A simple method for closure of tracheocutaneous fistula in children.

OBJECTIVE: To review the results of a simple technique of closure of persistent tracheocutaneous fistula (TCF) in children. DESIGN: Retrospective case series. SETTING: Tertiary pediatric otolaryngology referral center. PATIENTS: Children (age, < 18 years) who underwent repair of TCF from July 1, 1991, to August 31, 1996. INTERVENTIONS: Surgical closure of persistent TCF using multilayered closure of de-epithelialized local tissue. Tracheal dissection was not performed. A thermal hemostatic scalpel was used in some cases to assist in de-epithelialization and provide hemostasis without electrocautery near the airway. MAIN OUTCOME MEASURES: Success of closure and number and types of complications. RESULTS: Nine procedures were performed in 8 children. Seven (88%) of 8 primary procedures were successful, but early recurrent TCF developed in 1 patient. Revision surgery using an identical surgical technique, but maintaining endotracheal intubation for 48 hours, was successful in this patient. No complications occurred. CONCLUSIONS: This procedure is a simple, reliable method for closure of TCF in children.

Pediatric tracheobronchial foreign bodies: historical review from the Johns Hopkins Hospital.

We investigated changing trends in pediatric tracheobronchial foreign body removal and resident experience from 1939 to 1991. We retrieved the records of 234 cases of tracheobronchial foreign body removal at Johns Hopkins. The mean number of cases per year was 5.9. The most common foreign bodies removed were peanuts, accounting for 38.9%. The average yearly incidence of pediatric tracheobronchial foreign bodies remained relatively constant during the period studied. Our data suggested little change in outcome or complications with the advent of optical telescopes in the mid-1970s, despite their great value in improved visualization. Resident experience and training were evaluated by the number of cases attended by each resident during his or her training. The number varied from 1 to 8 cases, not including experience acquired at our sister institutions. Although complete data could not be obtained in many of the older medical records, our review suggests that despite the advantage offered by the optical forceps technology, proper training and experience in traditional rigid endoscopic techniques is still crucial to optimize outcome and minimize the risk of complications in pediatric tracheobronchial foreign body removal. Chevalier Jackson's recommendation that residency training include an animal laboratory course in foreign body removal still applies.

Airway foreign bodies.

The removal of airway foreign bodies can be challenging even for the most experienced endoscopist. A familiarity with and working knowledge of older time-tested techniques and instrumentation as well as of the newer rigid and flexible fiberoptic equipment is essential for all who desire to accept these challenging situations. Each instrument has inherent advantages, disadvantages, and limitations in certain situations. Occasionally, a foreign body may be removed more safely through open surgical procedures. A knowledge of the lessons learned and techniques developed by pioneering endoscopists coupled with continuing practice of different endoscopy techniques with a variety of instrumentation will prepare the endoscopist to handle unusual foreign body dilemmas with greater skill and safety.

Clinical experience with an endobronchial implant.

PURPOSE: To report clinical experience with an implantable capsule for treating endobronchial carcinoma by means of bronchoscopic insertion and retrieval. MATERIALS AND METHODS: The capsule consists of a plastic cylinder containing high-activity iodine-125 seeds and four restraining legs. Twelve patients with recurrent (n = 11) or inoperable carcinoma (n = 1) received a median dose of 4,500 (range, 2,633-6,299) cGy at a 1-cm radius from the center of the implant. RESULTS: No acute toxicities were observed. Five patients had complete regression of the endobronchial tumor, evidenced at bronchoscopy 2 months after therapy, and four patients had partial regression. Three patients failed to return for bronchoscopy. Symptomatic relief was achieved in eight of 10 patients with dyspnea, four of nine with cough, and two of three with hemoptysis. The median survival of the 12 patients was 6 months. The actuarial 1-year survival rate was 25%. CONCLUSION: This capsule is safe and efficacious in treating recurrent or inoperable carcinoma of the lung.

Endobronchial metastasis.

Endobronchial metastases from nonpulmonary neoplasms are rare. Since 1971, we have treated 23 patients with endobronchial metastases, the findings for which form the basis of this article. Many types of primary tumors are capable of endobronchial metastases, although breast, colon, and renal carcinomas predominate. The mean time from the diagnosis of the primary carcinoma to the diagnosis of endobronchial metastases was 59.9 months. Bronchoscopic results were diagnostic in all cases. Although the mean time for the appearance of endobronchial metastases is almost 5 years, on examination the majority of patients will have symptomatic extrabronchial metastatic disease, the quality of their survival will often be poor, and their survival time will be limited (12.5 months). Surgical resection should be confined to patients with localized disease.

Indications for open surgical removal of airway foreign bodies.

Airway foreign bodies can usually be extracted by skillful application of endoscopic techniques. We report our experience in the management of 2 infants in whom sharp, pointed objects dictated consideration for an open surgical approach. Clinical presentation and treatment options will be discussed in the successful management of these 2 patients, one with a crab claw in the subglottis and the other with an electronic diode in the lung. Extensive training and a full complement of modern instruments are required, but in highly selected cases, an open surgical procedure entails less risk than endoscopic extraction.

Laryngotracheal reconstruction for subglottic stenosis.

Laryngotracheal reconstruction (LTR) has been employed for the treatment of severe laryngotracheal stenosis for the past 6 years at Johns Hopkins Hospital. Thirty-one children underwent LTR with costal cartilage grafting, 24 of whom had Aboulker stents placed. Short stents were used in 22 patients. Six patients received definitive treatment in a single-stage LTR; 1 child had no stent placed. Twenty-six (84%) of the 31 patients were decannulated. It was concluded that decannulation can be obtained in selected patients with the short Aboulker stent or single-stage LTR. A new classification system for laryngotracheal stenosis, based on objective measurements and the separate analysis of posterior glottic fibrosis, was developed. The proposed classification system allows recommendations for treatment. Moreover, it can be easily reproduced and may facilitate comparison of results.

Bronchoscopic brachytherapy.

Increasing lung cancer mortality has created renewed interest in the bronchoscopic use of isotopes for palliation of recurrent airway carcinomas. In the first part of this paper we report our clinical experience with iodine-125 implantation for treatment of endobronchial carcinomas in 18 patients followed until death. Symptoms of cough, hemoptysis, and dyspnea were most effectively relieved with tumors limited to the bronchial lumen. Contraindications to this procedure include extensive extrabronchial tumors causing airway compression and severe debility. In the second part of this paper the development of a new isotope delivery system designed to overcome technical difficulties experienced in the treatment of some patients with interstitial iodine 125 is described. An isotope capsule was constructed to permit insertion and removal by means of a fiberoptic bronchoscope. This device was successfully tested in animals and is now approved for clinical trials. It represents a unique, new modality for treatment of superficial, multifocal, and less-advanced recurrent bronchogenic carcinomas.

Diagnosis of lung allograft rejection by bronchial intraepithelial Leu-7 positive T lymphocytes.

Currently there is no reliable technique for the diagnosis of lung allograft rejection. The presence of intraepithelial lymphocytes expressing the Leu-7 antigen is a specific marker of renal rejection. We examined whether immunoperoxidase techniques that detect Leu-7 positive lymphocytes could be used to diagnose lung rejection in heart-lung transplant recipients. In lungs from two autopsied patients with lung allograft rejection, numerous Leu-7 positive lymphocytes were present in the donor bronchial mucosa (32 and 65 cells/section), submucosa (23 and 80 cells/section), and submucosal glands (7 and 19 cells/section). These Leu-7 positive lymphocytes were associated with proximal airway injury, including squamous metaplasia, destruction of submucosal glands, and ulceration. In one case, there was bronchiectasis. Both cases also had distal airway bronchiolitis obliterans. In contrast, Leu-7 positive lymphocytes were not identified in the epithelium of the native trachea of these two patients; nor were they found in the bronchial epithelium of two sets of transplanted lungs without evidence of rejection. Only rare Leu-7 positive lymphocytes were evident in the epithelium (0 to 2 cells/section) and submucosal glands (0 to 1 cell/section) of 20 lungs from autopsied patients who had not received a transplant. Application of this technique to epithelial biopsy specimens obtained at bronchoscopic examinations demonstrated that it could be applied to the diagnosis of rejection in living heart-lung transplant recipients.

Bipolar cautery for the fiberoptic bronchoscope.

A bipolar electrocautery probe for use through the fiberbronchoscope has been designed and has proven useful in treating small endobronchial lesions and bleeding sites.

Infantile subglottic hemangiomas. An update.

Between 1913 and 1985, 323 cases of infantile subglottic hemangiomas have been reported in the English language literature. The purpose of this study is to review these cases, to report The Johns Hopkins Hospital experience with ten additional cases, and to compare the various methods of treatment in an attempt to identify the regimens associated with the best outcome. The majority of the patients presented before the age of 6 months with respiratory distress, most commonly inspiratory stridor. There was a 2:1 female to male preponderance. The diagnosis was established by endoscopy in the majority and confirmed by biopsy in one third, without serious bleeding complications. A plethora of treatment methods have been described, including the following: corticosteroids, tracheotomy, radiation therapy, radioactive implant therapy, surgical excision, cryotherapy, and carbon dioxide laser. These methods were reviewed and their results compared to our own. We conclude that several methods are effective, each having its advantages and disadvantages. We believe that immediate tracheotomy should be performed in cases with severe airway obstruction. Smaller lesions may be vaporized with the carbon dioxide laser without tracheotomy if postoperative care is provided in a pediatric intensive care unit. Corticosteroids may be used alone or in combination with other modalities. External radiation therapy and injection of sclerosing agents are not advised.

The Swallowing Center: concepts and procedures.

This paper describes the purpose and organization of a dedicated center at The Johns Hopkins Medical Institutions for the evaluation of swallowing problems. The multidisciplinary approach outlined will permit a better understanding and more accurate diagnosis of the functional or organic lesions affecting the swallowing mechanisms. Illustrative cases are presented.