Humanitarian Surgical Missions: Planning for Success.

Humanitarian surgical missions can provide much needed care for those who are otherwise unable to receive such care because of limited local health care resources and cost. These missions also offer excellent training opportunities and can be life-changing experiences for those who participate in them. A successful humanitarian surgical mission requires careful planning and coordination and can be challenging for those tasked with the responsibilities to organize and lead these missions. This article addresses many of the issues and challenges encountered when planning and leading humanitarian surgical missions and offers a template to be used by those who take on these challenges.

Humanitarian otologic missions: long-term surgical results.

OBJECTIVE: The purpose of this study was to determine the efficacy of treating chronic ear disease by performing a single surgical intervention in the austere environment of a developing nation. SUBJECTS AND METHODS: Data were collected from retrospective chart reviews on 121 patients who underwent surgical treatment of chronic ear disease during humanitarian surgical missions in South and Central America. Surgical outcomes and clinical course were assessed at 10 to 12 months after the initial surgery. RESULTS: A total of 117 patients were included in the study. Follow-up records were available for 75 patients (64%). A total of 20 surgeries were performed for dry perforations (group 1), 30 for chronically draining ears (group 2), and 25 for cholesteatomas (group 3). Surgical success was determined as 60 percent, 74 percent, and 92 percent for groups 1, 2, and 3, respectively. CONCLUSIONS: Surgical results during international otologic outreach missions to developing nations fall within the results expected in developed nations.

The large vestibular aqueduct: a new definition based on audiologic and computed tomography correlation.

OBJECTIVE: The study goal was to determine the prevalence and clinical significance of a large vestibular aqueduct (LVA) in children with sensorineural hearing loss (SNHL). STUDY DESIGN AND SETTING: We conducted a retrospective review of a pediatric SNHL database. One hundred seven children with SNHL were selected and their radiographic and audiometric studies were evaluated. Radiographic comparisons were made to a group of children without SNHL. RESULTS: A vestibular aqueduct (VA) larger than the 95th percentile of controls was present in 32% of children with SNHL. Progressive SNHL was more likely to occur in ears with an LVA and the rate of progressive hearing loss was greater than in ears without an LVA. The risk of progressive SNHL increased with increasing VA size as determined by logistic regression analysis. CONCLUSIONS: An LVA is defined as one that is >or=2 mm at the operculum and/or >or=1 mm at the midpoint in children with nonsyndromic SNHL. An LVA appears to be more common than previously reported in children with SNHL. A linear relationship is observed between VA width and progressive SNHL. SIGNIFICANCE: The finding of an LVA in children with SNHL provides diagnostic as well as prognostic information.

The influence of mutations in the SLC26A4 gene on the temporal bone in a population with enlarged vestibular aqueduct.

OBJECTIVE: To correlate genetic and audiometric findings with a detailed radiologic analysis of the temporal bone in patients with enlarged vestibular aqueduct (EVA) to ascertain the contribution of SLC26A4 gene mutations to this phenotype. DESIGN: A retrospective review of patients with EVA identified in a database of pediatric hearing-impaired patients. SETTING: A tertiary care pediatric referral center. PATIENTS: Seventy-one children with EVA and screening results for SLC26A4 mutations. MAIN OUTCOME MEASURES: Genetic screening results, audiometric thresholds, and radiographic temporal bone measurements. RESULTS: Seventy-one children with EVA were screened for SLC26A4 mutations. Mutations were found in 27% of children overall, while only 8% had biallelic mutations. The mean initial pure-tone average (PTA) was 59 dB; the mean final PTA was 67 dB. A bilateral EVA was found in 48 (67%) of the children; a unilateral EVA was found in 23 (33%). Progressive hearing loss (in at least 1 ear) was seen in 29 (41%) of the patients. The strongest genotype-phenotype interaction was seen in children with a bilateral EVA. Among children with SLC26A4 mutations, there was a significantly wider vestibular aqueduct at the midpoint and a wider vestibule width (P < .05) than in children without the mutation. Among patients with a bilateral EVA, children with any SLC26A4 mutation were more likely to have a more severe final PTA (64 dB vs 32 dB), larger midpoint measurement (2.1 vs 1.1 mm), and larger operculum measurement (3.0 vs 2.0 mm) than those without the mutation in their better-hearing ear (P < .05). CONCLUSIONS: In a population of pediatric patients with an EVA and hearing loss, SLC26A4 mutations are a contributor to the phenotype. Our data suggest that other genetic factors also have important contributions to this phenotype. The presence of an abnormal SLC26A4 allele, even in the heterozygous state, was associated with greater enlargement of the vestibular aqueduct, abnormal development of the vestibule, and possibly a stable hearing outcome.

Airway reconstruction in children with recurrent respiratory papillomatosis.

OBJECTIVE: To determine if children with recurrent respiratory papillomatosis were at increased risk of complications due to their disease following major airway reconstruction. METHODS: We retrospectively reviewed our airway surgery database and the medical records of all children diagnosed with recurrent respiratory papillomatosis who were evaluated at Cincinnati Children's Hospital Medical Center between January 1998 and August 2003. All patients with active airway papillomas or a history of recurrent respiratory papillomatosis who underwent open airway reconstruction at our institution were included in the study. RESULTS: Seven children with recurrent respiratory papillomatosis underwent major airway reconstruction. Six children had tracheotomies and five are now decannulated following their airway reconstruction. Five children had active papillomas at the time of surgery and none had significant worsening of their papillomas following their procedures. Two patients in remission underwent airway reconstruction without recurrence of their papillomas. CONCLUSIONS: Major airway reconstruction can be safely performed in children with recurrent respiratory papillomatosis.

Internet use by parents of children undergoing outpatient otolaryngology procedures.

OBJECTIVES: (1) To determine the prevalence of Internet medical information searches by parents prior to their child's surgical procedure, and (2) to evaluate whether Internet-based health information influences parents' medical decisions on behalf of their children. DESIGN: A questionnaire designed to gather information regarding preoperative use of the Internet by parents of children who were scheduled to undergo outpatient otolaryngology procedures. Parents were asked to respond to questions regarding Internet searches for information specific to their child's diagnosis and anticipated surgical procedure. SETTING: Tertiary care pediatric hospital. RESULTS: Internet access was available to 83% of respondents. Of those parents with Internet access, 48% searched the Internet for information regarding their child's diagnosis and surgical procedure. Of those who searched the Internet, 93% said they found information that was both understandable and helpful. More important, 84% of parents using the Internet said the information influenced or somewhat influenced the medical decisions they made on behalf of their child. Only 43% of parents discussed the information they found on the Internet with their child's surgeon. CONCLUSIONS: Approximately 50% of the parents in our study with Internet access used it to find medical information prior to their child's surgery. Parents who used the Internet found the information helpful and influential, although physicians remain the most important source of information that guides a parent or patient in their medical decision making. Ideally, surgeons would direct parents or patients to a few trusted Internet sites and be prepared to discuss this information.

Surfactant releases internal calcium stores in neutrophils by G protein-activated pathway.

Pulmonary surfactant with surfactant-associated proteins (PS+SAP) decreases pulmonary inflammation by suppressing neutrophil activation. We have observed that PS+SAP inserts channels into artificial membranes, depolarizes neutrophils, and depresses calcium influx and function in stimulated neutrophils. We hypothesize that PS+SAP suppresses neutrophil activation by depletion of internal Ca(++) stores and that PS+SAP induces depletion through release of Ca(++) stores and through inhibition of Ca(++) influx. Our model predicts that PS+SAP releases Ca(++) stores through insertion of channels, depolarization of neutrophils, and activation of a G protein-dependent pathway. If the model of channel insertion and membrane depolarization is accurate, then gramicidin-a channel protein with properties similar to those of PS+SAP-is expected to mimic these effects. Human neutrophils were monitored for [Ca(++)] responses after exposure to one of two different PS+SAP preparations, a PS-SAP preparation, gramicidin alone, and gramicidin reconstituted with phospholipid (PLG). [Ca(++)] responses were reexamined following preexposure to inhibitors of internal Ca(++) release or the G protein pathway. We observed that (i) 1% PS+SAP-but not PS-SAP-causes transient increase of neutrophil [Ca(++)] within seconds of exposure; (ii) 1% PLG-but not gramicidin alone-closely mimics the effect of PS+SAP on Ca(++) response; (iii) PS+SAP and PLG equally depolarize neutrophils; (iv) direct inhibition of internal Ca(++) stores releases or of G protein activation suppresses Ca(++) responses to PS+SAP and PLG; and (v) preexposure to either PS+SAP or PLG inhibits Ca(++) influx following fMLP stimulation. We conclude that PS+SAP independently depolarizes neutrophils, releases Ca(++) from internal stores by a G protein-mediated pathway, and alters subsequent neutrophil response to physiologic stimulants by depleting internal Ca(++) stores and by inhibiting Ca(++) influx during subsequent fMLP activation. The mimicking of these results by PLG supports the hypothesis that PS+SAP initiates depolarization via channel insertion into neutrophil plasma membrane.

Current airway management in craniofacial anomalies.

PURPOSE OF REVIEW: Airway obstruction requiring intervention occurs frequently among children with craniofacial anomalies. The presence of a craniofacial anomaly is a common reason for tracheotomy in the pediatric population. Because of the complications associated with tracheotomy, however, numerous other methods have been proposed to alleviate severe airway obstruction in this patient population. RECENT FINDINGS: Nonsurgical management of airway obstruction remains the initial treatment option in children with craniofacial abnormalities; however, a significant number of patients fail to respond to this management strategy. Perhaps the most significant recent alternative airway management technique is the use of distraction osteogenesis to advance the mandible and maxilla. This technique has been used both to achieve early decannulation and to avoid a tracheotomy in infants and children with craniofacial anomalies. SUMMARY: Multiple options exist for relieving upper airway obstruction in craniofacial patients, and the application of these treatment strategies is dependent on the patient's disease and the philosophy of the treating institution. Future research into the management of airway obstruction in children with craniofacial anomalies will need to focus on predicting which children will benefit from conservative management and which children will need distraction osteogenesis or a tracheotomy.

Effects of nasal saline spray on human neutrophils.

BACKGROUND: Nasal saline spray (NSS) used in the treatment of rhinitis and sinusitis often contains the preservative benzalkonium chloride (BKC). Previous studies have shown that corticosteroid nasal sprays and topical decongestants containing BKC damage respiratory mucosa, decrease mucociliary activity, and inhibit neutrophil functions in vitro. OBJECTIVE: To evaluate the effects of NSS with BKC on human neutrophils. DESIGN: Prospective, basic science observations. METHODS: Human neutrophils were exposed to NSS with BKC or to phosphate-buffered saline (PBS) at varying times and concentrations. The cells were examined for morphologic changes by light microscopy and for viability as determined by trypan blue exclusion. Lactate dehydrogenase levels were measured to quantify neutrophil cell lysis. In vivo morphologic changes were studied in neutrophils obtained from the oral mucosa in human volunteers who rinsed their mouths with NSS or PBS. RESULTS: Neutrophils exposed to NSS concentrations as low as 15% showed near-total cell lysis, and neutrophils exposed to 20% NSS demonstrated no cell viability by trypan blue staining. Phosphate-buffered saline-exposed cells were unaffected. The release of lactate dehydrogenase from lysed neutrophils increased sharply at NSS concentrations higher than 10% but remained stable in PBS-exposed cells. All neutrophils isolated from NSS oral rinses were lysed, while a mean of 78% of neutrophils from PBS rinses showed normal morphologic structure. CONCLUSIONS: Nasal saline spray with BKC is toxic to human neutrophils even at concentrations far lower than those found in commercially available preparations. Saline solutions without BKC appear to be safer alternatives, and additional studies are needed to determine the clinical significance of these findings.

Incidence of and risk factors for additional tympanostomy tube insertion in children.

OBJECTIVE: To determine the incidence and risk factors that account for additional tympanostomy tube placement among children who have undergone an initial placement of ventilation tubes. DESIGN: Retrospective case review of consecutive patients. SETTING: A tertiary care pediatric hospital. PATIENTS: Five-year consecutive series of 2121 children cared for in a hospital-based, tertiary care pediatric otolaryngology practice. INTERVENTION: Subsequent need for additional ventilation tube surgery. RESULTS: Four hundred twenty-three (19.9%) of the 2121 children who underwent initial placement of bilateral myringotomy tubes (BMTs) between April 20, 1995, and May 25, 1998, subsequently had a second set of tubes placed by May 25, 2000. Children 18 months or younger at the time of initial BMT placement were nearly twice as likely (26.3% vs 15.9%) to undergo a second BMT procedure when compared with children who were older than 18 months at initial surgery (P<.005). The probability of having a second BMT procedure was reduced if adenoidectomy was performed at the first BMT procedure (0.08 vs 0.24, P<.001). Adenoidectomy status, craniofacial deformities, and a family history of adenoidectomy or tonsillectomy with or without BMTs were independent risk factors for multiple BMTs. CONCLUSIONS: Epidemiologic analysis of this consecutive series of patients who underwent BMT placement in a tertiary care pediatric otolaryngology practice suggests that 1 in 5 patients will subsequently require a second set of ventilation tubes. Age younger than 18 months at the time of the initial BMT procedure is associated with an increased risk for additional surgery but is not an independent risk factor. Adenoidectomy reduces the incidence of subsequent BMTs following initial surgery.