Respiratory symptoms, atopy and bronchial hyperreactivity in professional firefighters.

The aim of the present study was to assess respiratory health in professional firefighters. A total of 101 male professional firefighters from Basel, Switzerland, were included in the study. A control group consisting of 735 male subjects of the general population was composed of the Basel sample of the Swiss Study on Air Pollution and Lung Diseases in Adults. All subjects were administered a standardised questionnaire, spirometry, skin-prick tests and bronchial challenge testing to methacholine. Respiratory symptoms at work were more frequent in firefighters compared with the control group, including burning eyes (21 versus 3%), running nose (19 versus 2%), itchy throat (26 versus 3%), cough (28 versus 3%), dyspnoea (7 versus 2%) and headache (25 versus 3%), respectively. Atopy was present in 51% of firefighters compared with 32% in the control group. The odds ratio for hyperreactivity to methacholine was 2.24 (95% confidence interval 1.12-4.48) for firefighters compared with the control group. Firefighters reported more respiratory symptoms at work and suffered more often from atopy compared with the control group. Bronchial hyperreactivity was more pronounced in firefighters, but it was not related to acute exposure or duration of employment. It remains unclear whether these findings were present at recruitment or developed after joining the workforce.

Clinical evaluation of cuff and tube tip position in a newly designed paediatric preformed oral cuffed tracheal tube.

BACKGROUND: To assess the adequacy of the position of the tracheal tube cuff and tracheal tube tip in the recently introduced preformed oral Microcuff paediatric endotracheal tube (PET) using the manufacturers recommendations for Microcuff tracheal tube size selection. METHODS: With Hospital Ethics Committee approval and informed parental consent, the tracheas of children from birth to adolescence were orally intubated with the preformed oral Microcuff PET. First, the position of the tracheal tube's intubation depth mark in relation to the vocal cords was assessed. Second, the distance 'tracheal tube tip-to-carina' was endoscopically measured with the patient supine and the head in a neutral position and the tube placed with the centre mark at the lower incisors or alveolar ridge. RESULTS: A total of 166 children aged from 0.1 to 16.4 yr (median 5.9 yr) were studied. In five patients the intubation depth mark was above (5 mm each), in 22 patients at the level of and in the remaining 139 patients below the vocal cords. No endobronchial intubation occurred. In four patients the distance 'tracheal tube tip-to-carina' was smaller than the safety margin to prevent endobronchial intubation during head-neck flexion. CONCLUSION: The new oral preformed cuffed tracheal tubes allow safe placement in almost all patients when inserted according to the tube bend. The critically low tube tip and the high cuff positions in a few tubes when placed according to the tube bend requires clinical alertness.

Shortcomings of cuffed paediatric tracheal tubes.

BACKGROUND: The goal of this investigation was to evaluate adequacy of the design of readily available paediatric cuffed tracheal tubes (CPTT). METHODS: In 15 series of cuffed (11) and uncuffed (four) paediatric tracheal tubes (ID: 2.5-7.0 mm) from four different manufacturers the following dimensions were measured: outer diameter of the tube, position and largest diameter of the tube cuff inflated at 20 cm H(2)O and position of depth markings and compared with age-related dimensions. RESULTS: Outer diameters for tubes with similar IDs varied markedly between manufacturers and between cuffed and uncuffed tracheal tubes from the same manufacturer. Cuff diameters at 20 cm H(2)O cuff pressure and cross-sectional cuff area at 20 cm H(2)O cuff pressure did not always cover maximal internal age-related tracheal diameters and cross-sectional areas. Placing the tube tip in the mid-trachea, the cuffs of cuffed tubes with ID 3.0, 4.0, or 5.0 mm would become positioned within the larynx. If the cuffs were placed 1 cm below the cricoid level, many of the tube tips would be dangerously deep within the trachea. Only five of the 11 cuffed tubes had a depth marking. In many of these tubes the distances from depth marking to tube tip were greater than the age-related minimal tracheal length. CONCLUSION: Most cuffed paediatric tracheal tubes are poorly designed, in particular the smaller sizes. A better design of cuffed tubes with a short high-volume, low-pressure cuff, cuff-free subglottic space and adequately placed depth markings are urgently needed.

Dorsal flexion of head and neck for rigid oesophagoscopy--a caution for hidden foreign bodies dropped into the epipharynx.

A 32-month-old girl presented with a swallowed coin in the mid-oesophagus verified by chest radiography. Rigid oesophagoscopy was performed under general anaesthesia with muscle paralysis and tracheal intubation with dorsal flexion of the head and neck. The coin could be grasped using 'optical forceps'. When the oesophagoscope-forceps assembly was removed, the coin had disappeared. Repeated explorations of the oesophagus including direct laryngoscopy were unsuccessful. A further direct laryngoscopy, while placing the head in the neutral position, revealed the coin just dislodging from the epipharyngeal space in the hypopharynx, from where it was removed with a Magill forceps (Arnold Bott, Glattbrugg, Switzerland). Dorsal flexion of the head and neck during foreign body removal may allow entry of the foreign body or easily fragmented foreign bodies into the epipharyngeal cavity. Exploration is recommend using naso-pharyngeal suction and direct laryngoscopy with the head in the neutral position before tracheal extubation in order to avoid acute airway obstruction.

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.

Sinonasal disease in cystic fibrosis: clinical characteristics, diagnosis, and management.

Cystic fibrosis is an autosomal recessive genetic disorder that causes dysfunction of exocrine glands, and has several clinical manifestations. Among those, sinonasal involvement is almost universal, with or without chronic sinusitis and/or nasal polyposis. This review will detail the pathophysiologic changes of the sinonasal mucosa, and the clinical manifestations, diagnosis, and treatment. Developmental anatomic abnormalities, which are identified radiologically, will also be demonstrated. Medical management is the first treatment for patients with cystic fibrosis, but effective treatment of sinonasal disease in cystic fibrosis relies heavily on surgery. In the past, nasal polyposis was the main indication for surgery, and consisted mostly of polypectomy alone. This procedure was associated with a high recurrence rate. The development of functional endoscopic sinus surgery has contributed to decreasing the morbidity of sinonasal surgery and the recurrence of nasal polyposis in cystic fibrosis. The evolution of the surgical techniques will be discussed and a review of the literature will be provided.

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.

[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.

Percutaneous versus surgical tracheostomy: a double-blind randomized trial.

OBJECTIVE: To compare surgical (SgT) and percutaneous (PcT) tracheostomies. BACKGROUND: Percutaneous tracheostomy has been said to provide numerous advantages over classical SgT. METHODS: A prospective randomized trial with a double-blind evaluation was used to compare SgT and PcT. SgT and PcT were performed according to established techniques (n = 70). The procedure was performed at the bedside in the intensive care unit in 21 cases (30%). The outcome measures were divided into procedure-related variables, perioperative complications, and postoperative complications. The procedure-related variables (location, duration, and difficulty) were evaluated by the surgeon. The perioperative and postoperative complications were divided into serious, intermediate, and minor. Perioperative and early postoperative (14 days) complications were evaluated daily by an intensive care unit nurse blinded to the technique used. Long-term postoperative complications were evaluated 3 months after decannulation by a surgeon blinded to the surgical technique. RESULTS: There were no major complications in either group. Most variables studied were not statistically different between the PcT and SgT groups. The only variables to reach statistical significance were the size of the incision (smaller with PcT, p < 0.0001), minor perioperative complications (greater with PcT, p = 0.02), and difficult cannula changes (greater with PcT; p < 0.05). Among nonsignificant differences, difficult procedures and false passages were more frequent with PcT, whereas long-term unesthetic scars were more frequent with SgT. CONCLUSIONS: Both techniques are associated with a low rate of serious or intermediate complications when performed by experienced surgeons. There were more minor perioperative complications with PcT and more minor long term complications with SgT.

Review of objective topographic facial nerve evaluation methods.

OBJECTIVE: This study is a critical review of the described methods for objective topographic evaluation of facial nerve function to identify areas of consensus and point to future research topics. SOURCES AND STUDY SELECTION: Original research articles on the subject were identified through the Medline database and reference cross-checking. DATA EXTRACTION AND SYNTHESIS: The articles were grouped according to the methodology used for topographic facial nerve evaluation. The advantages and shortcomings of each method are evaluated. The results obtained in each publication are presented in light of the method used. CONCLUSION: Measurements localized around the facial area under investigation show maximal displacement, whereas other sites exhibit much smaller displacements. Large displacements in these locations can be used to assess synkinesis and contractures. Large intersubject variability of the same measure is found. Both linear measurement and image-subtracting techniques hold promise. but until comparative studies are performed, the best method will remain controversial. Simple systems, accurately evaluating facial motor function, are yet to be developed.

Percutaneous or surgical tracheostomy: a meta-analysis.

OBJECTIVE: To compare percutaneous with surgical tracheostomy using a meta-analysis of studies published from 1960 to 1996. DATA SOURCES: Publications obtained through a MEDLINE database search with a Boolean combination (tracheostomy or tracheotomy) and complications, with constraints for human studies and English language. STUDY SELECTION: Publications addressing all peri- and postoperative complications. Studies limited to specific tracheostomy complications or containing insufficient details were excluded. Two authors independently selected the publications. DATA EXTRACTION: A list of relevant surgical variables and complications was compiled. Complications were divided into peri- and postoperative groups and further subclassified into severe, intermediate, and minor groups. Because most studies of percutaneous tracheostomy were published after 1985, surgical tracheostomy studies were divided into two periods: 1960 to 1984 and 1985 to 1996. The articles were analyzed independently by three investigators, and rare discrepancies were resolved through discussion and data reexamination. DATA SYNTHESIS: Earlier surgical tracheostomy studies (n = 17; patients, 4185) have the highest rates of both peri- (8.5%) and postoperative (33%) complications. Comparison of recent surgical (n = 21; patients, 3512) and percutaneous (n = 27; patients, 1817) tracheostomy trials shows that perioperative complications are more frequent with the percutaneous technique (10% vs. 3%), whereas postoperative complications occur more often with surgical tracheotomy (10% vs. 7%). The bulk of the differences is in minor complications, except perioperative death (0.44% vs. 0.03%) and serious cardiorespiratory events (0.33% vs. 0.06%), which were higher with the percutaneous technique. Heterogeneity analysis of complication rates shows higher heterogeneity in older and surgical trials. CONCLUSIONS: Percutaneous tracheostomy is associated with a higher prevalence of perioperative complications and, especially, perioperative deaths and cardiorespiratory arrests. Postoperative complication rates are higher with surgical tracheostomy.

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.

Frey syndrome before Frey: the correct history.

OBJECTIVE: To review the chronology of publications on gustatory sweating before Frey's landmark publication. METHODS: Reports on Frey syndrome were reviewed, and all references given to publications before 1950 were obtained and examined. References to prior publications in the obtained articles were similarly reviewed. The cases described in these publications were analyzed for their compatibility with the accepted clinical symptoms of Frey syndrome. RESULTS: Despite numerous references, the case described by Duphenix in 1757 is most probably a traumatic parotid fistula. The first reported case of Frey syndrome should be attributed to Baillarger in 1853.

Microscopic tonsillectomy: a double-blind randomized trial.

OBJECTIVE: To evaluate microsurgical bipolar cautery tonsillectomy (TEmic) by comparing it with traditional blunt dissection tonsillectomy (TEtrad). DESIGN: A double-blind prospective randomized trial with stratification in two age groups. PATIENTS: 200 consecutive patients undergoing tonsillectomy for tonsillar hypertrophy, or recurrent or chronic tonsillitis. OUTCOME MEASURES: Duration of surgery, intraoperative bleeding, daily postoperative pain and otalgia, postoperative bleeding episodes. METHODS: Duration of surgery and operative bleeding were evaluated by the anesthesiologist. The patients were instructed to record daily pain and otalgia. Final postoperative evaluation was done by a different physician, blinded to the surgical technique. RESULTS: Mean intraoperative bleeding was 12 ml for TEmic and 36 ml for TEtrad (P < 0.001). Mean duration of surgery was 37 minutes for TEmic and 36 minutes for TEtrad (NS). Otalgia was present in 41% of TEmic patients and 69% of TEtrad patients (p < 0.001). Daily postoperative pain was lower in the TEmic group than it was in the TEtrad group for the entire study period (10 days). Postoperative hemorrhage was present in three TEmic patients (3%) and in eight TEtrad patients (8%), a difference that did not reach significance (p > 0.1). CONCLUSION: Microsurgical bipolar cautery tonsillectomy compares favorably with traditional techniques in terms of intraoperative bleeding, postoperative pain, otalgia, and hemorrhage. This technique combines the hemostatic advantage of cautery dissection, the excellent visualization achieved by a microscope, and, with the use of a video, greatly improves the physician's ability to teach how to perform a tonsillectomy.

Local injection therapy in 107 patients with myofascial pain syndrome of the head and neck.

Myofascial pain syndrome of the head and neck is a frequent cause of facial pain and is characterized by tender trigger points. In a double-blind study of 107 patients, local injection therapy using one of three solutions was applied at the trigger points by intracutaneous injection of 0.3 ml solution followed by deep infiltration of the site. Results using bupivacaine 0.25%, lignocaine 1% and saline 0.9% were compared. There was no significant difference among groups with respect to reduction of pain and overall rating by patients of the therapeutic benefits. Fifty-three patients (49%) were free of symptoms after treatment, 40 patients (38%) reported substantial relief and in 14 patients (13%) symptoms remained unchanged. The findings suggest that relief of pain is mainly due to reflex mechanisms rather than to the pharmacological effects of the injected solutions. Physiological saline solution is recommended for use in local injection therapy.