Role of anxiety in young children's pain memory development after surgery.

Pediatric pain is common, and memory for it may be distressing and have long-lasting effects. Children who develop more negatively biased memories for pain (ie, recalled pain is higher than initial pain report) are at risk of worse future pain outcomes. In adolescent samples, higher child and parent catastrophic thinking about pain was associated with negatively biased memories for postsurgical pain. This study examined the influence of child and parent anxiety on the development of younger children's postsurgical pain memories. Seventy-eight children undergoing a tonsillectomy and one of their parents participated. Parents reported on their anxiety (state and trait) before surgery, and trained researchers observationally coded children's anxiety at anaesthesia induction. Children reported on their postsurgical pain intensity and pain-related fear for 3 days after discharge. One month after surgery, children recalled their pain intensity and pain-related fear using the same scales previously administered. Results revealed that higher levels of postsurgical pain and higher parent trait anxiety predicted more negatively biased memories for pain-related fear. Parent state anxiety and child preoperative anxiety were not associated with children's recall. Children who developed negatively biased pain memories had worse postsurgical pain several days after surgery. These findings underscore the importance of reducing parental anxiety and effective postsurgical pain management to potentially buffer against the development of negatively biased pain memories in young children.

The significance of Streptococcus anginosus group in intracranial complications of pediatric rhinosinusitis.

OBJECTIVE: To assess the significance of the Streptococcus anginosus group in intracranial complications of pediatric patients with rhinosinusitis. DESIGN: Retrospective cohort study. SETTING: Tertiary pediatric hospital. PATIENTS: A 20-year review of medical records identified patients with intracranial complications resulting from rhinosinusitis. In the 50 cases identified, S anginosus was the most commonly implicated bacterial pathogen in 14 (28%). Documented data included demographics, cultured bacteria, immune status, sinuses involved, type of intracranial complication, otolaryngologic surgical and neurosurgical intervention, type and duration of antibiotics used, and resulting neurologic deficits. Complications and outcomes of cases of S anginosus group-associated rhinosinusitis were compared with those of other bacteria. MAIN OUTCOME MEASURES: The severity and outcomes of intracranial complications of pediatric rhinosinusitis due to S anginosus group bacteria compared with other bacteria. RESULTS: Infection caused by the S anginosus group resulted in more severe intracranial complications (P = .001). In addition, patients with S anginosus group-associated infections were more likely to require neurosurgical intervention (P < .001) and develop long-term neurologic deficits (P = .02). Intravenous antibiotics were administered for a longer duration (P < .001) for S anginosus group-associated infections. CONCLUSIONS: Rhinosinusitis associated with the S anginosus group should be considered a more serious infection relative to those caused by other pathogens. Streptococcus anginosus group bacteria are significantly more likely than other bacteria to cause more severe intracranial complications and neurologic deficits and to require neurosurgical intervention. A low threshold for intervention should be used for infection caused by this pathogen.

Wound complications after cleft repair in children with Van der Woude syndrome.

Van der Woude syndrome (VWS; OMIM 119300) is an autosomal-dominant condition associated with clefts of the lip and/or palate and lower lip pits and is caused by mutations in interferon regulatory factor 6 (IRF6). The standard of practice for children born with cleft lip/palate is surgical repair, which requires proper wound healing. We tested the hypothesis that children with VWS are more likely to have wound complications after cleft repair than children with nonsyndromic cleft lip/palate (NSCLP). Furthermore, we hypothesized that children with VWS have more surgical procedures. A retrospective, case-controlled study was performed. Seventeen children with VWS and 68 matched controls with NSCLP were scored for the presence of wound complications after cleft repair, for the severity of complications, and for number of surgeries from age 0 to 10. Of the 17 children with VWS, 8 had wound complications. Of 68 controls, 13 had wound complications (P = 0.02). Of 8 wound complications in the VWS group, 6 were major, whereas of 13 complications in the control group, 9 were major (P = 0.04). Most wound complications were fistulae and occurred in isolated cleft palate and bilateral cleft lip. The mean number of surgeries in the VWS group was 3.0 compared with 2.8 in the control group (P = 0.67). Our studies suggest that children with VWS have an increased risk for wound complications after cleft repair compared with children with NSCLP. Furthermore, these data support a role for IRF6 in wound healing.

Unilateral vocal fold paralysis in premature infants after ligation of patent ductus arteriosus: vascular clip versus suture ligature.

OBJECTIVES: We investigated risk factors associated with unilateral iatrogenic vocal fold paralysis (IVFP) in the context of ligation of patent ductus arteriosus (PDA) and compared the rates of paralysis between vascular clip and suture ligation procedures. METHODS: We performed a prospective examination of infants with isolated PDA treated surgically during 1995 to 2005. Statistical significance was determined with a 2-tailed t-test. RESULTS: Of 68 PDA ligations, 13 cases of left-sided IVFP were diagnosed, for an overall incidence of 19%. All cases of IVFP occurred in 55 infants who weighed less than 1 kg at birth. Suture ligature was used in 60% of all PDA ligation patients, and vascular clips in 40%. The incidence of IVFP in patients with vascular clips (19%) was similar to the incidence in those with suture ligature (20%). Hoarseness or stridor was present in 69% of patients with IVFP, compared to 17% of normal controls (p <0.001). The rate of aspiration was not increased in the IVFP group; however, 15% of the patients with IVFP had episodes of decreased oxygen saturation, versus 7% of infants with normal vocal fold mobility. CONCLUSIONS: A hoarse infant with a birth weight of less than 1 kg who has undergone PDA ligation should be examined for unilateral IVFP. Vascular clips and suture ligature are associated with similar rates of IVFP.

Chronic cough and tonsillar hypertrophy: a case series.

Two patients with intractable chronic cough were found to have tonsillar tissue impinging on their epiglottis. In both case, tonsillectomy was curative. The observations in these patients are consistent with a previous report indicating chronic cough from the uvula in contact with the epiglottis with cough cessation following uvulectomy.

Median labiomandibular glossotomy approach to the craniocervical region.

INTRODUCTION: In children as well as adults, adequate access to the craniocervical junction and upper cervical vertebra can usually be achieved with a transoral-transpalatopharyngeal route. However, when access is necessary to achieve the C5 level and the upper cervical spine in children, this is very difficult. This is particularly so when the incisor opening is less than 2.5 cm. The median labiomandibular glossotomy provides such an approach. MATERIALS AND METHODS: Our experience with five children is presented in a representative case: a 4-year-old male with a family history of spondyloepiphyseal dysplasia presented with mild quadriparesis, 2 years earlier. This had rapid progression with severe upper cervical kyphosis. A standard transoral-transpalatopharyngeal approach or a lateral extrapharyngeal approach would not achieve exposure of the pathology. Hence, a median labiomandibular glossotomy was utilized for ventral decompression with an anterior interbody fusion between C2 and C4. Crown halo cervical traction was placed intraoperatively before a tracheostomy and tonsillectomy. A median labiomandibular glossotomy was then made with resection of the displaced odontoid process and the vertebral bodies of C3 and C4. This was followed by an anterior interbody fusion between the C2 and C4 vertebrae with costal rib grafts. RESULT AND CONCLUSION: He was successfully decannulated during the second postoperative week upon resolution of lingual edema. A planned staged dorsal occipitocervical fusion was performed 6 months later, at which time the ventral fusion was quite solid. He had full neurological recovery.

Cochlear implantation in deafness-dystonia-optic neuronopathy (DDON) syndrome.

To report the results of the first known cochlear implantation in a patient with deafness-dystonia-optic neuronopathy (DDON) syndrome (Mohr-Tranebaerg syndrome, DFN-1). DDON syndrome is an X-linked condition characterized by postlingual sensorineural hearing loss in early childhood followed by dystonia, psychosis, and optic atrophy in adolescence and adulthood. The gene responsible for the condition maps to Xq22 adjacent to the gene causally related to X-linked agammaglobulinemia. The audiometric characteristics of DDON syndrome are typical of auditory neuropathy, with spiral ganglion cells being the suspected site of pathology. Performance following cochlear implantation in auditory neuropathy patients is variable and has yet to be reported in any patients with DDON syndrome. The reported case describes a male initially diagnosed with X-linked agammaglobulinemia due to recurrent infections. Speech, language and hearing were typical of a child in the first year of life; however profound hearing loss developed and cochlear implantation was performed at age 4. Following implantation, further genetic workup determined that the patient carries a deletion that includes BTK and DDP1/TIMM8a, consistent with the diagnosis of X-linked agammaglobulinemia and DDON syndrome. The patient's performance with the cochlear implant was marginal even after 2 years of use, with continued poor scores in standardized speech, language and audiometric tests. Additionally, his most-comfortable-level implant setting requires higher-than-normal current applied to the electrode array. This case report supports other studies showing that DDON syndrome results in an auditory neuropathy. Further investigation is required to determine the efficacy of cochlear implantation in this patient population. DDON syndrome should be considered in patients with X-linked agammaglobulinemia and hearing loss.

Surgical correction of congenital lower lip sinuses in Van der Woude syndrome.

OBJECTIVE: To review the clinical outcome for patients with Van der Woude syndrome undergoing surgical excision of congenital lip sinuses. DESIGN: Retrospective chart review. SETTING: Multidisciplinary cleft-craniofacial team within a tertiary care hospital. PATIENTS, PARTICIPANTS: Seventeen patients with Van der Woude syndrome were identified from hospital records as having cleft lip and/or palate surgery performed at the University of Iowa, and six of these patients underwent simple surgical excision of lower lip sinuses. MAIN OUTCOME MEASURES: Incidence of postoperative complications and number of surgeries required per patient for correction of lower lip defect. RESULTS: All six patients undergoing surgical excision of lip sinuses had postoperative mucocele formation. These uniformly required one or two further surgeries for correction. There were no other complications associated with the procedures and no patient had a pre- or postoperative whistling deformity. Cosmetic outcome was thought to be satisfactory in all cases. CONCLUSIONS: Despite the overall improvement in cosmetic appearance following simple surgical excision of congenital lower lip sinuses, the high rate of mucocele formation and repeat surgery has led to cautious preoperative counseling regarding the risks and benefits of the procedure.

H-type congenital tracheoesophageal fistula: University Of Iowa experience 1985 to 2005.

OBJECTIVES: We review the diagnostic workup, associated disorders, surgical technique, and postoperative course of patients who underwent repair of H-type tracheoesophageal fistulas. METHODS: We performed a retrospective chart review of patients who received a diagnosis of tracheoesophageal fistula at the University of Iowa. RESULTS: Seven patients with an H-type tracheoesophageal fistula and a single patient with a missed proximal fistula associated with esophageal atresia were identified. Their symptoms included coughing with feeding, recurrent pneumonia, and episodic cyanosis. A delay in diagnosis was seen in 4 patients and ranged from 2.5 months to 5.9 years. In all patients, the diagnosis was made with an esophagogram. The level of the fistulas was between C5 and T3, and all were successfully repaired via a right cervical approach. CONCLUSIONS: A high index of suspicion for an H-type tracheoesophageal fistula should be maintained in the presence of neonatal respiratory symptoms, as the condition can be associated with a delay in diagnosis. Repeat esophagograms and bronchoscopy may be required for diagnosis. In the postoperative period, airway obstruction is a potential risk; however, long-term difficulty with swallowing, respiration, and phonation was not observed.

Prospective randomized trial comparing the effect of early suturing of tracheostomy sites on postoperative patient swallowing and rehabilitation.

PURPOSE: This study was designed to evaluate the effect of tracheostomy site suturing after decannulation on swallowing rehabilitation, the incidence of postoperative complications, the length of hospital stay, and overall cost saving in patients undergoing major head and neck cancer resections. DESIGN: Prospective, randomized, blinded, controlled clinical trial. METHODS: Seventy-five patients undergoing major head and neck cancer resections were block randomized to have their tracheostomy site sutured or not sutured at the time of decannulation. Two blinded speech-language pathologists conducted bedside swallowing assessments immediately after decannulation. Patients resumed oral feedings if they passed; otherwise, the assessment was repeated daily until they were able to resume oral feedings or required a G-tube. OUTCOME MEASURES: We monitored (1) time intervals during the admission from surgery to discharge, (2) the rate of aspiration, (3) complications, and (4) cost savings. RESULTS: Significant differences were seen in the mean time from decannulation and commencement of swallowing (suture arm, 0.58 days; nonsuture arm, 2.7 days; p = .013). There was also a significant difference seen for the time interval from decannulation to discharge from hospital (suture arm, 5.5 days; nonsuture arm, 8.3 days; p = .045) and for overall duration of hospital stay (suture arm, 14.6 days; nonsuture arm, 19.3 days; p = .025). The cost saving per patient in the suture group averaged $11 609, which translates to a yearly saving of 742 976 dollars. CONCLUSION: The suturing of the tracheostomy site in head and neck cancer patients after decannulation is a safe, effective, cost-saving manoeuvre that speeds the return of the patient's normal swallowing, promoting earlier discharge from the hospital.

Reovirus salvage of squamous cell cancer-contaminated wounds.

PURPOSE: To assess the susceptibility of human squamous cell carcinoma to reovirus infection in vitro and in vivo using a murine model of cancer-contaminated wounds. METHODS: The University of Michigan squamous carcinoma 22B cell line was cultured and inoculated with reovirus in vitro. The effect of the reovirus was assessed with microscopy and a standard 3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2H tetrazolium bromide (MTT) assay. We used the previously established cancer-contaminated wound SCID mouse model to test saline and reovirus irrigation in vivo. Fifty-five mice were used; 15 were controls, 20 had immediate irrigation, and 20 had delayed irrigation. Surgical sites were assessed for palpable tumour biweekly. RESULTS: The microscopy and MTT assay both showed evidence of reovirus-mediated squamous cancer cell lysis. The control mice grew palpable tumours in 80% of the wounds. Immediate irrigation with saline delayed the onset of palpable tumour and demonstrated a persistent reduction in the rate of development of palpable tumours (p = .004 compared with controls). This effect disappeared when the saline irrigation was delayed, resulting in a tumour development rate that was not significantly different from that of the control. Wounds that were irrigated with reovirus, both immediately and delayed, did not produce palpable tumour (p < .0005 when compared with controls). CONCLUSIONS: (1) The University of Michigan squamous cell carcinoma 22B cell line is susceptible to reovirus in vitro. (2) Immediate irrigation with saline resulted in a significant delay in clinically evident tumour growth and a reduction in the rate of tumour development in the SCID mouse model. (3) The reovirus irrigation resulted in a significant reduction of tumour development in both the immediate and delayed groups in the SCID mouse model. (4) The efficacy of the reovirus irrigation in the delayed group suggests that the major mechanism of action is through a selective and specific targeting of implanted cancer cells.