Paediatric tracheostomy tubes: recent developments and our current practice.

OBJECTIVE: A variety of paediatric tracheostomy tubes are available. This article reviews the tubes in current use at Great Ormond Street Hospital for Children and Evelina London Children's Hospital. METHODS: This paper outlines our current preferences, and the particular indications for different tracheostomy tubes, speaking valves and other attachments. RESULTS: Our preferred types of tubes have undergone significant design changes. This paper also reports further experience with certain tubes that may be useful in particular circumstances. An updated sizing chart is included for reference purposes. CONCLUSION: The choice of a paediatric tracheostomy tube remains largely determined by individual clinical requirements. Although we still favour a small range of tubes for use in the majority of our patients, there are circumstances in which other varieties are indicated.

Paediatric injection medialisation laryngoplasty: Recent Great Ormond Street Hospital experience.

INTRODUCTION: Unilateral vocal fold paresis may significantly impair the vocal quality and laryngeal competence of a child. Relatively little literature relates to injection medialisation laryngoplasty (IML) in children and previous reports have involved small numbers of heterogenous cases. METHODS: A retrospective review was conducted of paediatric patients managed by our multidisciplinary specialist voice clinic undergoing IML for unilateral vocal fold paresis. Cases of bilateral paresis, those characterised by vocal fold fixation, and patients without formal pre and post-operative voice evaluation were excluded. RESULTS: Eighteen IML procedures were performed in 12 children eligible for inclusion between 2005 and 2015. The average age at time of procedure was 12 years (range 9-15 years). Autologous fat was used in 5 procedures, succeeded by calcium hydroxylapatite (Radiesse® Voice) from 2011 (n = 13). A significant improvement in median GRBAS score components was observed after calcium hydroxylapatite injection in terms of grade (p = 0.008), breathiness (p = 0.002) and aesthenia (p = 0.016). A pre- and post-procedural Voice Handicap Index was self-completed by 6 patients receiving calcium hydroxylapatite injection; the median change in score was an improvement of 19 points (interquartile range 36.5). CONCLUSION: We describe the outcomes of a comparatively large paediatric series and have found IML using calcium hydroxylapatite to be a reliable technique associated with improved subjective outcome measures. Management of UVCP in the child is a challenge with particular investigative and interventional considerations. Further study supported by high quality subjective and, where possible, objective outcome measures, is required to better inform patient selection, timing of intervention and choice of injection material.

The bowel cancer awareness campaign 'Be Clear on Cancer': sustained increased pressure on resources and over-accessed by higher social grades with no increase in cancer detected.

AIM: To evaluate the impact of the national 'Be Clear on Cancer' bowel cancer reminder campaign on service and diagnosis at a single UK institution. Secondly, to evaluate the socio-economic background of patients referred before and after the reminder campaign compared with the regional demographic. METHOD: Suspected cancer 2-week wait patients in the 3 months precampaign, postcampaign and after the reminder campaign were included. Demographics, investigations and diagnosis were recorded. The postcode was used to allocate a National Readership Survey social grade. RESULTS: Three hundred and eighty-three referrals were received in the 3 months precampaign, 550 postcampaign and 470 postreminder campaign. There were significant increases in the monthly referral rates following the campaign (P < 0.001 in both the post- and postreminder periods). Significantly more patients from social grades AB and C1C2 than expected from regional demographics were referred precampaign and after the reminder campaign (P < 0.001 in each case). There were no significant differences between the proportions of patients diagnosed with colorectal cancer in the three study periods (P = 0.710). CONCLUSION: The 'Be Clear on Cancer' bowel cancer campaign has had a significant sustained impact on resources. It has failed to increase referrals among lower socio-economic grades, leading to an increase in 'worried well' referrals and no change in numbers, or the stage, of colorectal cancers diagnosed.

Peri-operative complications after adenotonsillectomy in a UK pediatric tertiary referral centre.

OBJECTIVES: Adenoidectomy and/or tonsillectomy are commonly performed in tertiary pediatric hospitals for the management of obstructive sleep apnea, often in children with significant comorbidities. This study examines the peri-operative course of a large series of complex patients undergoing such surgery at a major pediatric centre, reporting particularly cases of respiratory compromise requiring intensive care admission, both electively and unplanned. METHODS: This study was conducted by the pediatric ENT department at Great Ormond Street Hospital. All children undergoing adenoidectomy and/or tonsillectomy from July 2003 to December 2010 were included in this study. This involved a retrospective review of the case notes and hospital databases, with particular emphasis on those children requiring admission to the pediatric intensive care unit. RESULTS: A total of 1735 consecutive admissions for adenoidectomy and/or tonsillectomy (1627 individual patients aged 4-197 months, median 46 months) were included between 2003 and 2010 (998 adenotonsillectomies, 182 tonsillectomies and 555 adenoidectomies). In this group, 999/1627 patients (61.4%) had a diagnosis of sleep disordered breathing or sleep apnea, including 258 who had polysomnography. 407/1627 (25.0%) had no specific comorbidities which were felt likely to influence their surgical outcome. Established high risk factors included age less than 24 months (292), Down syndrome (99), neuromuscular problems (314), craniofacial abnormalities (94), storage diseases (23), morbid obesity (20), cardiovascular disease (133), respiratory disease (261), hemoglobinopathy (76) and coagulophathy (34). 300/1735 admissions were day cases and 1082/1735 were observed for one night. 353/1735 required more than one night in hospital (294 for two to three nights). 7/1735 had primary hemorrhage necessitating return to the operating room, all after tonsillectomy. 41/1735 (38 with major comorbidities) required peri-operative intensive care admission, mostly for respiratory support. Of these, 7 were admitted pre-operatively to intensive care, and 17 were planned post-operative transfers. Only 17/1735 required unanticipated post-operative admission to intensive care. Odds ratio analysis suggested a significantly higher chance of PICU admission in children with particular comorbidities (Down Syndrome, cardiac disease, obesity, cerebral palsy, craniofacial anomalies, mucopolysaccharidoses and hemoglobinopathy) when compared to children without comorbidities. Adenotonsillectomy was associated with a higher risk of PICU admission than adenoidectomy alone, but patient age less than 24 months was not associated with significantly higher rates of PICU admission. There were no peri-operative mortalities in this cohort. CONCLUSIONS: The peri-operative course was largely uneventful for the majority of children undergoing surgery during this period, particularly given the high prevalence of sleep apnea and other risk factors in this cohort. Major complications were uncommon, with 2.4% of these selected, typically high risk cases requiring peri-operative intensive care admission. Importantly, only 1% of all admissions required unanticipated transfer to intensive care. This has informed changes in peri-operative management in this unit, with implications for other pediatric tertiary referral centres.

MRI brain abnormalities in cochlear implant candidates: how common and how important are they?

OBJECTIVE: To investigate the incidence of abnormal findings on brain MRI in paediatric cochlear implantation candidates. METHODS: Retrospective review of brain MRI scans of cochlear implant patients between 2000 and 2009 who underwent MRI brain as part of their pre-operative work-up. RESULTS: MRI scans of 162 patients were reviewed (76 female patients and 86 male patients). The mean age at time of MRI scan was 3 years 8 months. Abnormalities were detected/ reported in 49 patients (30%). The total number of abnormalities detected was 51 (two patients had two separate abnormalities each). Of the abnormalities 82% could be related to known pre-existing conditions. 18% of the abnormalities were incidental/unexpected. Incidental/unexpected abnormalities were found in 9 patients (6%). Four of the patients with incidental abnormalities required referral and further investigations (2.5%). The most common abnormality detected was white matter changes (70%). All the white matter changes were related to pre-existing known medical conditions. CONCLUSION: At our institution abnormalities detected by pre-operative brain MRI scans on cochlear implant candidates are common (30%). The majority of abnormalities are related to known pre-existing medical conditions. Incidental findings are rare (4%) and approximately half of them required further investigation or referral.

Laryngotracheal reconstruction and cricotracheal resection in children: recent experience at Great Ormond Street Hospital.

BACKGROUND: Surgery for paediatric airway stenosis is constantly evolving. Surgery is the primary treatment modality via either an open or endoscopic approach. The objective of this study was to review the results of laryngotracheal reconstruction (LTR) and cricotracheal resection (CTR) procedures performed at Great Ormond Street Hospital over the past 10 years. METHODS: All patients who underwent open airway reconstruction surgery from January 2000 to December 2010 were included in this study. Patients treated entirely endoscopically were excluded. The data was collected using the electronic operating theatre database and the discharge summary database. RESULTS: Complete data was available for 199 patients who underwent open airway reconstruction from January 2000 to December 2010. The procedures included single stage LTR (57, 28.6%), two stage LTR (115, 57.7%), single-stage stomal reconstruction (14), single-stage CTR (8) and two-stage CTR (5). The diagnoses at the initial airway endoscopy were laryngeal web (22), subglottic stenosis (151), posterior glottic stenosis (9), suprastomal collapse (15), supraglottic stenosis (1) and tracheal stenosis (1). For those with subglottic stenosis, the stenosis was grade 1 in 1 patient, grade 2 in 26 patients, grade 3 in 117 patients and grade 4 in 6 patients. At the completion of intervention 175/199 (87.9%) patients reported improvement in their symptoms. Amongst the subglottic stenosis group, post LTR success was achieved in 100% with grade 1 stenosis, 92.3% with grade 2 stenosis, 88.1% in grade 3 stenosis and 83.3% in grade 4 stenosis. Of the two-stage LTR procedures, 100/115 (86.9%) had their tracheostomy removed and 15/115 (13.1%) have failed decannulation. Of the single-stage LTR group, 50/57 (87.7%) patients were better both on airway examination and symptomatically postoperatively. Of the single-stage stomal reconstruction group, 13/14 (92.8%) were better symptomatically and on airway examination. Patients who underwent single-stage CTR had a better airway on examination and were symptomatically improved in all cases (8/8). For the patients who underwent two stage CTR, the tracheostomy was removed in 3/5 (60%) and retained in 2/5 (40%). For the whole group, 15/199 (7.5%) patients underwent a revision LTR. On further analysis, revision LTR was required in 4/57 (7.1%) single-stage LTR, 9/115 (7.8%) two-stage LTR, 1/5 (20%) two-stage CTR and 1/8 (12.5%) single-stage CTR. In this study complications occurred in 13/199 (6.5%). CONCLUSIONS: Subglottic stenosis in children needs to be approached on the basis of the nature and severity of stenosis and the individual patient's general health. Good outcomes are achieved with both LTR and CTR. Good results are obtained both with single-stage and two-stage LTR, but restenosis remains a problem. An individual approach is required for treatment of paediatric airway stenosis to achieve good final outcomes. The overall success rate has increased only marginally in our institution over the last 20 years.

Branchial anomalies in children.

BACKGROUND: Branchial cleft anomalies are the second most common head and neck congenital lesions seen in children. Amongst the branchial cleft malformations, second cleft lesions account for 95% of the branchial anomalies. This article analyzes all the cases of branchial cleft anomalies operated on at Great Ormond Street Hospital over the past 10 years. METHODS: All children who underwent surgery for branchial cleft sinus or fistula from January 2000 to December 2010 were included in this study. RESULTS: In this series, we had 80 patients (38 female and 42 male). The age at the time of operation varied from 1 year to 14 years. Amongst this group, 15 patients had first branchial cleft anomaly, 62 had second branchial cleft anomaly and 3 had fourth branchial pouch anomaly. All the first cleft cases were operated on by a superficial parotidectomy approach with facial nerve identification. Complete excision was achieved in all these first cleft cases. In this series of first cleft anomalies, we had one complication (temporary marginal mandibular nerve weakness. In the 62 children with second branchial cleft anomalies, 50 were unilateral and 12 were bilateral. In the vast majority, the tract extended through the carotid bifurcation and extended up to pharyngeal constrictor muscles. Majority of these cases were operated on through an elliptical incision around the external opening. Complete excision was achieved in all second cleft cases except one who required a repeat excision. In this subgroup, we had two complications one patient developed a seroma and one had incomplete excision. The three patients with fourth pouch anomaly were treated with endoscopic assisted monopolar diathermy to the sinus opening with good outcome. CONCLUSION: Branchial anomalies are relatively common in children. There are three distinct types, first cleft, second cleft and fourth pouch anomaly. Correct diagnosis is essential to avoid inadequate surgery and multiple procedures. The surgical approach needs to be tailored to the type of anomaly of origin of the anomaly. Complete excision is essential for good outcomes.

Parotid duct ligation for treatment of drooling in children with neurological impairment.

OBJECTIVE: Multiple surgical procedures have been advocated for the management of problematic drooling in neurologically impaired children. Parotid duct ligation is a quick and simple operation conducted via an intra-oral approach and usually performed simultaneously with other procedures. In this study, we aimed to evaluate the effectiveness of parotid duct ligation as a discrete procedure. METHODS: All children who underwent bilateral parotid duct ligation as the solitary operative intervention at that time, between February 2003 and September 2006, were included in the study. RESULTS: Ten children were studied. Surgery was successful in 80 per cent of cases. One patient (10 per cent) had a post-operative wound infection. CONCLUSIONS: Bilateral parotid duct ligation is an effective yet conservative operation for drooling in neurologically impaired children. It requires minimal surgical dissection and has a low morbidity rate. It should be considered as a potential first-line procedure in children who aspirate, and as a further surgical option in anterior droolers or those who continue to drool unacceptably following prior surgical intervention.

Do you get value for money when you buy an expensive pair of running shoes?

OBJECTIVE: This investigation aims to determine if more expensive running shoes provide better cushioning of plantar pressure and are more comfortable than low-cost alternatives from the same brand. METHODS: Three pairs of running shoes were purchased from three different manufacturers at three different price ranges: low (40-45 pounds), medium (60-65 pounds) and high (70-75 pounds). Plantar pressure was recorded with the Pedar in-shoe pressure measurement system. Comfort was assessed with a 100 mm visual analogue scale. A follow-on study was conducted to ascertain if shoe cushioning and comfort were comparable to walking while running on a treadmill. Forty-three and 9 male subjects participated in the main and follow-on studies, respectively. The main outcome measure was the evaluation of plantar pressure and comfort. RESULTS: Plantar pressure measurements were recorded from under the heel, across the forefoot and under the great toe. Differences in plantar pressure were recorded between models and between brands in relation to cost. Shoe performance was comparable between walking and running trials on a treadmill. No significant difference was observed between shoes and test occasions in terms of comfort. CONCLUSIONS: Low- and medium-cost running shoes in each of the three brands tested provided the same (if not better) cushioning of plantar pressure as high-cost running shoes. Cushioning was comparable when walking and running on a treadmill. Comfort is a subjective sensation based on individual preferences and was not related to either the distribution of plantar pressure or cost.

Foot pressure in clubfoot--the development of an objective assessment tool.

BACKGROUND: There are no universal criteria for the assessment of clubfoot. The ideal method should assess functional deformity reliably and objectively. Biomechanical techniques have also been suggested but their role remains undefined. OBJECTIVE: This study aimed to assess surgically corrected clubfeet by biomechanical means with the intention to develop certain ratios to aid in objective assessment. METHODS: Thirteen children (16 feet) with idiopathic clubfoot, who had previously undergone surgery (lateral-posteromedial release), were reviewed. Various clinical measurements were collected and symptoms assessed using a specially designed questionnaire. Biomechanical (foot pressure) parameters were obtained using two systems: Podotrack and Dynamic Pedobarograph. RESULTS: The results showed that foot pressure data were able to demonstrate abnormalities in foot posture and pressure distribution, which could objectively identify clubfoot deformities. In particular, ratios were calculated, which could be used to determine severity and monitor progression. CONCLUSION: This study suggests that foot pressure analysis should be routinely used in the assessment of clubfoot. The ratios calculated would be of immense help to the clinicians in monitoring the success of treatment and for early prediction of relapse in patients treated for clubfoot.

Normal pressure values and repeatability of the Emed ST4 system.

The aims of this study were to assess the repeatability of the Emed ST4 system and identify the range of pressure values observed in the normal foot. Fifty-three healthy subjects, 17 females (32%) and 36 males (68%), were recruited. Measurements were performed on two occasions approximately 12 days apart. Peak pressure (PP), contact area (CA), contact time (CT), pressure-time integral (PTI), force-time integral (FTI) and instant of peak pressure (IPP) were recorded. The coefficient of repeatability (CR) was less than 16.9% for all 122 parameters considered. The highest areas of PP were found under the second and third metatarsal heads, with mean (S.D.) equal to 361 kPa (104) and 330 kPa (84), respectively, followed by the great toe 321 kPa (141) and heel 313 kPa (77). CA was highest under the heel at 35 cm(2) (5). The percentage CT was in the range 75-85% under the metatarsal heads, and 70% under the hallux. PTI was highest under metatarsal heads one to three and hallux. FTI was highest under the heel. Emed ST4 system was found to be repeatable. The ranges of the parameters documented can be applied in orthopaedic clinics as part of the assessment of pathological conditions.

Choosing a paediatric tracheostomy tube: an update on current practice.

OBJECTIVES: A variety of paediatric tracheostomy tubes are available. This article reviews those in current use at Great Ormond Street Hospital. METHODS: We outline our preferences and the particular indications for the different tubes, speaking valves and other attachments. RESULTS: Practice has changed significantly in recent years. One product has been re-sized by its manufacturer; others are no longer commonly used. An updated sizing chart is included for reference purposes, together with manufacturers' contact details. CONCLUSIONS: The choice of paediatric tracheostomy tube is driven by clinical requirements. A small range of tubes are suitable for the majority of children, but some will require other varieties in specific circumstances.

Off-the-shelf in-shoe heel inserts: does cost matter?

OBJECTIVE: A growing exercise culture has lead to an increase in the use of off-the-shelf heel inserts. While there are a variety of designs in a spectrum of cost ranges, probably the ease of availability and cost would mainly determine the choice of purchase. This study was designed to determine whether expensive designs provide better pressure attenuation under the heel than their less expensive counterparts. PARTICIPANTS AND DESIGN: Six brands of off-the-shelf heel inserts were tested. Selection of these was based purely on their availability in all sizes. Cost per pair ranged from 6 pounds sterling to 30 pounds sterling. Thirty-five asymptomatic subjects walked on a 10 m walkway, once with no inserts and once with each pair of inserts. The Pedar in-shoe system recorded a range of parameters under the heel. SETTING: Institute of Motion Analysis and Research, Ninewells Hospital and Medical School, University of Dundee. MAIN OUTCOME MEASURES: Evaluation of plantar pressure parameters under the heel. RESULTS: All inserts reduced peak pressure under the heel. Maximum force and pressure-time integral also decreased. Contact time generally increased with the use of inserts. Values of contact area with and without inserts were comparable. CONCLUSIONS: No significant differences were observed under the heel between the pressure attenuation properties of the lowest-priced and the most expensive designs, and hence the less expensive inserts can be considered as good as the expensive brands. However, the endurance power of these inserts may differ and this should be evaluated.

Blood volume and protein responses to skin heating and cooling in resting subjects.

The effects of alterations in skin temperature on intravascular volume and protein content have been investigated in resting subjects. With a normal core temperature (Tac) both skin cooling and skin heating caused hemoconcentration, and heating was associated with an increased rate of protein loss from the intravascular space. Raising of the skin temperature after cooling, with Tac depressed, and cooling of the skin after heating, with Tac raised, were associated with an immediate reversal of the hemoconcentration, and gain of protein by the intravascular space. It is concluded that intravascular volume responses to thermal stress are dependent on the skin and core temperatures obtaining immediately prior to imposition of the stress and that, in particular, a low skin temperature predisposes toward hemodilution on subsequent exposure to heat; sweating per se does not necessarily result in hemoconcentration. The association of hemodilution with augmentation of intravascular protein, and the rapidity with which extravascular protein can apparently gain entry to the intravascular space, is taken as indicating a possible direct return of protein through capillary walls.

Variability of response to hypnotics: sleep studies in man.

Effect of diazepam on sleep in man was investigated in a series of placebo controlled studies and the data on various measures from two groups (young adults and middle age) were retrospectively analysed. Variability of the measures between the two groups with placebo was not different, but the variability of their response to the drug was different, and that of the middle aged group was high. In the young adults there were drug effects, but in the middle aged group no drug effects could be established. The studies suggest that variability of data must be taken into consideration when it is used to indicate the most appropriate dose range. If the variability of response is low the data may indicate the likely effect of the drug on each individual. On the other hand if the variability is high then data obtained from analysis of the group may have limited relevance, and suggest doses which are too high for the majority of the individuals within that group.

Blood volume and protein responses to skin cooling and warming during cycling exercise.

The effects of alterations in mean skin temperature (Tsk) on intravascular volume and protein responses to 90 min of bicycle ergometer exercise have been studied in six male subjects. The onset of exercise was accompanied by an initial rapid haemoconcentration, followed by a slower, progressive haemoconcentration as core and skin temperatures increased. Cooling the skin after 30 min of exercise abolished the slow haemoconcentration, and thereafter, even when Tsk was raised to the pre-exercise level during the final 30 min of exercise, little further change in blood volume was observed. During skin warming, and during recovery from exercise, there was an increase in the total intravascular protein content compared with before exercise. It is concluded that the progressive haemoconcentration often described during cycling exercise may be attributed to an increase in skin blood flow occurring as a result of rises in core and skin temperature, the associated increase in filtration through the cutaneous capillaries causing a progressive loss of plasma volume. The mechanism of the augmentation of intravascular protein remains unclear.

Effect of saline loading during heat acclimatization on adrenocortical hormone levels.

Six male subjects were acclimatized to heat; once they were given sufficient 1% saline to prevent the occurrence of a salt deficit during acclimatization, and another time they were given no saline. Plasma aldosterone (PA), plasma cortisol (PC), plasma renin activity (PRA), and plasma electrolytes were measured before, during, and after and sweat electrolytes before and after the 11-day acclimatization program. PRA and PA were significantly increased by the acute stress of heat and exercise but were unaffected by acclimatization. These increases were attenuated, but not prevented, by drinking saline, whereas sweat [Na] and PC were reduced by acclimatization but were unaffected by saline. Thus adrenocortical activity has been shown not to be increased after heat acclimatization, and mineralocorticoid activity, although potentiated by a Na deficit, appears to be determined primarily by the acute stress of heat and of exercise. Hence, the increased Na conservation with acclimatization is likely to be a normal response to heat and exercise even in the absence of a negative Na balance.

Blood volume and plasma protein responses to heat acclimatization in humans.

The effects of heat acclimatization on intravascular volume and protein responses to acute heat stress and exercise were studied in six male subjects. Absolute values for hematocrit and hemoglobin concentration were lower after, than before, acclimatization, indicating hemodilution. Also, after acclimatization, the magnitude of the hemoconcentration response to exercise in the heat was significantly increased. There ws no change in the concentration of plasma protein during or after acclimatization compared with before acclimatization, but there was a net increase in the total intravascular protein content. It is suggested that the hemodilution associated with heat acclimatization may be explained in terms of an increase in the intravascular oncotic pressure following an exercise-induced augmentation of protein, occurring at the expense of the interstitial compartment. It is concluded that this hemodilution is unlikely to be primarily responsible for the cardiovascular adjustment accompanying heat acclimatization and that it should be regarded as a secondary feature of adaptation to heat.

Maximal oxygen uptake: its measurement, application, and limitations.

Maximal aerobic power (VO2 max) was determined by direct measurement in 10 male subjects whilst exercising on a bicycle ergometer, and whilst running uphill on a treadmill at speeds of 10 and 12 km/h. There was no significant difference between VO2 max measured at the two treadmill speeds, but the VO2 max measured on the bicycle was 20% lower than on the treadmill. An estimate of the variance of the treadmill determined VO2 max was obtained from repeated measurements on five subjects. The 95% tolerance interval about a single measurement of VO2 max was +/- 7.8 ml.kg-1.min-11. It is recommended that when indirect methods for determining VO2 max are calibrated against the direct method, the latter should be based upon the treadmill. Reservations are expressed concerning the value of the direct method for determining VO2 max, and of the concept of VO2 max as a measure of physical fitness.

A comparison of some indirect methods for predicting maximal oxygen uptake.

Nine male subjects took part in a comparative evaluation of four indirect tests commonly used for predicting maximum aerobic power (VO2 max). In three of these tests (involving cycling, stepping and walking) VO2 max was predicted from submaximal heart rates; in the fourth, VO2 max was predicted from the time taken to run 2 km. Additionally, VO2 max was predicted from the body fat content. All predicted values were compared with the VO2 max determined directly on a treadmill. The best estimates of VO2 max were provided by the timed run, and by the step test. Both heart rate measured during walking and body fat content proved totally inadequate for the reliable prediction of VO2 max. Taking into account such factors as cost, safety, and the time required for testing, it is concluded that the timed run is the submaximal test most suited to the indirect determination of VO2 max.