Closed rhinoplasty approach for excision of nasal dermoids.

OBJECTIVE: To assess the efficacy of excision of nasal dermoids through a closed rhinoplasty incision. This is the first description of the use of this approach for excision of superficial nasal dermoids. METHODS: Three boys aged five, nine and 12 years presented with midline nasal dermoids with minimal cutaneous involvement. Magnetic resonance imaging demonstrated distinct, cystic, superficial nasal masses. The cysts were excised through a closed rhinoplasty approach. In each case, completeness of extirpation was judged by histopathological examination of the excised specimen. Aesthetic outcome was recorded photographically. RESULTS: All three patients' cysts were completely excised, with excellent cosmetic results. CONCLUSIONS: The closed rhinoplasty incision is another approach in the surgeon's armamentarium for excision of small, superficial nasal dermoid cysts. In well selected cases, this approach gives optimal cosmetic results, provides adequate exposure with minimal dissection, and allows total extirpation.

Paediatric eosinophilic oesophagitis presenting to the otolaryngologist.

INTRODUCTION: The prevalence of eosinophilic oesophagitis is increasing. A Pubmed search for 'eosinophilic oesophagitis' and 'eosinophilic esophagitis' yielded 345 publications since 1976. Only seven were in otolaryngology journals.1-7 Patients typically present with dysphagia, vomiting, dyspepsia or food impaction and are therefore usually referred to a paediatric gastroenterologist; otolaryngologists are not usually involved in management. A missed diagnosis may result in oesophageal stricture. METHODS: Two patients, aged two and four years, were referred to the paediatric otolaryngology department with intermittent upper oesophageal food impaction. A paediatric gastroenterologist was involved in the investigation. Histological examination of oesophageal biopsies demonstrated changes consistent with eosinophilic oesophagitis. RESULTS: Both patients were expediently diagnosed, investigated and managed. CONCLUSION: A diagnosis of eosinophilic oesophagitis must be considered in patients presenting with food bolus impaction. Early involvement of a paediatric gastroenterology team in the diagnosis is recommended in children presenting with oesophageal symptoms, in order to avoid delayed diagnosis.

Aneurysmal bone cyst of the spine.

The authors present the case of an 11-year-old boy with a painful, rapidly expanding lesion in the posterior triangle of the neck. There was no history of cervical trauma. Computerized tomography of the neck revealed a unicameral (single-chambered) aneurysmal bone cyst involving the C3 vertebra. Treatment was by open resection and curettage; no recurrence was seen at six months. We discuss the natural history, differential diagnosis, radiographic appearance and treatment modalities for this unusual, benign, expanding, osteolytic lesion containing blood-filled cystic cavities.

Solitary infantile myofibroma compromising the airway.

Infantile myofibromatosis is an uncommon and benign condition presenting in the neonatal period. It is self-limiting disease that may present as a localised or generalised process. Various examples of this entity have been reported in the literature. This report describes a neonate with a rapidly growing oropharyngeal lesion obstructing the airway that had the typical histological features of an infantile myofibroma. This case report highlights that a solitary myofibroma may be incredibly extensive making complete excision impossible and can be particularly challenging to manage in terms of airway stabilisation.

Surgical outcome after paediatric cochlear implantation: diminution of complications with the evolution of new surgical techniques.

OBJECTIVE: Cochlear implantation is a commonly performed surgical procedure with specific aspects in the paediatric population. The surgical outcome associated with this procedure in a paediatric population is analyzed. METHOD: A retrospective study was performed of all children receiving a cochlear implant at The Hospital for Sick Children from 1990 to 1998. During this period, 104 patients received a cochlear implant. RESULTS: The complications encountered were classified as major (4%), minor (3%), and device failure (2%). The surgical techniques developed to decrease complications are discussed. CONCLUSION: Paediatric cochlear implantation is a safe procedure with a low incidence of complications. Nevertheless, the surgeon is now facing new challenges with cochlear implantation performed in patients with an abnormal cochlea, who carry a higher rate of complications, and cochlear reimplantation in case of device failure.

Factors contributing to limited open-set speech perception in children who use a cochlear implant.

Cochlear implants have enabled many children with severe to profound sensorineural hearing loss to develop speech perception skills. However, some children experience few gains while others develop high levels of speech perception. We identified potential factors contributing to poor performance with an implant by studying implanted children who do not develop functional speech perception. Five children were identified as developing no open-set word recognition skills after at least 2 years of implant use. This study group was compared to a randomly selected control group (n=10) and an age-matched control group (n=5). Pre-implant factors were examined using a Graded Profile Analysis and post-implant factors were assessed in a retrospective chart review. A greater number of pre-implant concerns were raised in the study group than in randomized controls (P<0.01). Chronological age and duration of deafness were pre-implant concerns in all study group subjects. A greater number of post-implant concerns were found in the study group than in randomly selected controls (P<0.005). We conclude that while appropriate selection of candidates for cochlear implantation is important in predicting speech perception outcomes, post-implant follow-up is also essential and must include regular monitoring of equipment, monitoring of stimulation levels with use of objective measures of stimulation levels if necessary, and consistent habilitation.

Changes in educational placement and speech perception ability after cochlear implantation in children.

OBJECTIVE: The purpose of this study was to evaluate the effect and relationship of paediatric cochlear implantation on educational placement and speech perception ability and to determine the effect of a multilingual background on educational placement and speech perception ability after cochlear implantation. DESIGN: This study consisted of a retrospective chart review of 83 implanted patients and a questionnaire sent to parents of 80 implanted children. SETTING: This study was conducted in a cochlear implant program at a tertiary care centre. METHODS AND OUTCOME MEASURES: From the chart review, the educational placements and speech perception scores of implanted children were determined before and after implantation. In the questionnaire, parents were asked about their preferred educational placement for their child, the language spoken at home, and their impressions of the chosen school program for their child. RESULTS: Of the children who were in nonmainstream school programs at implantation (n = 30), 50% moved toward mainstream with 9 (30%) reaching mainstream placement. Of the children who were preschool at implantation (n = 34), 24 (70%) were placed or planned to be placed in mainstream after implantation. The rate of improvement in speech perception ability was significantly higher in those children who moved toward or remained in mainstream than those who stayed at the same nonmainstream educational placement or moved away from mainstream. Children from a multilingual background were able to achieve similar educational placements and similar rates of progress of speech perception outcome as the only English-speaking children. CONCLUSIONS: Children with cochlear implants have increased educational opportunities, with those children in mainstream and those who have moved toward mainstream demonstrating improved progress in speech perception ability.

Pediatric rhabdomyosarcoma of the head and neck: is there a place for surgical management?

OBJECTIVE: To review and evaluate the place of surgical treatment in the management of rhabdomyosarcoma of the head and neck in children. DESIGN: Retrospective analysis of patient charts from January 1, 1972, to December 31, 1998. SETTING: Tertiary pediatric referral center. PATIENTS: Twenty-nine consecutive children with nonorbital head and neck rhabdomyosarcoma. INTERVENTIONS: Surgery, chemotherapy, and radiotherapy. MAIN OUTCOME MEASURES: Disease-free survival and long-term morbidity from treatment. RESULTS: Twenty patients had parameningeal and 9 had nonparameningeal head and neck tumors. All were treated with chemotherapy. For 18 patients, diagnostic biopsies were performed and they received radiotherapy. Eleven patients underwent surgery as definitive therapy. Using the Intergroup Rhabdomyosarcoma Study (IRS) staging system, 5 of these 11 patients had complete resection of tumor (IRS group I) and avoided radiotherapy. The other 6 patients required radiation because of compromised, regional, or incomplete resection of tumor. One had undergone regional resection with nodal involvement, and 2 had compromised resections with microscopic residual disease (IRS group II). Three had incomplete resections with gross residual tumor (IRS group III). Only 1 patient who underwent surgery ultimately died from recurrence at 2.7 years after an incomplete resection. The other 10 patients were relapse free at a median follow-up of 3.7 years (range 0.8-21.0 years). Long-term surgical morbidity was seen in 36% (4/11) of the patients and included facial nerve paralysis, trismus, and cosmetic deformity. CONCLUSIONS: Children with localized disease of the head and neck are able to undergo complete surgical resection, with low long-term surgical morbidity. By undergoing complete surgical resection, these children are able to avoid radiotherapy and its long-term complications, with no compromise in survival.

Hypoxia depresses nitric oxide output in the human nasal airways.

OBJECTIVES: The role of oxygen in the nasal air on nasal nitric oxide (NO) output was studied in 13 adult volunteers. METHODS: Nasal NO was measured while air containing oxygen (0%-100% in nitrogen) was aspirated through the nasal airway before and after the topical application of xylometazoline. RESULTS: The mean nasal NO output of the untreated nose was 507.8 +/- 161.9 nL/min (mean +/- SD) when 21% oxygen was aspirated through the nasal cavities in series and remained unaltered by 100% O2 (P = .79). Below 10% oxygen the reduction in nasal NO output correlated positively and significantly with the decrease in oxygen concentration (r2 = 0.14). NO output was 245.2 +/- 153.4 nL/min at 0% oxygen, a significant decline from 21% oxygen (P < .0001). Nasal vasoconstriction induced by xylometazoline and alterations in the blood oxygen content by a maximal breath-holding or breathing 100% oxygen did not alter nasal NO in hypoxia (P = .41). CONCLUSIONS: Nasal NO output is markedly depressed in hypoxia and is oxygen dependent at concentrations of less than 10%. Approximately 50% of nasally generated NO is produced from oxygen in nasal air or regulated by it.

Pediatric vocal fold paralysis: a long-term retrospective study.

OBJECTIVE: To review our experience of pediatric vocal fold paralysis (VFP), with particular emphasis on etiological factors, associated airway pathologic conditions, and treatment and prognostic outcomes. DESIGN: Retrospective case review of a cohort of patients presenting with VFP. SETTING: Tertiary referral center. PATIENTS: A consecutive sample of 102 patients presenting with VFP to Great Ormond Street Hospital for Children, London, England, over a 14-year period from 1980 to 1994. RESULTS: There was an almost equal distribution of unilateral (52% [n = 53]) and bilateral (48% [n = 49]) VFP. Iatrogenic causes (43% [n = 44]) formed the largest group, followed by idiopathic VFP (35% [n = 36]), neurological causes (16% [n = 16]), and finally birth trauma (5% [n = 5]). Associated upper airway pathologic conditions were noted in 66% (n = 23) of patients who underwent tracheotomy. Tracheotomy was necessary in only 57% (n = 28) of children with bilateral VFP. Prognosis was variable depending upon the cause, with neurological VFP having the highest rate of recovery (71% [5/7]) and iatrogenic VFP the lowest rate (46% [12/26]). CONCLUSION: Recovery after an interval of up to 11 years was seen in idiopathic bilateral VFP; this has significant implications when considering lateralization procedures in these patients.

[Surgical techniques and complications of pediatric cochlear implantation]. / Technique chirurgicale et complications de l'implantation cochléaire pédiatrique.

INTRODUCTION: Cochlear implantation has been performed in children since 1980, with thousands of children already implanted. The incidence of complications is around 7 to 10% in the literature. METHODS: This is a retrospective study of all children receiving a cochlear implant at the Hospital for Sick Children over 9 years. Surgical technique and outcome are analysed. RESULTS: There were 7 complications, all successfully treated, and involving no further consequences. 4 reimplantations were performed for device failure. DISCUSSION: Paediatric cochlear implantation is associated with a low incidence of complications. In this series, no complications were encountered on reimplantation.

The role of a graded profile analysis in determining candidacy and outcome for cochlear implantation in children.

Assessment of candidacy for cochlear implantation in children continues to present a challenge to cochlear implant programs. The efficacy of implantation depends on a number of factors and as a result a multidisciplinary approach has been adopted. At the Cochlear Implant Program at The Hospital for Sick Children, Toronto, we use a graded profile analysis (GPA) which has been adapted from the Children's Implant Profile (CHIP) developed by Hellman (S.A. Hellman, P.M. Chute, R.E. Kretschmer, M.E., Nevins, S.C. Parisier, L.C. Thurston, The development of a Children's Implant Profile, Am. Ann. Deaf. 136 (1991) 77-81). This structured assessment allows each potential candidate to be 'scored' in each category of assessment giving a potential range of -14 to +14. In this retrospective study of 109 candidates we examine the relationship between GPA scores and decision to implant. For those patients who were implanted, the relationship between GPA score and speech perception outcomes was also evaluated. Three distinct groups of children emerged from the analysis. The first group had scores less than 5 and were not considered to be suitable for implantation. Within the second group who scored between 5 and 8, there was no clear relationship between decision to implant and score. The last group, who scored 9-14, was considered to be generally suitable for implantation provided that there were no medical contraindications and the parents consented to implantation. There was a significant association between rate of improvement of speech perception and GPA score. Those patients with scores of 9 to +14 improved at a faster rate than group 5-8 (P < 0.05). The implications of these findings are discussed.

Assessment of cochlear damage after pneumococcal meningitis using otoacoustic emissions.

Three cases are reported of children in Ghana with pneumococcal meningitis and differing degrees of hearing loss. The children were examined up to 12 d after admission by means of otoacoustic emissions. The technique is objective, non-invasive, quick (< 5 min per ear) and suitable for use in paediatric wards.

Otoacoustic emissions: assessment of hearing after tympanostomy tube insertion.

This study evaluates the use of transient evoked otoacoustic emissions as an alternative to pure tone audiometry for the assessment of hearing after tympanostomy tube insertion. Otoacoustic emissions and pure tone audiometry were carried out in 32 patients in whom tympanostomy tubes had been inserted. Otoacoustic emissions were detected in 78% of patients, whereas pure tone audiometry testing was only possible in 59%. Of 13 children who were 3 years of age or under, otoacoustic emissions could be measured in 62%, compared to pure tone audiometry which was only possible in 8%. Otoacoustic emission testing took on average 3 min, which was less than half the time for pure tone audiometry testing which took 7 min.

Vocal fold palsy after use of the laryngeal mask airway.

We report two cases of left vocal fold palsy following use of the laryngeal mask airway. In both cases anaesthesia was uneventful with a duration of about 60 minutes. It is proposed that high intra-cuff pressures induced during anaesthesia resulted in distension of the hypopharynx and subsequent neuropraxia of the motor branches of the recurrent laryngeal nerve and the external branch of the superior laryngeal nerve.