Predictive clinical exam findings in post-tonsillectomy hemorrhage.

OBJECTIVES: Post tonsillectomy hemorrhage (PTH) is a common complication of tonsillectomy. Our objectives were to: 1) Examine the postoperative course of patients presenting to St. Christopher's Hospital for Children (SCHC) with PTH; 2) Compare patients with and without a blood clot visualized in the tonsillar fossa at time of presentation to determine if outcomes regarding return to the operating room (OR) differ. METHODS: This was a retrospective chart review conducted at an academic, tertiary, pediatric hospital in an urban setting. Pediatric patients who underwent a tonsillectomy with concurrent adenoidectomy and were admitted for observation following secondary post tonsillectomy hemorrhage were reviewed. The effects of age, gender, indication, and clinical exam findings on admission on the rate of eventual return to the OR for control of hemorrhage were also analyzed. Chi-square analysis and Fisher's exact test were used to compare the significance of categorical frequencies. RESULTS: The rate of blood clot presence in our cohort was 50.9% (28/55). Return to OR rates were defined as patients who began actively hemorrhaging following admission for observation, further stratified by presence or absence of clot on admission physical exam. There was a statistically significant higher rate of return to OR in patients who presented with a clot (46.6%) on clinical exam versus no clot (18.5%) after resolved post tonsillectomy hemorrhage (p < .027). Furthermore, patients with a blood clot present were significantly more likely to require OR sooner (21.31 h from admission) than those without a clot (100.75 h from admission) (p < .012). There was no statistically significant higher rate of blood clot presence or rate of return to OR in groups based on age, gender, or indication. DISCUSSION: Pediatric patients presenting after resolved secondary PTH with a blood clot visualized in the tonsillar fossa are more likely to require return to the OR for hemostasis and cautery than are those without a blood clot, and this is more likely to occur within 24 h of admission. Thus, patients with a blood clot on initial presentation may benefit from admission for a 24-h observation period, while a similar observation period may be unproductive for patients without a blood clot. CONCLUSIONS: Patients who present with a resolved secondary PTH and a blood clot present on clinical exam require return to the OR more often than patients presenting without a blood clot. While previously controversial, we feel that this demonstrates that a 24-h observation of a patient with a clot on exam is reasonable.

Granular cell tumor of the trachea in pregnancy: a case report and review of literature.

OBJECTIVES/HYPOTHESIS: The objectives were to present a case report of a woman with recurrent disease during consecutive pregnancies and to discuss the diagnosis and management of granular cell tracheal tumors, with particular attention to pregnancy and hyperestrogenic states. STUDY DESIGN: Case report and literature review. METHODS: A Medline search and comprehensive review of literature to assess all cases of granular cell tumors of the trachea were compared and collected, with particular attention to individual cases of pregnancy or cases related to the hyperestrogenic state. RESULTS: Thirty-two cases of granular cell tumors of the trachea were found. Only a few cases related to the hyperestrogenic state were obtained. The case report describes a woman with recurrent disease in subsequent pregnancies during the later stages of pregnancy. CONCLUSION: Few cases of granular cell tumors of the trachea have been reported, with even fewer being pregnancy related. The diagnosis and management of these tumors include careful attention to patient symptoms and airway management.

Esophageal hamartoma as an unusual cause of neonatal apnea and bradycardia.

Esophageal hamartoma is a rare entity, as only 7 cases have been previously reported in the English-language literature. Common symptoms include dysphagia, weight loss, and vomiting. Life-threatening airway obstruction can also occur. Because of the nonspecific nature of the symptoms, patients with these dangerous polyps are often misdiagnosed as having more common entities such as gastroesophageal reflux, peptic ulcer disease, or achalasia. Most of these tumors are missed on esophagoscopy and radiologic studies, and they can go undiagnosed for years. We diagnosed an esophageal hamartoma in an infant girl who had first presented when she was 8 days old with symptoms of apnea and cyanosis. The patient had undergone a multitude of tests since her birth, and she was eventually diagnosed with episodic bradycardia. When the patient was 6 weeks old, we discovered a polyp on nasopharyngolaryngoscopy, and we removed it by microdirect laryngoscopy and esophagoscopy. This patient was the youngest of the 8 who have now been reported to have been diagnosed with a hamartomatous polyp, and she was the only one to have presented with apnea (secondary to airway obstruction) and bradycardia. We recommend microdirect laryngoscopy and esophagoscopy to remove these pedunculated cervical esophageal lesions. A transcervical approach is warranted for sessile distal esophageal polyps. Esophageal polyps are an interesting entity in view of their rarity and intriguing presentations. Because esophageal obstructions can be life-threatening, further evaluation by laryngoscopy, bronchoscopy, and esophagoscopy is warranted when symptoms of dysphagia, vomiting, intermittent apnea, bradycardia, and weight loss persist despite conventional treatment.