 1/2 to 7 1/2 years after therapy revealed all of the patients to be within normal range for height and weight, but 3 of the 6 patients treated for 8 months or longer were in the lower range of normal. Steroid therapy is an effective method of protecting the airway in some patients with hemangiomas. Its disadvantage is that therapy may be necessary for several months. The risk of infections and growth suppression is minimized by using small maintenance dosage and alternate day therapy.

An unusual case of laryngeal scleroma.

An unusual case of nasal and laryngeal scleroma is presented. Laryngeal scleroma should be included in the differential diagnosis of obstructing lesions of the supraglottic airway. The immunoperoxidase staining method is useful in establishing the diagnosis in cases of equivocal culture and histopathologic appearance. It can further be used as an objective test to determine the effectiveness and duration of antibiotic therapy.

Corticosteroids in airway management.

Adrenal corticosteroids exert a strong suppressive influence on the basic inflammatory response that leads to tissue swelling. The corticosteroid effect is nonspecific. In upper airway obstruction caused by edema from infection, allergy, or trauma, corticosteroids will exert some degree of suppressive effect. The steroid effect is local and directly proportional to the concentration of steroids in the inflamed tissue. In upper airway obstruction steroids should be delivered to the inflamed tissue in high concentration with the least delay. Dexamethasone and methylprednisolone produce high blood levels within 15 to 30 minutes of intramuscular injection. Recommended initial doses for acute airway obstruction are dexamethasone, 1.0 to 1.5 mg/kg, or methylprednisolone, 5 to 7 mg/kg. The risk of harm from steroid therapy of 24 hours or less is negligible.

Dilation of esophageal strictures: comparative morbidity of antegrade and retrograde methods.

A total of 687 dilations of esophageal strictures were performed on 59 patients in the operating room over a 17-year period. Seventy-nine percent of the strictures were secondary to caustic ingestion and 89% of the dilations were in these patients. Antegrade dilations were performed 389 times and retrograde dilations were performed 298 times. Esophageal perforation occurred seven times with antegrade dilations. There were no perforations with retrograde dilations. The retrograde method using Tucker bougies is the safest and most successful method of dilating severe strictures.

Pathogenesis of subglottic stenosis from endotracheal intubation.

Subglottic stenosis is more likely to develop secondary to endotracheal intubation if one or more trauma-related risk factors are involved. Ulcerations occur most often in the posterior-lateral cricoid ring. They vary in size and may involve the entire circumference of the subglottic area. The ulcerations heal with fibrous scarring which, if extensive enough, results in subglottic stenosis.

Removal of blunt foreign bodies from the esophagus.

Historically, removal of blunt foreign bodies from the esophagus by esophagoscopy under general anesthesia has been considered to be relatively safe and effective. In recent years, alternative techniques of blind removal with balloon catheters or bougies have been advocated. This paper reports 246 esophagoscopies performed over a 19-year period to remove blunt esophageal foreign bodies. Eighty-one percent of the foreign bodies were coins and 74% were in children under 3 years of age. There were no deaths, no perforations, and no instances of mediastinitis. The only complications encountered were those due to esophageal erosion and/or respiratory problems secondary to long-standing foreign bodies. In the author's opinion, esophagoscopy is the best method for removal of all esophageal foreign bodies. There simply does not seem to be a need for alternative methods involving blind removal.

Abscesses of the neck in infants and young children. A review of 112 cases.

A review of 112 patients 5 years of age and younger with cervical abscesses is reported. Staphylococcus aureus and group A beta-hemolytic Streptococcus were cultured most often: in 39% and 17% of patients, respectively. Sixteen patients (14%) had unusual abscesses such as infected congenital cysts, cat-scratch disease, or myocobacterial abscesses. One patient had a necrotizing infection with group A streptococci and anaerobic streptococci. Intravenous antibiotic therapy was used in 104 patients, with 94% of these patients receiving a penicillin derivative, usually an antistaphylococcal penicillin. Ninety-six percent of the patients had incision and drainage of their abscesses; 8 patients required more than one incision and drainage. Two patients required airway intervention, 1 by intubation and 1 by trachetomy. Most pediatric cervical abscesses respond well to appropriate intravenous antibiotic therapy and incision and drainage.

Laryngeal stenosis from endotracheal intubation. A review of 58 cases.

During the decade of the 1970s, the Department of Otolaryngology at the Los Angeles County - University of Southern California Medical Center encountered 58 patients who requried tracheotomy for laryngeal stenosis secondary to endotracheal intubation. This included 19 children and 39 adults. We treated 50 of these patients, of whom 35 (70%) were decannulated after endoscopic management alone. One other patient could have been decannulated but needed the tracheotomy for medical reasons. Two other will probably be decannulated in the near future. Eight patients underwent open reconstructive procedures.