Association of Computed Tomography With Treatment and Timing of Care in Adult Patients With Peritonsillar Abscess.

Background: Peritonsillar abscess (PTA) is a common occurrence in adult patients, and an important question in such often-seen disease processes is whether we are treating these patients effectively, efficiently, and economically. We sought to determine if a diagnostic computed tomography (CT) scan was associated with a difference in clinical intervention in adult patients with PTA and if CT was associated with delaying this intervention. Methods: We conducted a retrospective case-control study examining therapeutic interventions in adults with PTA. Patients were divided into a control group (those diagnosed without CT, n=159) and a case group (those diagnosed with CT, n=203). Patients were examined for 3 outcomes: admission, bedside procedure (needle aspiration, incision/drainage), and surgical procedure (incision/drainage, tonsillectomy). In addition, we calculated times to admission, otolaryngology consultation, bedside procedure, and surgical procedure. Results: We found a significant association between CT and intervention, with the CT group more likely to be admitted (P< 0.001), the non-CT group more likely to undergo a bedside procedure (P<0.001), and the CT group more likely to undergo operative intervention (P=0.02). Mean times to otolaryngology consultation, admission, and bedside procedure were significantly longer in the CT group than in the non-CT group, determined by calculating the difference of the means with 95% confidence intervals for each comparison (P<0.001). Conclusion: We found that CT scans appear to be useful in the workup and treatment of adult patients with PTA, evidenced by significant differences in interventions between groups with and without CT scans. We also found that CT scans have the potential to delay these interventions, as the time to each intervention examined was significantly longer in patients who had a CT scan. Given the need to reduce cost, enhance efficiency, and eliminate harmful side effects (in this case, radiation exposure and delays in care), we question whether CT is the gold standard imaging method for diagnostic work up of PTA.

Intraoperative fistulograms in the management of branchial apparatus abnormalities in children.

OBJECTIVE: We sought to evaluate the role and efficacy of intraoperative fistulograms in visualizing branchial apparatus (fistula/sinus) abnormalities in the pediatric age group (3 months-12 years). METHODS: This was a retrospective analysis of 20 pediatric patients who underwent fistula and/or sinus excision during a period of 18 years (1988-2006). RESULTS: The male:female ratio was 11:9. Eighteen of the 20 patients presented with unilateral abnormalities, 2 with bilateral abnormalities. An intraoperative fistulogram was utilized in every instance. The fistulogram clearly differentiated the sinus tracts from complete fistulas in all cases. It was also highly useful in delineating the exact length and course of the sinus/fistula tracts. CONCLUSIONS: Intraoperative fistulograms are easy to do in the operating room on the day of the scheduled surgery. They are a very useful tool in the management of branchial apparatus abnormalities.

Establishing the Need for an Evidence-Based Treatment Algorithm for Peritonsillar Abscess in Children.

In this retrospective case series, we report clinical factors associated with pediatric peritonsillar abscess (PTA), with hopes of contributing to the design of an evidenced-based, economic treatment approach. Charts were examined for presenting symptoms and signs. Each of these were analyzed for association with the presence of PTA and for association with treatment. We found that, with the exception of leukocytosis, the signs/symptoms that prompted treatment correlate with those that indicate the presence of PTA. However, there are several signs/symptoms, namely, referred otalgia, cervical lymphadenopathy, and decreased oral intake, that were associated with PTA but unassociated with treatment. Treatment can be aided by establishing an algorithm that accounts for the symptoms/signs most correlated with true, drainable abscess.

Neonatal nasal septal deviation: Two cases of successful early surgical intervention.

Neonatal nasal septal deviations can occur as a result of trauma in utero or during birth. They are associated with significant clinical implications, including respiratory distress and failure to thrive. The incidence and classification of these deformities are varied in the otolaryngology literature. Some authors advocate conservative observation, but no consensus on management has been reached. We present 2 cases of neonatal septal deviation that occurred during difficult deliveries. We repaired the defects with closed reduction in the operating room within the first 2 weeks of life to good effect.

Association Between Computed Tomographic Scan and Timing and Treatment of Peritonsillar Abscess in Children.

Importance: There is not a consensus on the best diagnostic algorithm for children with a potential peritonsillar abscess. The association of computed tomographic (CT) scanning in children with a pertonsillar abscess and intervention chosen by the treating physician, or the potential delay of treatment associated with such imaging, has not yet been explored. Objectives: To determine if use of a CT scan is associated with a difference in clinical intervention for peritonsillar abscess and to determine if use of a CT scan is associated with delay of this intervention. Design, Setting, and Participants: A retrospective case-control study examined therapeutic interventions, based on the presence or absence of a diagnostic CT scan, in children diagnosed with peritonsillar abscess from November 1, 2006, to November 1, 2015. Children who presented either to the emergency department or to their pediatrician with a peritonsillar abscess were divided into 2 groups: those diagnosed without the use of a CT scan (controls; n = 38) and those diagnosed with the use of a CT scan (cases; n = 30). Main Outcomes and Measures: Patients were examined for 2 outcomes: admission or no admission. The groups were also examined for type of intervention performed: bedside procedure (needle aspiration or incision and drainage), surgical procedure in the operating room (needle aspiration, incision and drainage, or tonsillectomy), no procedure, or both bedside and surgical procedure. In addition, the time to an otolaryngology consultation and to each of the above interventions was calculated. Results: Thirty children underwent a CT scan, while 38 did not. The mean age of children who underwent a CT scan was 14.3 years (range, 3-18 years) and 11.3 years (range, 1-18 years) for those who did not, for an absolute difference of 3 years (95% CI, 0.38-5.62). Among 68 patients (27 boys and 41 girls), there was no significant association between CT scan and admission or between CT scan and type of procedural intervention. However, there was a clinically significant association between CT scan and time to intervention. Mean time to an otolaryngology consultation was 369 minutes in the CT scan group and 63.4 minutes in the control group for an absolute difference of 305.6 minutes (95% CI, 208-404). Mean time to admission was 340 minutes in the CT scan group vs 166 minutes in the control group for an absolute difference of 174 minutes (95% CI, 65.3-283). Mean time to bedside procedure was 493 minutes in the CT scan group compared with 175 minutes in the control group for an absolute difference of 368 minutes (95% CI, 130-606). No significant association was found between use of CT scan and mean time to surgical intervention: mean time to surgical intervention in the CT scan group and the control group was 1.71 days and 1.64 days, respectively, for an absolute difference of 0.06 days (95% CI, -1.54 to 1.66). Conclusions and Relevance: Use of a CT scan is not associated with a difference in intervention in children with peritonsillar abscesses. It is, however, associated with a clinically significant delay in treatment; namely, time to an otolaryngology consultation, time to admission, and time to bedside procedure.

Intracapsular versus standard tonsillectomy: review of literature.

For the past century, standard (total) tonsillectomy has been the preferred method for treating illness resulting from tonsillar infection and hypertrophy. With the advent of antibiotics, however, more cases of tonsillitis are treated medically. As a result, tonsillectomies are being performed less frequently for infection than for obstructive symptoms associated with tonsillar hypertrophy and sleep-disordered breathing. This shift has led to the re-emergence of the tonsillotomy, and more specifically the partial or intracapsular tonsillectomy, as an option for treating tonsillar hypertrophy, mainly in an effort to reduce the post-operative complications of pain, subsequent dehydration from lack of oral intake, and, potentially, delayed postoperative bleeding. The following is a review of the literature comparing intracapsular tonsillectomy to standard tonsillectomy for tonsillar hypertrophy associated with sleep-disordered breathing.

Respiratory failure after superior-based pharyngeal flap for velopharyngeal insufficiency: A rare complication.

Velopharyngeal insufficiency (VPI) is an uncommon pediatric disorder often associated with congenital syndromes. After speech therapy, surgery is the standard management. Many surgical approaches to VPI repair have been reported and the complications of these procedures are well documented. To date, there have been no published cases of respiratory failure secondary to pneumomediastinum, pneumopericardium, and bilateral pneumothoraces with associated subcutaneous emphysema after superior-based pharyngeal flap. We present the first case in the literature. Our proposed etiology for the respiratory failure is air tracking from the flap donor site to the pleural spaces of the thoracic cavity via the visceral or prevertebral fascia following positive pressure ventilation.

Power-assisted partial adenoidectomy.

OBJECTIVE: To describe partial adenoidectomy using a powered microdebrider and review the experience with the procedure. STUDY DESIGN: Prospective study and review. METHODS: To perform a power-assisted partial adenoidectomy, the surgeon directs the window in the microdebrider blade tip toward the tissue, which is drawn in by suction; the rotating blade then shaves the tissue. Studies have compared this adenoidectomy technique with curette procedures. RESULTS: In a comparative prospective study, we found that operating time and time required for hemostasis were significantly shorter (P =.001) with power-assisted partial adenoidectomy than with curettage. There was no significant difference between the two procedures in blood loss or complication rate. These results were similar to those of previous studies. Overall, we have performed more than 1000 power-assisted partial adenoidectomies. No long-term complications have occurred, blood loss remains low, and surgeons are satisfied with the technique because of its speed, improved visibility during resection, and precision. CONCLUSION: We and other authors have found power-assisted partial adenoidectomy to provide a faster, more precise operation than curette techniques, with benefits for both patient and surgeon.

Powered partial adenoidectomy.

OBJECTIVE: To confirm our clinical impression that the powered microdebrider is superior to curettes for performing partial adenoidectomy (removal of the superior one half to three fourths of the adenoid pad). DESIGN: Observational study of 100 children undergoing partial adenoidectomy with the powered microdebrider compared with 40 children undergoing conventional partial adenoidectomy with curettes. SETTING: Private and public tertiary care centers. PATIENTS: All patients younger than 20 years undergoing partial adenoidectomy at the respective institutions during the study period. INTERVENTIONS: Partial adenoidectomy as indicated for chronic otitis media, airway obstruction, or chronic or recurrent tonsillitis with either the powered microdebrider or curettes. MAIN OUTCOMES MEASURES: Operative time (with specific quantification of the time required for tissue removal and hemostasis), blood loss, complications, and subjective ease of use. RESULTS: Operative time was 59% shorter for the microdebrider group (mean, 3 minutes 22 seconds; range, 1 minute 6 seconds to 12 minutes 45 seconds) than for the conventional group (mean, 8 minutes 8 seconds; range, 1 minute 2 seconds to 22 minutes 0 seconds) (P<.001). Blood loss was comparable for both groups (powered group: mean, 2.0 mL/kg; range, 0.4 to 9.4 mL/kg; conventional group: mean, 2.0 mL/kg; range, 0.3 to 6.7 mL/kg; P=.34). There were no intraoperative or postoperative complications in either group. Surgeon satisfaction with the microdebrider was high. CONCLUSIONS: The powered microdebrider for partial adenoidectomy is quicker and is not associated with blood loss or complications above that of conventional partial adenoidectomy. The degree of control afforded by the microdebrider technique is of utmost value in preventing complications such as velopharyngeal insufficiency, and this is now our procedure of choice.

Hemifacial microsomia.

Hemifacial microsomia is the second most common congenital facial anomaly, second only to cleft lip and palate. While its precise etiology is not yet known, it is likely caused by a disruption in the development of the first two branchial arches early in embryologic development. The resulting phenotype is one of varying degrees of unilateral hypoplasia of the mandible, ear deformity, and macrostomia. Early diagnosis of hemifacial microsomia is important not only to plan for surgical reconstruction of affected features, but also to lead the physician in further evaluation for associated abnormalities or disabilities. This article will introduce the reader to the most common variants seen in hemifacial microsomia, discuss the possible etiologies of the anomalies, and will highlight the importance of evaluating these patients early in life for such potentially disabling but correctable problems such as hearing loss, feeding disabilities, and neurological deformities.

The efficacy of mitomycin and stenting in choanal atresia repair: a 20 year experience.

OBJECTIVE: To determine the efficacy of topical mitomycin and stenting in patients that have undergone endoscopic repair of choanal atresia. METHODS: Retrospective review of 37 endoscopic operations on pediatric patients for choanal atresia. RESULTS: Twenty-six sides were operated on in 17 patients; 37 total operations were performed. All 17 patients were repaired endoscopically with 1 patient requiring transpalatal revision surgery. Eight patients (47%) had a unilateral atresia and 9 (53%) were bilateral. Eleven total sides (42%) were treated initially with mitomycin. Eighteen percent of those sides required post-operative dilation vs. 40% of the sides not treated with mitomycin (p=0.39) and no patient in the mitomycin group required revision surgery compared to 20% of patients not treated with mitomycin (p=0.24). Significantly fewer sides in the mitomycin group (9%) developed granulation vs. those treated without (53%) (p=0.03). The average number of procedures performed (1.18 vs. 2.53; p=0.002) was significantly fewer in those patients treated with mitomycin vs. not. A greater amount of sides in the stent group developed granulation tissue (50% vs.0%; p=0.023). The average number of procedures performed was significantly greater in those patients treated with a stent (2.33 vs. 1.12; p=0.008). The average time spent in the hospital was significantly shorter (7.09 vs. 2.33 days; p=0.02) in those patients treated without stenting. CONCLUSION: Topical mitomycin is efficacious as an adjuvant therapy as it was associated with the formation of less granulation tissue, a lower rate of restenosis and fewer surgeries. Stenting was associated with significantly more procedures, greater formation of granulation tissue and longer overall hospital stays. However, consideration should be given toward stent placement in all neonates for the prevention of post-operative airway obstruction. LEVEL OF EVIDENCE: 2c.

Improving outcomes in a high-output pediatric otolaryngology practice.

OBJECTIVES: To identify factors associated with efficient operating room work flow on high volume pediatric otolaryngology days and the effects on provider and perceived parent satisfaction. METHODS: Retrospective review was performed of a sample of 20 days with greater than 10 cases per day performed by a pediatric otolaryngologist operating in 2 rooms. Turnover time and complications were the main outcome measures. Providers from otolaryngology and anesthesia that participated in these days were surveyed regarding efficiency, safety, and satisfaction. RESULTS: 223 cases were performed over 20 operative days. The average turnover time was significantly longer in "major" surgeries (p=0.03), cases with multispecialty involvement (p=0.01), cases requiring intubation (p<0.001), and in cases where a fellowship trained pediatric anesthesiologist (p=0.01) or CRNA was present (p<0.001). When comparing "fast" (<25min average turnover) operative days vs. "slow" (>25min average turnover) days, presence of a non-fellowship trained anesthesiologist (p<0.001), and the presence of an anesthesiology resident (p=0.03) were significantly associated with "fast" days, while the presence of a CRNA was associated with "slow" days (p<0.001). A significantly greater proportion of patients required intubation on "slow" turnover days vs. "fast" days (p=0.13). Only one complication was observed (0.4%). 48 providers were surveyed with a 63% response rate. Reported satisfaction amongst providers was significantly greater on days with at least 10 cases (p=0.047) and on days with turnover times of 25min or less (p<0.001). Pre-operative nursing evaluation/preparation of the patient, inter-provider communication and delays in room cleaning/setup were identified most often as causative factors responsible for delays in turnover. CONCLUSIONS: High-operative volume operating days are common in pediatric otolaryngology and can be safely performed in an efficient manner. Appropriate scheduling and high-level communication between providers is needed to ensure success on these days. Identified areas of potential inefficiency can be a starting point for work flow optimization practices.

Balloon dilation in the management of severe airway stenosis in children and adolescents.

BACKGROUND/PURPOSE: Children and adolescents with airway stenosis pose a clinical challenge. Recently, balloon dilation has been described, primarily for the treatment of early, immature, less severe airway stenosis. We describe our experience with 8 children and adolescents managed with balloon dilation, including severe, mature subglottic and tracheal stenosis. METHODS: This is a case series of 8 children and adolescents with acquired subglottic and tracheal stenosis treated by the primary author with balloon dilation between August 2006 and April 2010 at an academic tertiary care center. In the four patients who were tracheotomy-dependent at the time of presentation, suprastomal stents or Montgomery T-tubes were used. In 1 patient with 99% subglottic stenosis (SGS), balloon dilation and stenting were used to create a lumen prior to laryngotracheal reconstruction (LTR). RESULTS: All 4 patients with tracheotomy were decannulated. The remaining 4 patients were successfully managed without tracheotomy. CONCLUSIONS: Mature, severe laryngeal and tracheal stenosis in pediatric patients can be successfully managed with balloon dilation. In the most severe cases with prior tracheotomy, stenting is necessary. Balloon dilation with stenting can also facilitate LTR. In patients without prior tracheotomy, tracheotomy and stenting can often be safely avoided with appropriate postoperative management.

Multiple branchial cleft anomalies in conjunction with a congenital dermal fistula of the lower extremity: first report of the Guarisco-Winters syndrome.

Branchial cleft anomalies are congenital remnants of the embryologic branchial clefts persisting past the embryo stage. Most occur singly and sporadically, though syndromic associations are described. Multiple branchial cleft anomalies coincident in the same patient are exceptionally rare, and rarer still are peripheral dermal sinus tracts on the extremities, with one prior documented case. We report the first case of multiple branchial cleft anomalies with a peripheral dermal sinus of the ipsilateral lower extremity. Numerous concurrent congenital anomalies exist in the patient, representing the first description of the Guarisco-Winters syndrome. The patient is intellectually and developmentally age-appropriate in all other regards.

Update on the diagnosis and treatment of caustic ingestion.

Caustic ingestion is a serious medical problem with a variety of clinical presentations and a complicated clinical course. This article reviews the epidemiology and pathophysiology of caustic ingestion as well as the most current approaches to diagnosis and treatment. Finally, a recent case will be presented that highlights the difficulty this problem poses to a medical team.

Obstructive lesions of the pediatric subglottis.

PURPOSE: To compile information regarding obstructive subglottic lesions in children, including anatomy, pathogenesis, prevention, evaluation, and treatment options, required for implementation of a multi-faceted treatment plan. METHOD: Review of the literature. CONCLUSIONS: Although they are infrequent, obstructive subglottic lesions pose significant challenges to treating physicians, from airway management and injury prevention to decannulation and voice rehabilitation. Most patients with these lesions require multidisciplinary care and long-term treatment and can nearly always be treated successfully.

Serum citrulline levels correlate with enteral tolerance and bowel length in infants with short bowel syndrome.

OBJECTIVE: To determine if serum levels of CIT (a nonprotein amino acid synthesized by the intestine) correlate with total parenteral nutrition (PN)-independence in children with short bowel syndrome (SBS). STUDY DESIGN: We prospectively obtained serum amino acid profiles over a 24-month interval from all infants with SBS 3 weeks to 4 years of age. Remaining small intestine length was recorded at surgery, and percent enteral calories tolerated (enteral calories divided by enteral plus parenteral calories x 100) was determined in 24 infants with SBS and 21 age-matched controls (blood drawn for non-gastrointestinal symptoms). RESULTS: Mean CIT for controls was 31 +/- 2 micromol/L. In patients with SBS (n = 24), serum CIT correlated linearly with percent enteral calories (R = 0.85; P <.001) and with bowel length (R = 0.47; P < or =.03). CIT level in patients with SBS weaned off PN was 30 +/- 2 micromol/L; in those subsequently weaned off PN, 20 +/- 2 micromol/L; and in those who would remain PN-dependent, 11 +/- 2 micromol/L ( P < or =.01). Serum CIT > or =19 micromol/L had 94% sensitivity and 67% specificity for being off or coming off total PN. CONCLUSIONS: Serum CIT level >19 micromol/L in children with SBS is associated with development of enteral tolerance and may be a useful predictive test.