Tracheotomy in children: evolution in indications.

OBJECTIVES: To evaluate the evolution of indications for tracheostomy in children. METHODS: A retrospective review of 46 children undergoing tracheostomy between 1996 and 2001. RESULTS: The indications for tracheostomy were classified in two groups:(1) prolonged ventilator dependence (57%), (2) upper airway obstructions (43%). The average age of the tracheostomy was 3 years and 8 months. This was higher in the first group (5.5 years). Decannulation was accomplished in 52%. The indications for tracheostomy were evaluated and were found to decrease in frequency for upper airway obstructions. An increasing indication was for chronic disorders requiring prolonged ventilator dependence. Complications occurred in 50% of children. Overall mortality was 13-2.7% directly related to the tracheostomy. CONCLUSIONS: Evolving indication has been ventilator dependence. Upper airway obstruction as an indication has diminished in frequency, especially with the concomitant progress of endoscopic techniques.

Endolaryngeal cysts presenting with acute respiratory distress.

This is a retrospective review of benign cysts of the adult endolarynx that presented as airway emergencies in four teaching hospitals of Dublin, Ireland, over 2 years. During that period nine patients with endolaryngeal cysts necessitating emergency airway intervention were managed. All cases were treated by endoscopic microlaryngeal marsupialization after securing the airway either at the same time or as a staged procedure. Four of these patients required tracheostomies, one performed under local anaesthesia and the others after initial endotracheal intubation. Definitive treatment was carried out in six cases at initial endoscopic diagnosis. Three of the tracheostomized patients had a staged management, two because of their medical status and one for further investigations. On the basis of our findings we suggest that all benign cysts around the endolarynx should simply be called 'endolaryngeal cysts' instead of the current practice of trying to classify them into various histological and morphological types with no prognostic or management differences. Benign cysts of the endolarynx presenting with airway obstruction would appear to be more frequent than is generally maintained in the literature.

Bone anchored hearing aids: reality, failure and current status.

Bone Anchored Hearing Aids have both cosmetic and acoustic advantages over most conventional hearing aids and hence is a popular choice today. We report the first Irish group of patients who received a BAHA over a six year period of time and evaluated outcomes of these subjects using subjective assessment. The medical records of all patients who received a BAHA at the Mater and Children's University Hospital, Dublin, were reviewed. A questionnaire had been sent to the patients to obtain long-term subjective information. Twenty three patients were identified. The commonest indication for surgery was found to be the presence of a discharging mastoid cavity, followed by congenital ear malformations. Surgical procedures were carried out as a single stage in 16 patients. Questionnaires were sent to 19 patients; sixteen patients responded in total. BAHA has a beneficial outcome to the quality of life and has significantly reduced ear discharge. The one stage technique was found to have a lower complication rate.

Pearls and pitfalls in the management of branchial cyst.

INTRODUCTION: Although branchial cysts may present as asymptomatic swellings, about one-third present acutely due to inflammation. The use of fine-needle aspiration biopsy (FNAB) and computerized tomography (CT) is controversial. The treatment of inflamed cysts is also controversial. AIMS: To compare the findings of FNAB and CT between cases of branchial cysts presenting as an asymptomatic swelling, and those presenting acutely due to inflammation, and to examine the management of infected cysts. MATERIALS AND METHODS: Retrospective review of the medical records of 39 adult patients with histologically proven branchial cysts treated by the senior author (C.V.T.) between 1994 and 2003. RESULTS: Twenty-eight patients presented with an asymptomatic swelling. Eleven presented acutely with inflammation. A higher incidence of indeterminate fine needle aspirates and atypical CT features were found in the inflamed group. Initial treatment in the infected group consisted of intravenous antibiotics, followed by aspiration or surgical exploration in non-resolving cases. Interval excision after six weeks was performed in all inflamed cases without complication. CONCLUSIONS: FNAB is recommended in all cystic neck lumps to rule out malignancy, but may be inconclusive, especially in inflamed cysts. Inflamed cysts are best treated with intravenous antibiotics, with or without aspiration or incision and drainage, followed by interval excision.

The safety and effectiveness of the Le Fort I approach to removing central skull base lesions.

The difficulty of gaining access to the central skull base has led to the development of many surgical approaches to this area during the past decade. Yet we believe that the Le Fort I technique, which has been used for almost 140 years in orthognathic surgery, is still an excellent approach to treating anterior skull base lesions. This procedure, which entails the horizontal sectioning of the dentoalveolar maxillary segment, seemed to fall out of favor with otolaryngologists after a few reports of complications surfaced during the past 10 to 15 years. In this article, we report a series of seven patients whom we treated with a Le Fort I approach during a 3-year period for a variety of benign and malignant anterior skull base lesions. We have encountered no significant complications of surgery or recurrence of disease at a maximum postoperative followup of 3 years.

Post-nasal space oncocytoma: a different approach to a rare tumour.

Oncocytomas are rare tumours that occur predominantly in the major salivary glands, particularly the parotid of older individuals. We present the exceptionally rare occurrence of an oncocytoma in the post-nasal space and its treatment for the first time via a Le Fort I osteotomy. The potential for local spread to the surrounding skull base makes it vital to achieve good oncological clearance. We found that this was possible using the Le Fort I technique and would recommend that this approach should be considered in future, when approaching such lesions.

Nitinol stents: their value in tracheobronchial obstruction.

Recurrent tracheobronchial obstruction whether due to a benign or malignant cause is not always amenable to surgery and one is left with the dilemma of what to do for a patient who is slowly asphyxiating. Various modalities have been employed in the past with varying degrees of success. However due to the recent innovations in 'superelastic' biocompatible alloys we present our clinical experience with a new generation of metallic stents made from Nitinol. Over a 12-month period we inserted eight stents in six patients with malignant and benign tracheobronchial obstruction. Almost all patients had dramatic improvement in their symptoms and there was little airway reaction observed up to 18 months after insertion. However, one should exercise caution in inserting them for benign conditions as we regard them as permanent implants. Also evident is the inherent morbidity in this group of patients and this needs to be carefully considered prior to treatment.

Head and neck schwannomas--a 10 year review.

Schwannomas of the head and neck are uncommon tumours that arise from any peripheral, cranial or autonomic nerve. Twenty-five to 45 per cent of extracranial schwannomas occur in the head and neck region and thus are usually in the domain of the otolaryngologist. They usually present insidiously and thus are often diagnosed incorrectly or after lengthy delays, however, better imaging and cytological techniques have lessened this to some degree more recently. For benign lesions conservative surgical excision is the treatment of choice bearing in mind possible vagal or sympathetic chain injury. Malignant schwannomas are best treated with wide excision where possible. The role of adjuvant therapy remains uncertain and irrespective of treatment modality prognosis is poor with an overall survival of 15 per cent. However, recent advances in ras oncogene inhibitors may hold hope for the future.

Antibiotic prophylaxis post-tonsillectomy: is it of benefit?

The decision to prescribe antibiotics post-tonsillectomy still remains controversial. However, recent changing trends in the tonsillar tissue microflora have been widely reported, with Haemophilus influenzae, Staphylococcus aureus and anaerobic organisms all being implicated. All of the above are beta-lactamase producers and thus render lactamase prone antibiotics inactive. We compared two groups of children, one on Amoxycillin and clavulanic acid (a lactamase stable antibiotic with anaerobic cover) for 1 week post tonsillectomy--Group A (N = 44), and another group on no treatment--Group B (N = 34). We compared tonsillar core, surface and postoperative tonsillar fossae bacteriological profiles in the two groups. The tonsil core pathogens included H. influenzae (64%) of which 9.5% were beta-lactamase producers, Streptococcus viridans (55.9%), S. aureus (37%) of which 86% were beta-lactamase producers, and anaerobes which were found in 25% of samples. We found that there was considerably less morbidity in those children receiving postoperative antibiotics compared to those who did not, as judged by the amount of analgesia consumed (p = 0.379), time to resumption of normal diet (p = 0.0072) and pain analogue scores (p = 0.0006). We feel that treating children who have undergone tonsillectomy with amoxycillin and clavulanic acid significantly reduces postoperative morbidity.

The Westaby T-Y tracheobronchial stent in otolaryngology.

The Westaby T-Y tracheobronchial silicone stent can be used for the relief of upper airway obstruction beyond the limit of a standard tracheostomy tube. We report on our experience in the use of the Westaby tube in 10 patients over a five-year period. The general features of the tube, indications for its use, and its method of insertion are described. The versatility and advantages over other stents are discussed. Two cases reports are described and the clinical course and outcomes of the individual patients are outlined.

Congenital vascular anomalies and persistent respiratory symptoms in children.

Congenital cardiovascular anomalies are a rare but treatable cause of stridor in the paediatric population. Despite this, we and the authors of other series have found a delay in referral for endoscopic diagnosis. The duration of symptoms prior to endoscopic diagnosis ranged from 6 weeks to 10 years. It has been estimated that up to 3% of the population have congenital anomalies of the aortic arch complex and we feel that many patients currently being diagnosed as having recurrent croup or atypical asthma must be excluded from this group. We had 16 cases of congenital vascular anomalies causing tracheobronchial compression. Fifteen were due to innominate artery compression and one was due to a double aortic arch. Presenting symptoms included stridor (100%), persistent cough (75%), chronic dyspnoea (75%), reflex apnoea (60%), recurring respiratory tract infections (56%) and dysphagia (25%). Direct laryngoscopy and bronchoscopy was diagnostic in all cases and is our investigation of choice. Eleven underwent aortopexy (69%), one had division of the non-dominant aortic arch (6%) and four were managed conservatively (25%). They were followed for up to 9 years post-operatively and 75% had complete resolution of their symptoms. We feel that only a high clinical index of suspicion will enable these potentially fatal anomalies to be diagnosed.