Subglottic stenosis: evaluation and management.

Surgical correction of subglottic stenosis aims to provide an adequately enlarged lumen while preserving vocal quality and airway protection. Treatment success is predicted upon a thorough preoperative evaluation and tailoring the repair to address the severity and location of the individual lesion. Understanding the complex pathophysiology of subglottic stenosis along with the wide variety of available surgical options will aid the surgeon in achieving a successful outcome.

Posterior laryngeal cleft.

The posterior laryngeal cleft is a rare congenital anomaly which results from absence of fusion of the posterior cricoid lamina and possibly the tracheoesophageal septum. A high degree of suspicion is required for early diagnosis and repair to prevent significant morbidity and mortality from recurrent aspiration pneumonia. Minor clefts may be repaired endoscopically, whereas severe laryngotracheoesophageal clefts require a multidisciplinary approach with combined extrathoracic and intrathoracic repair. Associated congenital anomalies increase the mortality of the laryngeal clefts and may complicate the timing of surgical repair.

Pediatric airway foreign bodies.

Foreign body aspiration (FBA) is a leading cause of accidental death in children less than one year old and is the cause of death in 7% of children less than four. Food items, especially peanuts, are the most common items aspirated in infants and toddlers, whereas older children are more likely to aspirate non-food items such as pen caps, pins, and paper clips. A high degree of suspicion is required to diagnose FBA. A history of a witnessed choking episode is most important in early diagnosis. An asymptomatic period is common after aspiration and contributes to a delay in diagnosis of greater than one week in 12% to 26% of patients. This delay in diagnosis causes increased morbidity from bronchial inflammation, obstruction, and pneumonia which is resistant to treatment. Prompt endoscopic removal of the foreign body with an open rigid bronchoscope under general anesthesia is the mainstay of therapy.

Cystic hygromas of the head and neck.

Cystic hygroma is a congenital lymphatic malformation with a predilection for the head and neck and that usually presents in the pediatric population. This is a benign lesion but is often challenging to deal with. This paper reviews some of the characteristic features of this lesion including its presentation, pathophysiology, evaluation, and treatment.

Chronic aspiration in children.

Chronic aspiration in children can cause life-threatening pulmonary consequences as well as multiple hospital stays and costly nursing requirements. Causes of aspiration vary widely and must be accurately assessed for treatment to be optimal. This disorder can be successfully controlled with a number of medical and surgical interventions. Rarely, children with severe neurologic disorders will continue to aspirate saliva despite treatment with voice-conserving measures. In cases of life-threatening aspiration, laryngotracheal separation can be lifesaving.

Pediatric tympanoplasty: the role of adenoidectomy.

A chronic dry perforation in a child presents a dilemma with regard to timing of intervention or whether intervention is appropriate at all. Many studies have looked at elements associated with eustachian tube function in hopes of finding prognostic factors. Adenoidectomy has been shown to be very effective in the treatment of chronic and recurrent otitis media. Intuitively, it would seem to play a role in pediatric tympanoplasty; however, no study has thoroughly investigated this issue to date. To evaluate the role of adenoidectomy in pediatric tympanoplasty, we performed a retrospective review of all patients younger than 18 years who had a simple dry perforation and underwent a Wullstein's type I tympanoplasty. Thirty-six patients were identified for review during the 7-year study period. The patients were grouped into those who had previous adenotonsillectomy (n = 12), those who had prior adenoidectomy alone (n = 10), and those who had neither (n = 14). Initial success of tympanoplasty was noted to be high in all three groups. However, at 6-month follow-up, the success for the group who had not had prior adenoidectomy or tonsillectomy dropped dramatically (14.3%), whereas the other two groups maintained success rates in excess of 75% (p = 0.002). This relationship remained fairly constant throughout the 2 years of follow-up. Although our population under study is somewhat small, the results support a potentially advantageous role of adenoidectomy for pediatric tympanoplasty. These results and their implications will be discussed.

Tonsillectomy and adenoidectomy in children: current indications.

The indications for tonsillectomy have undergone considerable refinement in recent years. In patients that fail to respond to conservative medical management for tonsil and adenoid disorders in children, surgical management often yields excellent results.

Retropharyngeal space infection: changing trends.

Retropharyngeal space infection, now a rare entity since the introduction of modern antibiotic chemotherapy, has traditionally been described to occur in children less than 4 years of age with suppurative disorders of the ear, nose, and throat. Recent reports suggest a changing trend in the epidemiology, bacteriology, diagnostic imaging, treatment, and clinical course of this entity. However, the medical literature concerning this topic over the last two decades has consisted mainly of case reports. We reviewed eight cases of retropharyngeal space infection at our institutions over a 15-year period, representing one of the largest clinical series of its kind in the last 20 years. Patient ages ranged from 3 months to 41 years. Findings of these cases and 13 cases from similar reports obtained by a MEDLINE computer search of the recent literature were analyzed. Results show a trend toward occurrence in older age groups, polymicrobial infections, successful use of CT scan as a diagnostic modality, and fewer patients requiring incision and drainage. These findings will be discussed and contrasted to conventional wisdom.

Perioperative management of paediatric microstomia.

Paediatric microstomia may occur congenitally in the whistling face syndrome but is more often acquired after accidental thermal injuries such as biting an electrical extension cord or ingesting household lye. The surgical correction of microstomia includes separation and cosmetic reconstruction of the fused lips and postoperative oral splinting. Microstomia from lye ingestion may be associated not only with limited mouth opening but also with such severe intraoral scarring that common landmarks guiding either rigid or flexible fibreoptic laryngoscopy are obscured, rendering oral and nasotracheal intubation difficult or impossible. We report a case of paediatric microstomia after lye ingestion in which conventional direct laryngoscopy, flexible fibreoptic laryngoscopy, and multiple blind nasal approaches to tracheal intubation were unsuccessful. However, tracheostomy was avoided and successful tracheal intubation was accomplished using a new rigid tubular pharyngolaryngoscope.

Congenital head and neck masses in infants and children. Part II.

Congenital head and neck masses in children are a diverse group of lesions. Thyroglossal duct abnormalities are the most common, followed by branchial apparatus abnormalities, lymphangiomas (cystic hygroma), and subcutaneous vascular abnormalities (hemangioma, AVM). It is important to note that cutaneous hemangiomas are not included in this discussion of congenital masses. If they are considered within the general topic of congenital head and neck masses, vascular lesions by far are the most common. Teratomas and dermoid cysts represent true congenital neoplasms and are relatively uncommon. Several rare lesions have been noted in the discussion and should be included in the differential diagnosis. The diagnosis of these particular masses depends largely on history and physical examination. The location of the mass itself greatly limits the differential diagnosis. Ancillary studies such as plain x-rays, ultrasound, CT scanning, and angiography are useful in further limiting the possible diagnoses. Subcutaneous hemangiomas, ectopic thyroid, congenital goiter, and fibromatosis colli can be treated medically or with simple observation. Surgery is reversed for enlarging lesions or lesions affecting vital structures. The remainder of the congenital head and neck masses generally require early excisions to avoid complications of infection, airway obstruction, nutritional compromise, or the risk of malignant transformation.

Pneumocephalus secondary to a high-pressure water injury to the nose.

We report a case of pneumocephalus following a water jet injury to the nose incurred during a water-skiing fall. Pneumocephalus due to this type of injury has not been previously reported, to our knowledge. Since this unusual injury may be associated with serious complications, it must be promptly recognized and treated.

Tracheotomy in the first year of life.

Much has been written concerning complications of pediatric tracheotomies, but few studies have reviewed the complication rates of tracheotomies performed in the first 12 months of life. We reviewed the records of 60 patients who underwent tracheotomy in the first year of life between 1976 and 1988. This study includes 30 full-term infants and 30 premature infants, 16 of whom were very low birth weight preterm infants (less than or equal to 32 weeks' gestation and less than 1,500 g birth weight). Overall complication rates were 3% intraoperative, 13% early postoperative, and 38% late postoperative. The early postoperative complication rate in preterm infants was nearly double that of full-term infants. The late postoperative complication rate of patients undergoing tracheotomy for airway obstruction was more than double that of patients requiring tracheotomy for pulmonary indications. Duration of tracheotomy, however, was felt to be the most important factor in the development of a late postoperative complication.

The difficult dilation: a method for dilation of severe esophageal strictures in children.

Occasionally severe esophageal strictures will develop in children that will not allow the passage of standard Jackson or bougie dilators. These small strictures can be successfully treated using a standard intubating laryngoscope for visualization and Rush urethral Filiform dilators.

The perioperative management of neonates with congenital oropharyngeal teratomas.

Oropharyngeal teratomas are rare congenital neoplasms that distort orofacial anatomy and often cause respiratory embarrassment at birth. Immediate management of such lesions should include establishment of a secure upper airway, radiographic exclusion of midline central nervous system anomalies, and early surgical excision to prevent asphyxia or permanent disfigurement. Perioperative assessment and surgical management are reported for three oropharyngeal teratomas.

Diverse etiologies of facial paralysis in children.

Facial paralysis (FP) in children is most often idiopathic, however, many diverse and identifiable etiologies exist. Twenty-five cases of children admitted consecutively to the Children's National Medical Center over 8.5 years for the evaluation of FP were reviewed retrospectively. In 21 (84%) of the patients the FP was discovered to be secondary to a specific etiology or associated with a recognizable syndrome. In 7 cases, the FP was an initial manifestation of a serious underlying disorder. Causes of the FP in this series include: otitis media, mastoiditis, temporal lobe abscess, osteopetrosis, both blunt and penetrating trauma, iatrogenic surgical injury, facial burns, cerebellar astrocytoma, leukemia rhabdomyosarcoma, intracerebral arteriovenous malformation, Goldenhar syndrome, and Melkersson-Rosenthal syndrome. Four (16%) patients were diagnosed as having Bell's palsy. Methods of management, including the use of electrodiagnostic testing are described.

Severe upper airway obstruction in children secondary to lingual tonsil hypertrophy.

Lingual tonsil hypertrophy in children is a rarely reported disorder. Two cases of severe upper airway obstruction in pediatric patients secondary to marked lingual tonsil enlargement are reported. Both children were effectively treated with lingual tonsillectomy. The surgical technique, using an insulated Bovie tip, is described.