Epistaxis in healthy children requiring hospital admission.

OBJECTIVES: To determine the outcomes for healthy children who require admission to hospital with acute epistaxis. METHODS: A 10-year retrospective review of admissions with acute epistaxis under the Otolaryngology Department in a tertiary pediatric centre was performed. RESULTS: There were 14 cases (11 males, 3 females), with mean age 7.8 years (1.9-18.3 years). Three patients had a history of recent aspirin ingestion, and one had sustained nasal trauma. Mean hemoglobin at presentation was 105g/L (75-150), and no patient was diagnosed with a bleeding disorder. Four patients underwent surgical intervention, and one patient received a blood transfusion or blood product. The mean length of hospital stay was 3.6 days (2-14 days). CONCLUSIONS: Acute epistaxis in healthy children that requires hospital admission is generally not a marker for an underlying bleeding disorder. It is associated with a short inpatient stay, and usually requires minimal intervention.

Palliative surgery for neoplastic unilateral vocal cord paralysis.

BACKGROUND: Locally advanced, recurrent or metastatic neoplasms are the commonest causes of unilateral vocal cord paralysis (UVCP). The aim of the present study was to evaluate both survival and results of treatment of vocal cord medialization procedures in this group of patients. METHODS: Fifty-seven patients (36 male, 21 female) with UVCP considered to be due to advanced malignancy who underwent medialization (Teflon injection or type I thyroplasty) between January 1994 and July 2000 were retrospectively reviewed. RESULTS: The malignancy responsible for UVCP was non-small-cell lung carcinoma (NSCLC) in 43 patients, small-cell lung carcinoma (SCLC) in four patients, thyroid carcinoma in three patients and metastatic lower cervical lymph nodes in seven patients. All patients complained of dysphonia and 29 patients had symptoms of aspiration. Teflon injection was performed in 44 patients and thyroplasty in 13. Improvement in voice occurred in 51 patients (89%) and resolution of aspiration in 28 patients (97%) after 2 months. The median time from onset of symptoms of UVCP to death in NSCLC was 170 days; SCLC, 69 days; thyroid carcinoma, 783 days; and metastatic lower cervical lymph nodes, 304 days. CONCLUSION: Surgical treatment of neoplastic UVCP provides satisfactory palliation of symptoms, and management decisions should be based on patient survival expectations.

Neuromuscular disorders presenting as congenital bilateral vocal cord paralysis.

Congenital bilateral vocal cord paralysis (BVCP) can be associated with an underlying neuromuscular disorder, and may present before other features of the neuromuscular disorder become apparent. All infants less than 12 months of age presenting with BVCP between July 1987 and July 1999 at the Royal Children's Hospital, Melbourne, in whom a neuromuscular disorder was subsequently diagnosed were followed. Three children in whom BVCP was diagnosed soon after birth and before recognition of an underlying neuromuscular disorder were identified. All presented with upper airway obstructive symptoms at birth, had a diagnosis of bilateral abductor vocal cord paralysis made at awake flexible laryngoscopy, and had no underlying structural laryngeal abnormality on microlaryngoscopy and bronchoscopy. Two children required a tracheostomy, and 1 child was weaned from nasopharyngeal continuous positive airway pressure after 3 weeks. Subsequent neuromuscular symptoms were recognized between 4 months and 7 years later, leading to diagnoses of facioscapulohumeral myopathy, spinal muscular atrophy, and congenital myasthenia gravis. In each case, the prognosis for recovery from symptoms related to BVCP reflected that of the underlying neuromuscular disorder. This experience suggests that congenital BVCP may be a feature of an unrecognized neuromuscular condition. This possibility should be considered particularly in the presence of associated neurodevelopmental or neuromuscular dysfunction, or in cases in which BVCP is progressive.

Laryngo-pharyngeal carcinoma in childhood.

Laryngo-pharyngeal carcinoma is rare in children. We present two cases of squamous cell carcinoma of the laryngopharynx in children less than 15 years of age. Both patients presented with a prolonged history of symptoms and extensive disease at diagnosis. Early visualisation the vocal cords with flexible larygnoscopy is important in children presenting with symptoms suggestive of laryngeal pathology. Long-term complications of definitive local therapy for laryngopharyngeal carcinoma are important in young children. Evidence from studies in adult patients suggests that adjuvant chemotherapy may play a role in laryngeal preservation in a select group of patients.

Chromosomal abnormalities in idiopathic congenital bilateral vocal cord paralysis.

Idiopathic congenital bilateral vocal cord paralysis (BVCP) can occur as an isolated abnormality or as part of a multisystem disorder. The chromosomal abnormalities found in 4 children who presented with idiopathic congenital BVCP in association with other congenital abnormalities between January 1991 and April 1999 are described. Three children had abductor paralysis, and tracheostomy was required in 1. The fourth child had adductor paralysis and required a feeding gastrostomy for management of aspiration. There was no clinically significant improvement in vocal cord function observed in any child. Idiopathic congenital BVCP, when associated with other congenital disorders, may occur as a consequence of an underlying chromosomal abnormality, and chromosome studies should be performed in this group of children. Similarly, the possibility of vocal cord dysfunction should be considered in children who are found to have chromosomal abnormalities. A chromosomal abnormality appears to preclude the possibility of early spontaneous improvement in vocal cord function.

Failed paediatric laryngotracheoplasty.

INTRODUCTION: Clinical experience with the surgical treatment of paediatric laryngeal stenosis is decreasing, and therefore it is important to highlight the factors that may contribute to failure. METHOD: Retrospective study of 28 children undergoing laryngotracheoplasty (LTP) for laryngeal stenosis was carried out over an 11-year period. RESULTS: Twenty-one patients were decannulated after their initial surgery. One child died prior to stent removal, and the initial surgery was unsuccessful in six patients. Four of these underwent a second LTP. Three additional patients were decannulated, including one patient following endoscopic surgery only. One child is waiting decannulation, one child has not undergone further surgery, and another has undergone multiple failed LTP and remains dependent on the tracheostomy. CONCLUSIONS: Factors identified as contributing to surgical failure in this series included severity of stenosis, cause of stenosis, presence of gastro-oesophageal reflux, other airway abnormalities, timing of surgery, type of surgery employed, and factors related to post-operative management.

Airway problems in children of deaf parents: two case reports.

Airway problems in children usually present with audible symptoms, making them potentially unrecognizable when both parents are deaf. Other hearing observers may not be available to appreciate audible symptoms and polysomnography is inappropriate as a screening tool. We present two cases that highlight the need for additional vigilance and a greater index of suspicion for the presence of significant upper airway obstruction in dealing with the children of hearing-impaired parents.

Meningococcal septicemia post adenotonsillectomy in a child: case report.

Hemorrhage, nausea and vomiting and poor oral intake remain the most commonly encountered complications after adenotonsillectomy in the pediatric population. Life-threatening infectious complications such as meningitis have rarely been reported. We report a case of meningococcal septicemia complicating adenotonsillectomy in a 3-year-old male child. Possible etiologies postulated include: septicemia following transient bacteremia, increased meningococcal carrier rate, transient immune deficiency, and mucosal damage promoting bacterial translocation. This case highlights the responsibility of the otolaryngologist to maintain medical review, especially when recovery following TA is slow.

Acute epiglottitis in adults: the Royal Melbourne Hospital experience.

BACKGROUND: To examine the common presentations and management of acute epiglottitis in adults. METHOD: Retrospective clinical study of 17 consecutive adult patients who presented to the Royal Melbourne Hospital between January 1988 and December 2000 was undertaken. RESULTS: The mean patient age was 47 years (range 20-87 years) and the male-to-female ratio was 1.8 : 1.0. Peak incidence occurred in September during early spring. All patients presented with sore throat and dysphagia; however, respiratory distress was only noted in 65%. The most common signs were temperature and tachycardia. Four patients (23%) required endotracheal intubation, which was performed electively in three and as an emergency in one. Three of 14 blood cultures were positive, two yielded Haemophilus influenzae type b and one yielded Streptococcus mitis. One of the four throat cultures was positive for Haemophilus influenzae type b. Twelve patients underwent awake flexible laryngoscopy under topical anaesthetic as part of their initial assessment, and there were no complications associated with this procedure. There was no mortality. CONCLUSIONS: The diagnosis of acute epiglottitis in the adult population is difficult as respiratory distress may be absent. Patients who have a significant sore throat with no obvious aetiology should have direct visualization of their larynx by flexible laryngoscopy. Lateral X-ray of neck is of limited value. Once diagnosed, these patients should be hospitalized and monitored as airway obstruction may develop rapidly.

Bronchial granuloma - where's the foreign body?

Airway masses are uncommon in children. The majority of bronchial tumors are granulomata secondary to an inhaled foreign body. However, other rare diseases like primary bronchopulmonary tumors should always be considered in the evaluation of a bronchial granuloma in children. The differential diagnosis of bronchial granuloma is presented. We report a 7-year-old girl with a 3-year history of recurrent cough and fevers who was found to have a bronchial granuloma in the left upper lobe bronchus. The diagnosis of foreign body-related granuloma was eventually made after combined and repeated rigid and flexible bronchoscopy. This case highlights the need to search aggressively for a foreign body in the presence of an airway granuloma in children, even in the absence of a history of aspiration.

Long-term outcome of surgically treated acquired subglottic stenosis in infancy.

There is little information about the long-term outcome of infants with acquired severe subglottic stenosis (SGS) who require surgical intervention. We retrospectively identified infants with acquired subglottic stenosis who required anterior cricoid split (ACS) or tracheostomy for primary airway management; some of these children later required laryngotracheoplasty (LTP). All children were treated at our hospital from 1989-1997. During follow-up, we assessed patients for persistent symptoms (stridor at rest, exercise limitation, difficulty with respiratory tract infections, recurrent croup, and voice alteration), and we measured lung function when possible. We identified 34 infants with acquired SGS: 13 treated primarily with tracheostomy, and 21 with ACS. Nine patients could not be extubated following ACS and required tracheostomy, while the 12 who were extubated were followed up at a mean time of 76 months postoperatively; 3 had moderate stridor at rest, 1 moderate exercise limitation, and none had recurrent croup. Four of 5 who had lung function measured had moderately severe extrathoracic airflow limitation. From the tracheostomy group (n = 13) and the failed ACS group (n = 9), 2 patients were decannulated without further surgery, 17 underwent LTP, and 2 have LTP planned. Fifteen of the 17 patients who had LTP have been decannulated. Follow-up, at a mean time of 58 months postoperatively, showed none with stridor at rest, 3 with moderate exercise limitation, none with recurrent croup, and 2 with moderate voice alteration. All 5 patients who had lung function measured had airflow limitation, 1 being severe. In conclusion, ACS facilitates extubation in selected patients with severe, acquired SGS of infancy, and the long-term outcome of patients successfully extubated is excellent. Failure of ACS invariably means tracheostomy, and subglottic repair by LTP is associated with a good long-term outcome.

Intracellular recording from posterior cricoarytenoid motoneurons in the rat.

The ability to maintain coordinated vocal cord abduction and upper airway patency is dependent on the integrity of the posterior cricoarytenoid (PCA) motoneurons and their multiple neural connections. Study of the PCA motoneurons represents the initial step in understanding the complex mechanisms responsible for coordinated vocal cord abduction and may provide an insight into the possible pathological processes underlying the various clinical presentations of vocal cord dysfunction. Intracellular recordings were made from 11 PCA motoneurons in Sprague-Dawley rats, which all showed an inspiratory augmenting discharge pattern that is also characteristic of phrenic nerve activity. The resting membrane potential was -56+/-11 mV. Two PCA motoneurons were injected with Neurobiotin to demonstrate neuronal morphology, which was found to be similar to that obtained by retrograde labeling with cholera toxin B subunit. The technique described for intracellular recording of PCA motoneurons should allow more detailed morphological, electrophysiological, and immunohistochemical information to be obtained, to thereby identify some of the factors responsible for maintaining normal function of the PCA muscle.

Identification of posterior cricoarytenoid motoneurons in the rat.

The posterior cricoarytenoid (PCA) muscle is the sole abductor of the larynx and is controlled by motoneurons located in the nucleus ambiguus. These motoneurons receive inputs from a variety of interneurons, including those that impart respiratory modulation, and are responsible for the phasic inspiratory activity of the PCA muscle. Identification of PCA motoneurons is therefore an essential initial step in understanding the mechanisms responsible for coordinated vocal cord abduction. We identified PCA motoneurons in the rat model by retrograde labeling, and following antidromic activation. A total of 194 neurons were identified by retrograde labeling with cholera toxin B subunit (CTB). Labeling was exclusively ipsilateral where the contralateral vagus and superior laryngeal nerves had been divided. The neurons were multipolar, with dimensions of 33.2 +/- 6.4 microm (mean +/- standard deviation) in length and 22.4 +/- 3.4 microm in width. The neurons were located within a range of 0.6 to 2.4 mm caudal to the caudal pole of the facial nerve, 1.2 to 1.7 mm lateral to the midline, and 1.5 to 2.3 mm deep to the dorsal surface of the medulla. The PCA motoneurons were antidromically activated by focal stimulation of the PCA muscle. The extracellular field was recorded in 5 rats, and the PCA motoneurons were found within a range of 0.8 to 1.7 mm caudal to the caudal pole of the facial nerve, 1.5 to 2.0 mm lateral to the midline, and 1.9 to 2.4 mm deep to the dorsal surface of the medulla. The mean conduction velocity ranged from 37.0 +/- 5.8 to 68.6 +/- 5.0 m/s. An extracellular antidromic field potential, which corresponds to the distribution of the PCA motoneuron pool demonstrated by retrograde labeling with CTB, can be reliably obtained in a rat model following focal PCA muscle stimulation.

Unilateral tonsillar enlargement and tonsillar lymphoma in children.

The clinical presentation and surgical and pathological findings of 46 children with unilateral tonsillar enlargement (UTE; age range 2 to 13 years, mean age 6.5) who underwent tonsillectomy for biopsy purposes between 1975 and 1995 were compared with those of 7 children who received treatment for tonsillar lymphoma (TL; age range 2 to 9 years, mean age 4.8) during the same period. There was no history of rapid tonsillar enlargement in children in the UTE group, and only 20 (43%) were symptomatic. Symptoms included recurrent sore throats in 10 patients (22%), snoring in 5 (11%), nasal obstruction in 4 (9%), and dysphagia in 1 (2%). No children had systemic symptoms or significant cervical lymphadenopathy. In contrast, tonsillar enlargement was observed to occur within a 6-week period in all children with TL, and 6 (86%) children had symptoms at presentation that included dysphagia in 5 (71%), snoring in 3 (43%), night sweats in 2 (29%), and fever and rigors in 2 (29%). Cervical lymphadenopathy greater than 3 cm was present in 6 (86%) children, while 1 child (14%) had hepatosplenomegaly. There was no histopathologic evidence of neoplasia in the UTE group, and a true discrepancy in size between the two tonsils was confirmed in only 21 of 44 (48%) cases. All 7 patients in the TL group had non-Hodgkin's lymphoma. All received chemotherapy, with 5 of the 7 cured and 2 dying of disease. The data suggest that tonsillectomy should be performed for biopsy purposes in UTE where there is a history of progressive enlargement, significant upper aerodigestive tract symptoms, systemic symptoms, suspicious appearance of the tonsil, cervical lymphadenopathy, or hepatosplenomegaly. The diagnosis of TL should also be considered when UTE is present in an immunocompromised child or one with a previous malignancy, when acute tonsillitis is asymmetric and unresponsive to medical treatment, or when rapid bilateral tonsil enlargement occurs. Observation is appropriate management for other cases of UTE.

Superolateral subperiosteal orbital abscess complicating sinusitis in a child.

Orbital complications of sinusitis in children generally occur as a consequence of ethmoid sinusitis due to preferential spread across the lamina papyracea. A case is presented of a subperiosteal abscess (SPA) in the superolateral orbital wall complicating frontal sinusitis in a 6-year-old female. Congenital bony dehiscences exist in the lateral floor of the frontal sinus, which may allow direct spread of infection through to that region. While the general principles of managing orbital complications of sinusitis are applicable, the surgical approach for a SPA complicating frontal sinusitis differs from that of the typical medial SPA, and the clinician should be mindful of this variation when planning surgical treatment.

Vallecular cysts in newborns and young infants.

Vallecular cyst is a rare cause of stridor and respiratory distress in infancy and has been associated with sudden airway obstruction resulting in death. In a retrospective review of eight cases over a 20-year period all infants developed symptoms during the first week of life. All had stridor and feeding difficulties and two required endotracheal intubation. Other common findings included signs of increased work of breathing and episodes of cyanosis. Failure to thrive was present in five patients diagnosed later than the first week of life. An abnormal or a hoarse cry was present in only two patients. Diagnosis in all cases was made by endoscopy. Where a VC is clinically suspected, it is important to stress the need to visualize the base of the tongue during any diagnostic endoscopic procedure. At endoscopy, a smooth localized mass arising from and distorting the lingual surface of the epiglottis was identified. Histologically, the cysts contained respiratory epithelium with mucous glands with an external lining of squamous epithelium. Treatment by cyst marsupialization is safe and definitive, in particular when performed by CO2 laser.

Extradural frontal abscess complicating nasal septal abscess in a child.

Nasal septal abscess (NSA) is an uncommon sequel to minor nasal trauma. Abscess extension beyond the nasal cavity is rarely documented. A case of a 10-year-old boy who presented with a NSA associated with a large extradural frontal abscess is presented and indications for CT scanning in the workup of pediatric patients with NSA is discussed.

Tension pneumothorax secondary to grass head aspiration.

Aspiration of inflorescence or grass heads (seed head of grasses) often presents with atypical signs and symptoms because grass heads have a tendency to rapidly migrate to the periphery of the lung. If this is not recognized, it can lead to delay in diagnosis and serious complications. Removal with rigid bronchoscopy maybe difficult, and surgery is often needed. We report a case of a seven-month-old child who had a delayed diagnosis of grass head aspiration and subsequently presented with a life threatening tension pneumothorax. This case highlights the importance of obtaining a detailed history in cases of foreign body aspiration and the need to include it in the differential diagnosis of unexplained respiratory symptoms, especially those of sudden onset in children.

Neonatal upper airway assessment by awake flexible laryngoscopy.

Awake flexible laryngoscopy (AFL) provides simple and quick assessment of both the structure and function of the upper airway. To determine its value in neonates, a prospective study was carried out over 2 years of 110 neonates (80 term, 30 premature) under 6 weeks of age (corrected for prematurity) presenting with symptoms suggestive of upper airway disease who underwent AFL performed by the author. A diagnosis was made in 79 cases, while no cause was found for the symptoms in 31. The commonest diagnoses were vocal cord paralysis (29; bilateral 16, unilateral 13), nasal stenosis (9), laryngomalacia (9), glossoptosis (7), subglottic stenosis (6), and choanal atresia (5; bilateral 2, unilateral 3). The AFL was repeated in 31 neonates and the condition was found to be stable in 16, improved in 8, resolved in 2, and progressed in 1, and an additional diagnosis was made in 4. Endoscopy under general anesthesia with or without corrective surgery was performed in 15 neonates (7 also having repeat AFL). The diagnosis was confirmed in 14 and an additional tracheal abnormality was found in 1. The AFL was complicated by cyanosis in 2 neonates and epistaxis in 1, but all complications resolved with minimal intervention. These data suggest that the neonatal upper airway can be relatively safely and reliably assessed by AFL performed by an experienced clinician.

Respiratory activity of the rat posterior cricoarytenoid muscle.

An anatomic and electrophysiological study of the rat posterior cricoarytenoid (PCA) muscle is described. The intramuscular nerve distribution of the PCA branch of the recurrent laryngeal nerve was demonstrated by a modified Sihler's stain. The nerve to the PCA was found to terminate in superior and inferior branches with a distribution that appeared to be confined to the PCA muscle. Electromyography (EMG) recordings of PCA muscle activity in anesthetized rats were obtained under stereotaxic control together with measurement of phrenic nerve discharge. A total of 151 recordings were made in 7 PCA muscles from 4 rats. Phasic inspiratory activity with a waveform similar to that of phrenic nerve discharge was found in 134 recordings, while a biphasic pattern with both inspiratory and post-inspiratory peaks was recorded from random sites within the PCA muscle on 17 occasions. The PCA EMG activity commenced 24.6 +/- 2.2 milliseconds (p < .0001) before phrenic nerve discharge. The results are in accord with findings of earlier studies that show that PCA muscle activity commences prior to inspiratory airflow and diaphragmatic muscle activity. The data suggest that PCA and diaphragm motoneurons share common or similar medullary pre-motoneurons. The earlier onset of PCA muscle activity may indicate a role for medullary pre-inspiratory neurons in initiating PCA activity.