[Evaluation of an educational intervention on the standard of neonatal resuscitation: orotracheal versus nasotracheal intubation]. / Quelle technique d'intubation enseigner dans un programme de formation à la réanimation en salle de naissance : voie orotrachéale ou nasotrachéale ?

UNLABELLED: Proficiency in endotracheal intubation is an essential step in the neonatal resuscitation process. This skill is difficult to acquire and its mastery requires experience. Recent changes in neonatal resuscitation guidelines (ILCOR 2006) have resulted in a decrease in the opportunities to practice intubations. Appropriate education and training is therefore essential. The goal of this study was to assess the skills of neonatal care professionals in performing intubation via orotracheal (OT) and nasotracheal (NT) routes. METHODS: OT and NT intubation attempts were compared during training on a neonatal mannequin (Laerdal, Neonatal Resuscitation Baby((R))) at each course of an educational intervention on neonatal resuscitation organized in level 1-3 institutions of the Maternités en Yvelines Perinatal Network. The duration of these attempts was noted; intubation in less than 30s was considered successful. RESULTS: Thirty-two midwifery students (STD), 103 midwives (MW) and 25 pediatricians (PED) participated in the study. The median (IQR) time for intubation was less with the OT route than with the NT route for STD (12.0 vs 23.0s; p=0.001), MW (14.0 vs 25.0s; p=0.001), and PEDs (13.0 vs 20.0s; p=0.007). The success rates for intubation in less than 30s were higher for the OT than the NT routes for STD (100% vs 66%; p=0.001), MW (97% vs 69%; p=0.001) and PED (92% vs 88%; p=NS). CONCLUSION: This study confirms that OT intubation training resulted in a higher success rate and lower duration for intubation. Practical courses in neonatal resuscitation should include training with OT intubation.

Inlay butterfly cartilage tympanoplasty in children.

OBJECTIVE: To assess the results of inlay butterfly cartilage tympanoplasty in children. STUDY DESIGN: Before-and-after trial; follow-up duration, 26.6 +/- 19.9 months (mean +/- standard deviation). SETTING: Tertiary referral center. PATIENTS: Fifty-nine pediatric cases of tympanic membrane perforation. INTERVENTION: Inlay butterfly cartilage tympanoplasty was performed under general anesthesia according to the technique originally described by Eavey and modified by Lubianca-Neto (i.e., without any associated split-thickness skin graft). MAIN OUTCOME MEASURES: Percentage of perforation closures, surgical complications, preoperative and postoperative puretone hearing thresholds; the results of inlay butterfly cartilage tympanoplasty were compared with those obtained in a retrospective series of 29 underlay fascia temporalis myringoplasties. RESULTS: The 71% "take rate" of inlay butterfly cartilage tympanoplasty was not significantly different from the 83% take rate obtained with underlay fascia temporalis tympanoplasty (p = 0.23, chi test). The anatomic results were improved when the graft diameter was at least 2 mm larger than the size of the perforation (81% take rate) (p = 0.009, chi test). No iatrogenic cholesteatoma was observed. Pure-tone hearing thresholds were improved at 0.5, 1, and 2 kHz, and stable at 4 kHz. Hearing levels were not different from those obtained with underlay fascia temporalis tympanoplasty. CONCLUSION: Inlay butterfly cartilage tympanoplasty is a safe, efficient, time-saving, and easy technique of tympanoplasty in children. Anatomic results may be improved by associating a split-thickness skin graft and/or by trimming a tragal graft much larger than the size of the perforation.

Recovery of [13C]-bicarbonate as respiratory 13CO2 in parenterally fed infants.

Ten infants on continuous total parenteral nutrition (TPN) were infused with NaH13CO3 for 6 h in order to assess the amount of 13C recovered as breath 13CO2. Protein intake was 2.8 +/- 0.3 g/kg/d and non-protein energy intake 107 +/- 4 kcal/kg/d (447 +/- 18 kJ/kg/d), provided either as glucose alone or as an isoenergetic glucose-lipid mixture. In the five infants receiving glucose as the sole non-protein energy source, total CO2 production (559 +/- 50 mumol/kg/min), natural 13C abundance of breath CO2 (-11.8 +/- 0.6 delta % versus PDB) and basal 13CO2 production (6.1 +/- 0.6 mumol/kg/min) were higher than in the five infants infused the glucose-lipid mixture (465 +/- 30 mumol/kg/min, P less than 0.02; -16.1 +/- 0.5 delta %, P less than 0.01 and 5.0 +/- 0.3 mumol/kg min, P less than 0.02, respectively). There was a good agreement, in the glucose-infused infants, between the net glucose oxidation rate measured by indirect calorimetry (25.6 +/- 2 g/kg/d) and the glucose oxidation rate estimated from the 13C natural abundances of breath CO2 and infused substrates (23.5 +/- 3 g/kg/d). Steady state 13C enrichment of breath CO2 was reached in all infants after 120 min infusion and ranged from 11.0 to 21.5 delta % over baseline. Steady state 13C enrichment was negatively related to total CO2 production (r = -0.72; P less than 0.02). In contrast, steady state 13CO2 production in excess of baseline was only correlated to bicarbonate infusion rate (r = 0.95; P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Quantitative assessment of human cochlear function by evoked otoacoustic emissions.

The amplitudes of evoked otoacoustic emissions (EOE) and their detection threshold were measured in 44 normal young adults and 118 patients with two categories of cochlear dysfunction, acoustic trauma and presbycusis. A different method was used for each category: detection of click EOE or of stimulus frequency emissions. A partial correlation and multivariate analysis was performed for both groups of results to investigate the relations between EOE threshold one pure tone audiometric thresholds (250 to 8000 Hz). Only one significant correlation was found, linearly relating EOE threshold and hearing threshold at 2 kHz (P less than 0.001), independently of the origin of cochlear dysfunction. It suggests that EOE threshold is not frequency-specific since the frequency of EOE at threshold was nearly always close to 1 kHz. A simple model is proposed, based on the assumption that EOE amplitudes and threshold are proportional to the total number of residual active sites in the organ of Corti, i.e. to the total length of active basilar membrane. It is shown that this model accounts for the results disclosed by the statistical analysis and fits the experimental data. It can be used for quantitatively predicting the residual cochlear activity of a patient. However, the EOE threshold is only sensitive to already important cochlear alterations and this parameter does not seem to allow a follow-up of early stages of cochlear dysfunction.

Evoked otoacoustic emissions in newborn hearing screening.

Evoked otoacoustic emissions (EOEs) were recorded in a group of normally hearing neonates (n = 100 ears) to study the basic properties of EOEs and the parameters influencing them. The results obtained with EOE recordings were compared with those of behavioral screening investigations. The main properties of EOEs in neonates are: 1. EOEs can be recorded in 98% of the tested ears or neonates; 2. there were no statistically significant variations in EOE detection thresholds of neonates between the ages of 1 and 4 days; 3. no statistical difference in the EOE threshold was found between males and females; 4. all EOEs exhibited a broadband spectrum with high-component frequencies; 5. EOEs demonstrating narrowband frequency peaks super-imposed on the broadband component had detection thresholds lower than EOEs without narrowband frequency peaks. EOEs can be used as a screening test. The main clinical interest of this test is to detect the presence (i.e., normal auditory peripheral function) or the absence (i.e., pathological peripheral auditory function) of EOEs in response to a 30-dBHL click stimulation. The results of this study have important applications concerning the possible clinical use of EOEs for screening peripheral auditory dysfunction in neonates.

Spontaneous and evoked otoacoustic emissions in preterm neonates.

Spontaneous (SOEs) and evoked otoacoustic emissions (EOEs) were recorded in a group of preterm neonates (N = 134 ears) in order to study the basic properties of SOEs and EOEs as a function of gestational age. In the study, it was found that: 1. EOEs were recorded in 93% of the tested ears; 2. SOEs were recorded in 61% of the tested ears; 3. there were no statistically significant variations of EOE amplitude with gestational age; 4. EOE spectrum did not vary with age; and 5. the two main factors influencing EOE amplitude were the SOE presence and the fast Fourier transform spectrum, especially the lower limit of the spectrum. Thus, the maturation of outer hair cell properties appears to be complete at 32 weeks of gestational age. Because a number of infants at risk for hearing loss are preterm babies, screening for EOEs, an objective, rapid, and nontraumatic technique, may prove useful in evaluating peripheral auditory dysfunction in preterm neonates.

Surgical removal of subglottic hemangiomas in children.

OBJECTIVE: To examine the indications and the results of surgical excision of severe subglottic hemangiomas. DESIGN: Retrospective study and case series. SETTING: Four academic tertiary care centers of pediatric otolaryngology. PATIENTS: Twenty children were included from 1991 to 1997. All presented with severe subglottic hemangiomas resistant to classical treatments such as corticosteroids and/or CO2 laser. INTERVENTION: Six children were operated on using laryngotracheal reconstruction and prolonged stenting by a reinforced Silastic roll and 14 children were operated on by a single-stage laryngotracheoplasty and postoperative intubation in a pediatric intensive care unit. RESULTS: All patients were successfully decannulated or extubated and have been free from recurrent hemangiomas. CONCLUSION: The surgery of severe subglottic hemangiomas is a reliable technique in selected patients and should be considered in corticoresistant or corticodependent, circular, or bilateral hemangiomas.

Gastropharyngeal reflux in infants and children. A pharyngeal pH monitoring study.

Gastroesophageal reflux has been shown to play an important role in chronic and acute inflammatory disorders of the airway. In particular, gastroesophageal reflux has been suggested to be the cause of pharyngolaryngeal problems, according to the literature, at any age. However, to our knowledge, the presence of acid in the pharynx in pathological cases has not yet been proved. A series of eight patients (aged 2 months to 7.5 years) with recurrent acute laryngotracheitis underwent a two-channel pH monitoring for 23 to 24 hours. One pH probe was placed in the lower esophagus, the other in the pharynx, at the level of the epiglottis. Acid gastroesophagopharyngeal reflux was demonstrated in every patient. A significant difference with a series of six control subjects was noted in terms of esophageal and pharyngeal pH monitoring. The most significant item is the total time the pH in the pharynx was below 6. Despite the limited number of patients, this study suggests the role of gastroesophageal reflux in recurrent laryngotracheitis in infants and children.

Size of endotracheal tube and neonatal acquired subglottic stenosis. Study Group for Neonatology and Pediatric Emergencies in the Parisian Area.

OBJECTIVE: Risk factors for acquired laryngotracheal stenosis in newborn infants are poorly known. The extreme scarcity of acquired laryngotracheal stenosis in young infants in France, compared with the published rate in the English literature, suggested that these patients may be treated in a different way in France. A prospective study was performed to analyze local features. DESIGN: Six-month multicenter inception cohort study. SETTING: Seven neonatal intensive care units of referral centers in the area of Paris, France. PATIENTS: A total of 247 intubated surviving neonates in a consecutive sample during 6 months. INTERVENTION: A file was completed with sex, birth weight, gestational age, underlying disease, and every feature concerning the intubation period and the outcome. MAIN OUTCOME MEASURES: All the collected data were compared with those available from previous studies in the English literature. RESULTS: After extubation, respiratory outcome was uncomplicated in 242 cases. The five patients with dyspnea were treated medically and recovered. A much higher rate of extubation difficulties was reported in the English literature. The rate of stenosis in this series was significantly lower than in previously reported studies. The differences between this and other series seem to be higher birth weights, shorter duration of intubation, and, most important, a smaller tube size (2.5 mm in neonates weighing less than 2500 g and 3.0 mm in those weighing 2500 g or more). CONCLUSIONS: Although this is a limited series and many unknown variables can differ from those in previous studies, the size of the endotracheal tube appears to be a major risk factor for acquired laryngotracheal stenosis in the neonate. Further studies seem necessary to point out additional factors.

Surgical treatment for laryngotracheal stenosis in the pediatric patient.

We report our experience with laryngotracheal stenosis (LTS) in children during the last 12 years. Documentation and follow-up were available for 115 patients who underwent surgery for acquired or congenital LTS. Most were severe cases according to Cotton's classification. Forty-six weighed less than 10 kg at the time of surgery; 45 had pure congenital subglottic stenosis; 70 had acquired subglottic stenosis, mainly due to endotracheal intubation. The surgical techniques used have been various. The three main types of procedure were castellated laryngotracheoplasty, anterior cartilage rib grafting, and anterior and posterior cricoid cuts with or without grafting. All cases but 1 (44/45) of congenital subglottic stenosis have been successfully decannulated, 7 requiring a second procedure. The decannulation rate for acquired SGS was 89% (62/70), but 14 patients required multiple procedures. Current trends in subglottic stenosis management in our institution are presented.

Objective low-frequency audiometry by distortion-product acoustic emissions.

The aim of this study was to measure distortion-product otoacoustic emissions (DPOEs) in a clinical setting. First, DPOE input-output functions were automatically realized to determine the ratio of the pure tones (primaries) f2 and f1 that would elicit the most significant DPOE input-output function. The DPOE input-output functions presented two separate portions for the f2/f1 ratio, ranging from 1.18 to 1.26: (1) below 60-dB sound pressure level (SPL), a saturating portion with a DPOE detection threshold at 36-dB SPL; and (2) above 66-dB SPL, a linear portion. For other f2/f1 ratios, DPOE input-output functions had a more linear behavior. The DPOEs generated by primary intensities below 60-dB SPL, which show saturating behavior, probably have their origin in the properties of outer hair cells. This indicates that DPOE measurements in a clinical setting must be realized with precise stimulus values: (1) f2/f1 ratio near 1.22, and (2) primary intensities below 60-dB SPL. Second, DPOE input-output functions were realized for DPOEs varying from 707.5 to 342 Hz. No more saturating plateau could be observed with DPOEs below 512.5 Hz, suggesting that active mechanisms are absent below 725 Hz within the human cochlea. These data permit us to establish the bases of an objective low-frequency audiometric test.

Vestibular function in children with the CHARGE association.

BACKGROUND: Histopathological examinations and computed tomographic scans of the temporal bone in patients with the CHARGE association (a malformative syndrome that includes coloboma, heart disease, choanal atresia, retarded development, genital hypoplasia, and ear anomalies, including hypoplasia of the external ear and hearing loss) have shown an absence of semicircular canals and a Mondini form of cochlear dysplasia. Until recently, no information was available concerning a possible loss of vestibular function, which could be a factor in retarded posturomotor development. To our knowledge, this is the first report of otolith tests done on patients with the CHARGE association. OBJECTIVE: To test residual vestibular function in patients with the CHARGE association. STUDY DESIGN: In 7 patients with the CHARGE association, we made electro-oculographic recordings of vestibulo-ocular responses to earth-vertical and off-vertical axis rotations to evaluate the function of the canal and the otolith-vestibular systems. RESULTS: None of the 7 patients had semicircular canals in the computed tomographic scan, and none had canal vestibulo-ocular responses to earth-vertical axis rotation, but all had normal otolith vestibulo-ocular responses to the off-vertical axis rotation test. CONCLUSIONS: These results support the hypothesis of a residual functional otolith organ in the hypoplastic posterior labyrinth of children with the CHARGE association. The severe delays in psychomotor development presented by these children are more likely a consequence of multiple factors: canal vestibular deficit, visual impairment, and environmental conditions (long hospital stays and breathing and feeding problems). The remaining sensitivity of the otolith system to gravity and linear acceleration forces in these children could be exploited in early education programs to improve their posturomotor development.

Transnasal endoscopic repair of congenital defects of the skull base in children.

OBJECTIVE: To examine imaging findings and methods of endoscopic treatment of congenital skull base defects in children. DESIGN: Retrospective study and case series. SETTING: Academic tertiary care center. PATIENTS: Four patients (aged 12 and 14 months and 8 and 13 years) were included from 1995 to 1997. Three presented with a nasal glioma, which was recurrent in 1 case. The fourth patient presented with bacterial meningitis due to a spontaneous cerebrospinal fluid leak. Computed tomography and magnetic resonance imaging were used to locate the defect of the skull base. INTERVENTION: Transnasal endoscopic resection of the glioma or the meningocele, with immediate repair of the skull base defects using free mucosal flaps and/or pediculized mucosal flaps and/or conchal cartilage together with fibrin glue and nasal packing during a 3-week period. RESULTS: None of the 4 patients has experienced recurrent cerebrospinal fluid leaks or postoperative meningitis. CONCLUSIONS: The transnasal endoscopic repair of congenital meningoceles is a reliable technique in select pediatric patients. Computed tomography and magnetic resonance imaging provide information that can be used to help the surgical procedure.

Bacteremia during tonsillectomy.

To determine the risk of bacteremia during tonsillectomy, we cultured blood specimens that were taken from 32 children during surgery and tonsillar swabs that were obtained just before excision, and compared the results with quantitative cultures of the excised tonsillar tissue. Twenty-five children had Haemophilus influenzae within the tonsillar tissue (density range, 10(3) to 10(8) colony-forming units per gram), and seven had Streptococcus pyogenes (density, 10(3) colony-forming units per gram in one case, 10(5) colony-forming units per gram in one case, and 10(6) colony-forming units per gram in five cases). Twelve perioperative blood cultures were positive; H influenzae was found nine times, and Micrococcus species was found one time, and alpha-hemolytic streptococci were found two times. Haemophilus influenzae was always present in the corresponding tonsillar specimens, although there was no apparent relationship between the density of colonization of the tonsillar tissue and a positive blood culture.

The CHARGE association: the role of tracheotomy.

OBJECTIVES: To evaluate the need for a tracheotomy and its timing during the evolution of an association of malformations, including coloboma, heart defects, choanal atresia, developmental and growth retardation, genitourinary malformation, and ear anomalies (CHARGE association). DESIGN: Retrospective study from January 1988 through December 1997. SETTING: Four academic tertiary care centers. PATIENTS AND METHODS: Forty-five patients with CHARGE association having at least 3 cardinal malformations (growth retardation excluded) and review of the malformations and respiratory manifestations encountered. All the patients underwent endoscopic exploration on several occasions. We reviewed the nature and the timing of therapeutic interventions performed on the airway. RESULTS: Two patients died (one patient of septicemia, the other of unknown causes). Abnormalities of blood gas levels and/or sleep were found in 30 patients (67%), were responsible for cardiorespiratory arrest in 9 (20%), and required admission to the intensive care unit in 21 (47%). Pharyngolaryngeal anomalies leading to dyspnea (discoordinate pharyngolaryngomalacia, glossoptosis, retrognathia, laryngeal paralysis, cleft, stenosis, and difficult intubation) were found in 26 patients (58%). Tracheobronchial anomalies (esophagotracheal fistula, esophageal atresia, and tracheomalacia) were present in 18 patients (40%). Resection of the aryepiglottic folds was attempted 3 times, but without success. Tracheotomy was necessary in 13 patients (29%) at a median age of 2.4 months (mean duration, 25 months). Among these infants, the posterior nasal choanae were patent in 10 patients at the time of tracheotomy. Gastroesophageal reflux was encountered in 36 patients (80%). Prolonged enteral feeding was necessary in 21 patients (47%), with gastrostomy in 16 (of whom 9 needed a tracheotomy). These feeding difficulties and airway problems were highly correlated. CONCLUSIONS: We encountered multiple, complicated airway abnormalities. Resection of aryepiglottic folds was inadequate. Often, a tracheotomy could not be avoided in these patients, regardless of choanal patency. Tracheotomy needs to be performed early to avoid hypoxic events. In some selected patients, ventilation using bilevel positive airway pressure may be an alternative.

Cartilage tympanoplasty for posterosuperior retraction pockets of the pars tensa in children.

OBJECTIVE: To assess the functional and anatomic results of cartilage grafting in children with a severe retraction pocket of the posterosuperior part of the pars tensa and operated on by pocket excision and cartilage grafting. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Fifty six children (60 ears) with severe posterosuperior retraction pockets. INTERVENTION: Excision of the pocket and tympanic reinforcement with a tragal or conchal cartilaginous graft. MAIN OUTCOME MEASURES: Postoperative anatomic (otoscopy, computed tomography) and functional (pure tone audiometry thresholds) outcome. The follow-up time was 27 +/- 18 months (mean +/- SD). RESULTS: Retraction recurrences requiring additional surgery occurred in 5 cases (8%). The risk of recurrence was lower in children older than 10 years and when the whole surface of the pars tensa was reinforced (chi(2) test, p< 0.05 for both factors). Functionally, hearing was improved even when the ossicular chain was intact. In case of disrupted ossicular chain, direct contact between the graft and eroded incudostapedial joint gave good hearing results. CONCLUSIONS: Cartilage reinforcement of the whole surface of the pars tensa is probably the best treatment of a severe posterosuperior retraction pocket. The flexibility and thinness of cartilage from the cymba conchae makes it particularly suitable in this indication.

Surgical treatment for laryngeal paralysis in infants and children.

Clinical and endoscopic data of 219 cases of laryngeal paralysis in newborns, infants, and children are briefly reported. The management of severe cases of persistent dyspnea then is discussed, according to the literature. Of 219 cases, 22 young patients underwent a surgical procedure because of lack of spontaneous recovery and poor tolerance of their disease after 6 to 9 months of follow-up. Arytenoidectomy technique has been used three times and arytenoidopexy 19 times, with fair to excellent results. Other possible treatments for infants are discussed. On the basis of this important series of surgical pediatric cases, the arytenoidopexy technique is advocated, besides arytenoidectomy, to avoid the risks of a long-term tracheostomy in young patients with vocal cord paralysis and severe dyspnea.

Aryepiglottic fold excision for the treatment of severe laryngomalacia.

Laryngomalacia is the most common laryngeal anomaly. Clinical presentation is most often associated with stridor, which usually resolves spontaneously by the second year of life. Infrequently, laryngomalacia can be severe and cause dyspnea and feeding difficulties. These children require surgical treatment, including tracheostomy. A new procedure has been recently described for the endoscopic excision of the aryepiglottic folds. The authors report results in 39 patients who have been treated with this procedure. One failure required tracheostomy. No recurrence of dyspnea was noticed in the other children. Gastroesophageal reflux, associated with 50% of our cases, was also noted in our only failure. We advocate endoscopic treatment in children with severe laryngomalacia.

Congenital nasal pyriform aperture stenosis: diagnosis and management of 20 cases.

The objective of this study was to review the characteristics of congenital nasal pyriform aperture stenosis (CNPAS) in a series of 20 children seen between 1993 and 1996. The diagnosis was made by physical examination and computed tomography scan. A single central maxillary incisor was detected in 12 cases (60%). Three children had morphological abnormalities of the pituitary gland shown on magnetic resonance imaging. One child had an antidiuretic hormone deficiency, and another child had a growth hormone deficiency. Two children had craniosynostoses, 1 of which was Apert's syndrome. All patients underwent operation by a sublabial approach, and 1 was referred for a columellar necrosis after nasal stenting. After surgery, all patients showed improvement, and the nasal stenting was usually removed 1 week after surgery. Follow-up revealed normal breathing. In conclusion, CNPAS was previously considered to be an unusual cause of nasal obstruction in neonates and infants. The number of cases treated recently in our department suggests that this newly recognized entity is more common than expected.

Bilateral evoked otoacoustic emissions in a child with bilateral profound hearing loss.

Recording of bilateral evoked otoacoustic emissions in a 3-year-old girl with bilateral profound hearing loss is presented. No component of auditory-evoked brain stem potentials was recorded. Findings on computed tomography of the inner ear were within normal limits. At retest 3 months later, these results were unchanged. Explanations for this particular condition are presented together with a review of the literature.