Safety of Ibuprofen for Postoperative Pain After Palatoplasty: A Pilot Study.

OBJECTIVE: To determine the safety of ibuprofen used for postoperative pain control following palatoplasty in pediatric patients. DESIGN: Retrospective chart review. SETTING: Tertiary care, pediatric hospital. PARTICIPANTS: Patients who received ibuprofen for postoperative pain control after palatoplasty. MAIN OUTCOME MEASURES: Number of doses of ibuprofen given during hospitalization and the presence of postoperative primary or secondary bleeding following palatoplasty. Detection of postoperative hemorrhage was obtained from (1) chart review from inpatient hospitalization after palatoplasty, (2) chart review of each patient's 3-week postoperative clinic visit, and (3) phone call to caretakers from primary author. RESULTS: Thirty-two patients underwent palatoplasty who received ibuprofen for control of postoperative pain. Mean number of inpatient doses given was 4.8 (range: 1-17). None (0%) experienced hemorrhage in the hospital before discharge. Thirty-two (100%) patients were seen at a 3-week follow-up and no (0%) episodes of postoperative hemorrhage were noted. Seventeen (53%) caretakers of patients responded to contact by phone and confirmed no subsequent bleeding. CONCLUSIONS: Ibuprofen may not increase postoperative hemorrhage after palatoplasty. Further studies will be needed to evaluate safety on a larger scale.

A Comparison of Nonopioid and Opioid Oral Analgesia Following Pediatric Palatoplasty.

OBJECTIVE: This article evaluates postoperative analgesia in pediatric palatoplasty patients using nonopioid oral medications. DESIGN: This study was a retrospective chart review. SETTING: The setting for this study was a tertiary-care children's hospital. PARTICIPANTS: Study participants were pediatric patients who underwent palatoplasty procedures performed by a single surgeon. INTERVENTIONS: Interventions included nonopioid and opioid oral medications for postoperative analgesia. MAIN OUTCOME MEASURES: The adequacy of nonopioid versus opioid oral analgesia was assessed by (1) time to discontinue IV fluid, (2) total IV morphine doses for breakthrough pain, (3) daily IV morphine doses for breakthrough pain, (4) time to discharge from the hospital, and (5) perioperative weight change. Group comparisons of outcome measures were performed using a two one-sided test. RESULTS: A total of 61 patients were identified who received three standard pain regimens: acetaminophen + ibuprofen (12), hydrocodone/acetaminophen (23), and hydrocodone/acetaminophen + ibuprofen (26). There was sufficient evidence to suggest equivalence in outcome measures for acetaminophen + ibuprofen versus hydrocodone/acetaminophen and hydrocodone/acetaminophen + ibuprofen for the following: time to discontinue IV fluid (P = .02, 90% confidence interval [CI] = -0.42 to 0.17; P = .007, 90% CI = -0.28 to 0.34), daily IV morphine doses (P = .023, 90% CI = -0.83 to 0.65; P = .032, 90% CI = -0.92 to 0.28), time to discharge from the hospital (P = .017, 90% CI = -0.40 to 0.27; P = .015, 90% CI = -0.24 to 0.39), and perioperative weight change (P = .002; 90% CI = -0.25 to 0.46; P < .0001; 90% CI = -0.34 to 0.18). There was no sufficient evidence to suggest equivalence for total IV morphine doses (P = .189, 90% CI = -1.51 to 1.78; P = .169, 90% CI = -1.51 to 0.88). CONCLUSIONS: Oral acetaminophen and ibuprofen alone may provide similar analgesia to traditional regimens with reduced risks following pediatric palatoplasty.

Diagnosis and Management of Velopharyngeal Dysfunction.

Velopharyngeal dysfunction (VPD) describes any condition whereby the velopharyngeal valve does not properly close during the production of oral sounds. VPD contains multiple causes, including velopharyngeal mislearning (nasopharyngeal sound substitution for an oral sound), velopharyngeal incompetence (neurolophysiologic dysfunction causing poor pharyngeal movement), and velopharyngeal insufficiency (a structural or anatomic defect prevents velopharyngeal closure). Evaluation for VPD is best performed within the context of a multidisciplinary team and consists of history and physical examination, perceptual speech evaluation, and instrumental assessment of speech with either video nasoendoscopy or multiview speech fluoroscopy.

Congenital Tongue Mass With Concomitant Cleft Palate and Bifid Tongue: A Case Report and Review of the Literature.

A case report of a congenital, lingual, salivary gland choristoma with bifid tongue and cleft palate is presented. The patient was born with airway obstruction in supine positioning. Laryngoscopy revealed a midline tongue mass that extended into the hypopharyx and pathological examination showed a congenital ectopic salivary gland. The bifid tongue was repaired at the time of surgical excision. Literature review revealed nine additional cases of congenital lingual mass, bifid tongue, and cleft palate. The most common tongue mass reported was hamartoma (40%), but the differential diagnoses include hamartoma, teratoma, and salivary choristoma.

Current management of congenital branchial cleft cysts, sinuses, and fistulae.

PURPOSE OF REVIEW: Branchial anomalies comprise approximately 20% of pediatric congenital head and neck lesions. This study reviews current literature detailing the diagnosis and management of first, second, third and fourth branchial cysts, sinuses and fistulae. RECENT FINDINGS: Branchial anomalies remain classified as first, second, third and fourth cysts, sinuses and fistulae. Management varies on the basis of classification. The imaging study of choice remains controversial. Computed tomography fistulography likely best demonstrates the complete course of the tract if a cutaneous opening is present. Treatment of all lesions has historically been by complete surgical excision of the entire tract. Studies of less invasive procedures for several anomalies are promising including sclerotherapy and endoscopic excision of second branchial cysts, and endoscopic cauterization or sclerotherapy at the piriform opening for third and fourth branchial sinuses. An increased risk of complications in children less than 8 years is reported in children undergoing open excision of third and fourth branchial anomalies. SUMMARY: Branchial anomalies are common congenital pediatric head and neck lesions but are comprised by several diverse anomalies. Treatment must be tailored depending on which branchial arch is involved and whether a cyst mass or sinus/fistula tract is present.

Accuracy and safety of tracheoscopy for infants in a tertiary care clinic.

OBJECTIVE: To assess the diagnostic accuracy and safety of office-based tracheoscopy when combined with flexible fiberoptic laryngoscopy (FFLT). Flexible laryngoscopy on infants is routinely performed by otolaryngologists in the clinic. The addition of tracheoscopy may improve overall airway assessment but is rarely performed due to the suspected risk of airway compromise. DESIGN: A 6-year retrospective medical record review. SETTING: Tertiary care hospital. PATIENTS: Thirty-one infants younger than 1 year with complete data from preoperative FFLT and microlaryngoscopy and bronchoscopy (MLB) were examined. MAIN OUTCOME MEASURES: Results from 241 MLB procedures were reviewed. RESULTS: Laryngomalacia (LM) and tracheomalacia (TM) were identified more often by FFLT than by MLB. In particular, the detection rate for LM and TM by MLB, as seen preoperatively by FFLT, was 79% and 61%, respectively. Compared with FFLT, MLB accurately diagnosed the severity of LM and TM only 55% and 65%, respectively, of the time. Fiberoptic laryngoscopy revealed synchronous airway lesions in 62% of infants with LM, while MLB discovered synchronous airway lesions in 54%. Static airway lesions were more frequently diagnosed with MLB. No respiratory events occurred during FFLT. CONCLUSIONS: In an appropriate patient, FFLT is a safe and effective diagnostic tool for common infant tracheal and laryngeal abnormalities. Detection and characterization of dynamic airway lesions is better achieved by FFLT than by MLB.

Diagnosis and management of pediatric cervicofacial venous malformations: retrospective review from a vascular anomalies center.

OBJECTIVES/HYPOTHESIS: Venous malformations are rare congenital aberrations of vein development frequently presenting in the head and neck. Without treatment, venous malformations cause progressive disfigurement, dysfunction, and bleeding. In this study, we analyzed a cohort of pediatric patients with cervicofacial venous malformations (CFVM), with the goal of developing a treatment algorithm for these complex lesions. STUDY DESIGN: Eleven-year retrospective chart review. The setting was a vascular anomalies center at a pediatric tertiary hospital. Nineteen patients (10 male, 9 female), aged 11 months to 17 years, presented with CFVM. METHODS: Patient charts were reviewed for demographics, signs and symptoms, timing of first and subsequent interventions, total number and type of interventions performed, and procedural complications. A family questionnaire supplemented outcome measures by determining the perception of disease control. RESULTS: Presenting symptoms for CFVM include growth (100%), disfigurement (63%), pain (58%), respiratory compromise (42%), and dysphagia (32%). A mean of 6.7 interventions were performed per patient (median, 6; range, 2-12), requiring a mean of 0.8 excisions, 4.6 laser treatments, and 1.3 sclerotherapy injections. Average age at first procedure was 8.5 years. Time between treatments averaged 8.9 months. Four complications occurred in 127 procedures (3.1%). Questionnaire responses indicated subjective improvement following therapy. A management algorithm could be developed from therapeutic outcomes. CONCLUSIONS: Treatment of CFVM can be safely and successfully performed with a combination of laser therapy, sclerotherapy, and surgical excision. A treatment algorithm involving multiple procedures during childhood can lead to successful management of CFVM.

CO2 laser resurfacing of intraoral lymphatic malformations: a 10-year experience.

OBJECTIVE: To evaluate the safety and efficacy of CO(2) laser resurfacing in the symptomatic treatment of intraoral lymphatic malformations (LM). DESIGN: Retrospective review. METHODS: Charts were reviewed on 26 patients (16 male, 10 female) from January 1997 to July 2007 who underwent CO(2) laser resurfacing for symptomatic treatment of intraoral LM. A questionnaire was given in order to elucidate effectiveness in controlling symptoms and speed of postoperative recovery. RESULTS: Mean age at time of first treatment was 9.2 years (median 6.8). Mean number of treatments was 3.0 (median 2.5). Average time between treatments was 9.7 months (median 5.6). Questionnaires were returned for 17 patients (65%). Common preoperative symptoms included swelling, bleeding, vesicle formation, and pain. All 17 patients reported symptomatic improvement after laser treatment. Five patients (29%) tolerated oral intake immediately, 10 (59%) the following day, and 1 (6%) was gastric tube dependent. Four patients (24%) returned to normal activity immediately after treatments, six (35%) by the following day, six (35%) within a few days, and one (6%) within a week. No postoperative complications were seen. CONCLUSION: CO(2) laser resurfacing appears to be both safe and efficacious in treatment of symptoms related to intraoral LM. Intermittent treatments for recurrent symptoms is expected.

Intralesional steroid injection for proliferative parotid hemangiomas.

OBJECTIVE: To evaluate the efficacy of proliferative phase intralesional steroid injections in the treatment of parotid hemangiomas. DESIGN: Retrospective analysis of pediatric patients with parotid hemangiomas treated with intralesional steroid injections during the proliferative phase. SETTING: Vascular Anomalies Center, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas, USA. PATIENTS: Twenty-one pediatric patients, ages 4-39 months. METHODS: Between 2001 and 2006, 21 patients received steroid injections for 23 parotid hemangiomas (bilateral in 2 patients). A total of 1-3 injections over the first year of life were given at 6-25 week intervals. RESULTS: Main outcome measures included softening, decreased growth rate, and/or decrease in size. After injection, achievement of outcome measures occurred with all lesions. No incidence of tissue atrophy or facial nerve injury was seen. Four of 21 (19%) patients developed failure to thrive (FTT). CONCLUSION: Parotid hemangiomas can be effectively controlled with proliferative phase intralesional steroid injections. Injections may limit the need for future extensive surgery. Further prospective randomized trials are needed to support these claims. Failure to thrive may be a potential complication of intralesional steroid injection. Endocrine/growth monitoring should be considered when treating with intralesional steroids.

Coblation adenotonsillectomy: an improvement over electrocautery technique?

OBJECTIVES: To compare postoperative complication rates of coblation and electrocautery adenotonsillectomies. STUDY DESIGN: Retrospective chart review. RESULTS: From January 2000 to June 2004, 1997 pediatric patients underwent adenotonsillectomy. 745 coblation, and 1252 electrocautery tonsillectomies were performed. Primary bleed, secondary bleed, and dehydration were seen in 3, 35, and 23 coblation, and 9, 41, and 64 electrocautery tonsillectomies, respectively. Data analysis revealed no significant difference in primary and secondary hemorrhage rate, but a higher dehydration rate in the electrocautery group (P=0.0423). A total of 602 coblation, 763 curette/cautery, and 632 electrocautery adenoidectomies were performed. Neck pain was seen in 0, 17, and 3 patients, respectively. Data analysis showed a higher incidence of neck pain with the curette/cautery technique compared with coblator and cautery techniques (P=0.0006 and P=0.0119, respectively). CONCLUSIONS: Coblation tonsillectomy had similar rates of primary and secondary hemorrhage when compared with electrocautery tonsillectomy but a lower incidence of postoperative dehydration. Coblation adenoidectomy caused less postoperative neck pain than curette/cautery adenoidectomy without significant advantage over cautery adenoidectomy. EBM RATING: B-3b.