Simulated reflux and laryngotracheal reconstruction: a rabbit model.

OBJECTIVES: (1) To test the feasibility of a rabbit model using a pharyngostomy tube to simulate gastroesophageal reflux and (2) to study the effects of gastroesophageal reflux on laryngotracheal reconstruction using a new rabbit model. DESIGN: Prospective randomized trial. SUBJECTS: Thirty-three New Zealand white rabbits. INTERVENTIONS: Anterior cartilage laryngotracheoplasty and pharyngostomy tube placement into the pyriform sinus were performed in 33 rabbits, 22 of which are included in this analysis. Beginning postoperative day 1, hydrochloric acid at a pH of 1.5 with pepsin (n = 7) or at a pH of 4.0 with pepsin (n = 8) was irrigated twice daily through the pharyngostomy tube to simulate gastroesophageal reflux, and a control group received twice-daily isotonic sodium chloride solution irrigations (n = 7). MAIN OUTCOME MEASURES: Specimens were scored by a pathologist masked to individual groups using a newly modified inflammation scoring system. In addition, cross-sectional areas of the cartilage grafts and subglottic airway lumina were compared. RESULTS: Inflammation scores were significantly higher in rabbits receiving hydrochloric acid and pepsin irrigations at a pH of 4.0 (P =.04) but not in those in the pH 1.5 group. Cartilage necrosis was prominent in all groups, and airway sizes and cross-sectional areas of the grafts were not significantly different among the 3 groups. CONCLUSIONS: Cartilage necrosis is prominent during the early stages after laryngotracheoplasty. Inflammation can be increased using hydrochloric acid and pepsin irrigations but is difficult to predict based on this study. Although we confirmed the feasibility of this model, further modifications of this study are proposed to improve animal survival and data collection.

Peritonsillar abscess in children: a 10-year review of diagnosis and management.

OBJECTIVE: peritonsillar abscess is the most common deep neck infection in adults and children. However, pediatric patients with their smaller anatomy and often inability to cooperate with exam and treatment, provide a challenge. This study reviews the experience over the last 10 years at a children's hospital in the diagnosis and treatment of pediatric peritonsillar abscess. METHODS: a retrospective chart review of 83 children diagnosed with a peritonsillar abscess by the Otolaryngology service over a 10-year period (March 1989-February 1999) were reviewed. Presenting signs and symptoms, physical findings, age, season of presentation, prior pharyngitis history, and prior treatment was collected from the charts. Additionally, diagnostic studies (if any), treatment performed, bacteriology, and outcome/complications were noted. RESULTS: due to either an inability to cooperate fully for examination and treatment, or because of an earlier history of significant recurrent pharyngitis or obstructive tonsillar hypertrophy, half of the children required treatment in the operating room. Twenty-six out of 83 (31%) underwent a quinsy tonsillectomy. Length of stay was relatively short (0.9 days). There were no recurrent PTAs in our series, although four children initially treated with incision and drainage required tonsillectomy for persistent symptoms or residual abscess. Ten of those not treated with tonsillectomy (19%) required interval tonsillectomy for recurrent pharyngitis. CONCLUSION: limited by the ability to cooperate with treatment, children often require different treatment plans. We offer a treatment algorithm for managing children with PTAs that takes into account their age, level of cooperativeness, co-morbidities and prior history of pharyngitis, PTA or obstructive sleep disorder.

Recurrent respiratory papillomatosis.

Recurrent respiratory papillomatosis (RRP) is the most common benign neoplasm of the larynx in children. Despite its benign histology, RRP has potentially morbid consequences and is often difficult to treat because of its tendency to recur and spread throughout the respiratory tract. Long neglected from an epidemiological standpoint, recent initiatives to better understand this disease process have been launched through coordination between the Centers for Disease Control and Prevention and the American Society of Pediatric Otolaryngology. In this clinical review, I discuss what we currently know regarding the etiology, epidemiology, and transmission of this disease. Clinical features including pertinent aspects of the history, physical examination, airway endoscopy, and other considerations are highlighted. A detailed description of the surgical and anesthetic management of these challenging cases is presented. Adjuvant modalities of surgical and nonsurgical treatment and their indications are discussed. Ongoing research initiatives and the Practice Guidelines of the Recurrent Respiratory Papillomatosis Task Force are also included.

Potpourri aspiration presenting as tension pneumothorax.

Foreign body aspiration in children is a relatively common occurrence, with peanuts, seeds, or other food particles representing the most common items. Because radiological findings such as mediastinal shift, postobstructive emphysema, and pneumonia are notoriously inconsistent, diagnosis hinges on an accurate history, which may be correlated by physical examination and radiography. We present the case of a 2-year-old girl with delayed treatment of a bronchial foreign body who presented with tension pneumothorax before endoscopy. After chest tube removal, her pneumothorax recurred, thereby bringing about the question of bronchial erosion. Furthermore, an uncommonly reported aspirated object, household potpourri, was encountered.

Recurrent respiratory papillomatosis of the larynx: current diagnosis and treatment.

Treating children with recurrent respiratory papillomatosis can be very rewarding as more information is learned about human papillomavirus. The future goals are reducing the morbidity and mortality of this disease process. The establishment of the national recurrent respiratory papillomatosis patient registry and coordinated efforts between basic scientists involved in human papillomavirus research and clinicians involved in the treatment of recurrent respiratory papillomatosis should aid the endeavor.

Pediatric tracheotomies: changing indications and outcomes.

OBJECTIVE/HYPOTHESIS: To study the outcomes and complications associated with pediatric tracheotomy, as well as the changing trend in indications and outcomes since 1970. STUDY DESIGN: Retrospective chart review at a major tertiary care children's hospital. METHODS: On children who underwent tracheotomy at Children's Hospital of the King's Daughters (Norfolk, VA) between 1988 and 1998, inpatient and outpatient records were reviewed. Of 218 tracheotomies, sufficient data were available on 204. Indications for tracheotomy were placed into the following six groups: craniofacial abnormalities (13%), upper airway obstruction (19%), prolonged intubation (26%), neurological impairment (27%), trauma (7%), and vocal fold paralysis (7%). RESULTS: The average age at tracheotomy was 3.2 +/- 0.6 years. Although the prolonged intubation group was significantly younger than all others, the neurological impairment and trauma groups were significantly older. Decannulation was accomplished in 41%. Time to decannulation was significantly higher in the neurological impairment and prolonged intubation groups, but was significantly shorter in the craniofacial group. Complications occurred in 44%. Overall mortality was 19%, with a 3.6% tracheotomy-related death rate. Comparison of our series to other published series of pediatric tracheotomies since 1970 shows fewer being performed for airway infections and more for chronic diseases, with a corresponding increase in duration of tracheotomy and decreased decannulation rates. CONCLUSIONS: Tracheotomy is a procedure performed with relative frequency at tertiary care children's hospitals. While children receiving a tracheotomy have a high overall mortality, deaths are usually related to the underlying disease, not the tracheotomy itself.

Impact of tympanostomy tubes on child quality of life.

BACKGROUND: The objective benefits of tympanostomy tubes for otitis media are well established, but the subjective impact of surgery on child quality of life (QOL) has not been systematically studied. OBJECTIVES: To determine the subjective impact of tympanostomy tubes on child QOL, and to compare the variability in QOL before surgery with that observed after surgery. DESIGN: Prospective, observational, before-and-after trial. SETTING: Fourteen referral-based pediatric otolaryngology practices in the United States. PATIENTS: Consecutive (64%) and convenience (36%) sample of 248 children (median age, 1.4 years) with otitis media scheduled for bilateral tympanostomy tube placement as an isolated surgical procedure. INTERVENTION: Tympanostomy tubes were inserted as part of routine clinical care. Validated measures of QOL (OM-6 survey), satisfaction with health care decision (Satisfaction With Decision Scale), and satisfaction with office visit; surveys were completed at baseline (visit 1), at surgery (visit 2), and after surgery (visit 3). MAIN OUTCOME MEASURES: Short-term changes in QOL before surgery (visit 1 to visit 2) and after surgery (visit 2 to visit 3). RESULTS: Changes in QOL before surgery were mostly trivial, and were smaller than changes observed after surgery (P<.001). Large, moderate, and small improvements in QOL occurred after surgery in 56%, 15%, and 8% of children, respectively. Physical symptoms, caregiver concerns, emotional distress, and hearing loss were most improved, but significant changes were also seen for activity limitations and speech impairment. Trivial changes occurred in 17% of children, and 4% had poorer QOL. Predictors of poorer QOL were otorrhea 3 or more days (10% of variance) and decreased satisfaction with surgical decision (3% of variance). Hearing status, child age, type of otitis media (recurrent vs chronic), and office visit satisfaction were unrelated to outcome. CONCLUSIONS: Tympanostomy tubes produce large short-term improvements in QOL for most children. The best outcomes occur when postoperative otorrhea is absent or minimal, and when parents are satisfied with their initial decision to have surgery. Further research is needed to document the long-term impact of tubes on child QOL.

Postsurgical follow-up of children with tympanostomy tubes: results of the American Academy of Otolaryngology-Head and Neck Surgery Pediatric Otolaryngology Committee National Survey.

Postsurgical follow-up of children with tympanostomy tubes is becoming a contentious issue in this era of managed care. Primary care providers believe themselves to be capable of evaluating these children. Otolaryngologists, on the other hand, have more specialized equipment available to them (suction apparatus, otomicroscopes, audiology devices, etc) for treating suppurative infections and monitoring the tympanic membrane for structural changes. In addition, the otolaryngologist is placed in an uncomfortable legal and ethical position if access to the patient with a tube-related complication is denied by the primary care provider. Attempts to develop an American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) policy statement have been hampered by a lack of data on the incidence and severity of tube-related complications and the role that otolaryngologists can play in reducing these sequelae. A survey designed by the AAO-HNS Pediatric Otolaryngology Committee was distributed to 1000 board-certified otolaryngologists and all members of the American Society of Pediatric Otolaryngologists and the American Academy of Pediatrics-Otolaryngology Section regarding current practice patterns and practitioners' experiences with tympanostomy tube complications. Specific information regarding complications that could have been avoided with earlier otolaryngology referral was also obtained. The results of the survey and its implications for AAO-HNS policy are presented.

Resistant bacteria in middle ear fluid at the time of tympanotomy tube surgery.

This study was performed to determine the prevalence of resistant Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis isolated from middle ear fluid of children undergoing placement of ventilation tubes. The extent of resistance to commonly prescribed antibiotics and the risk factors associated with this resistance were also examined. Children who had fluid present in their middle ears at the time of ventilation tube placement from May 1996 to May 1997 were included in the study. Middle ear fluid was plated onto culture media in the operating room, and antimicrobial resistance of cultured organisms was ascertained. Risk factors for this resistance were determined from the medical history and analyzed. Cultures of 244 patients (355 ears) were positive for organisms in 29.6%. Penicillin resistance was found in 38.2% of S pneumoniae cultures. Beta-lactamase production was found in 65.1% and 100% of H influenzae and M catarrhalis specimens, respectively. Risk factor analysis revealed young age, day care attendance, and number of antibiotic courses to most reliably predict the presence of resistant microorganisms.

Initial results from the national registry for juvenile-onset recurrent respiratory papillomatosis. RRP Task Force.

OBJECTIVE: To characterize the spectrum of juvenile-onset recurrent respiratory papillomatosis (RRP) in the United States and to obtain data about the natural course of the disease and its response to treatment. SETTING: Twenty tertiary-care pediatric otolaryngology centers throughout the United States. PATIENTS: All patients with active RRP aged less than 18 years at the participating sites. MAIN OUTCOME MEASURES: Number of surgical procedures performed per year, progression of papillomas to previously nondiseased anatomical sites, drug interventions and other adjuvant therapy, and need for tracheostomy. RESULTS: Data were collected from 399 children enrolled from January, 1, 1997, through December 31, 1998. There were 51.9% male; 62.7% white, 28.3% black, 9.0% other or unknown racial group; 10.8% Hispanic ethnicity. Mean age at diagnosis was 3.8 years (range, 0.1-16.3 years) and mean duration of disease was 4.4 years (range, 0.03-18.9 years). The mean number of surgical procedures per child was 4.4 per year (range, 0.2-19.3 per year). Children whose RRP was diagnosed at younger ages (<3.0 years) were 3.6 times more likely to have more than 4 surgical procedures per year (P=.001) and almost 2 times more likely to have 2 or more anatomical sites affected (P=.008) than were children whose RRP was diagnosed at later ages (> or =3.0 years), after adjusting for sex, race, and years of treatment. CONCLUSIONS: Children whose disease was diagnosed before age 3 years were more likely than children aged 3 years or older to have more severe disease as measured by the mean number of surgical procedures performed and by the number of anatomical sites affected. The registry will form the basis for future analysis on the outcome of disease, natural course of RRP under management strategies, prevention strategies, and public health importance.

Anatomy and physiology of pediatric swallowing disorders.

The anatomy and physiology of the act of swallowing is complex. Because the swallowing mechanism matures with age, it is important to understand this maturation process from neonate to older child to appreciate the impact of this changing physiology on pediatric swallowing disorders. This article reviews the relevant anatomy, neurologic control mechanism, and physiology of swallowing in neonates and children.

Outpatient tonsillectomy and adenoidectomy clinical pathways: an evaluative study.

PURPOSE: The purpose of this study is to examine two different dimensions of an outpatient pediatric tonsillectomy and adenoidectomy (T&A) clinical pathway at a tertiary care children's hospital. First, the analysis investigates whether the T&A clinical pathway effectively aids in the decision to discharge a pediatric patient as a day surgery (DS) (less than 12 hours) rather than as an outpatient observation surgery (OPO) (12 to 23 hours). Second, the pathway's impact on quality and financial outcomes is explored. PATIENTS AND METHODS: Forty prepathway pediatric T&A patients were randomly selected and matched to 40 pathway pediatric T&A patients by age, gender, medical history, and surgeon to form a retrospective cohort. Using chi-square and analysis of variance, the two groups were compared by type of discharge (DS or OPO), length of stay, readmission rates, and costs. RESULTS: The results show that patients on a pathway were more likely to be discharged as a DS. The shift toward DS discharges effected significant reduction in average length of stay and overall direct costs. Furthermore, there was no difference in readmission rates. CONCLUSION: These results indicate that the development and implementation of a pathway is an effective method in reducing length of stay and overall direct costs while maintaining quality outcomes.

Tube placement: a prospective, randomized double-blind study.

Bilateral myringotomy with tympanostomy tube placement is the second most frequently performed pediatric surgical procedure, next to circumcision. Postoperative pain relief for children undergoing this procedure has been an ongoing concern. The authors undertook a prospective, randomized, double-blind, placebo-controlled clinical study in 200 consecutive children to investigate the efficacy of oral acetaminophen, acetaminophen with codeine, ibuprofen, and placebo administered preoperatively in relieving postoperative pain in children undergoing this procedure. All children received topical analgesia consisting of antibiotic eardrops mixed with 4% lidocaine intraoperatively. There was no significant difference in postoperative pain score between the four groups (P > 0.4447). Thus it is likely that the intraoperative administration of antibiotic eardrops mixed with 4% lidocaine is all that is required to alleviate postoperative pain in children undergoing myringotomy with tympanostomy tube placement. Preoperative oral analgesics are apparently of little added benefit.

The utility of preoperative hemostatic assessment in adenotonsillectomy.

Routine preoperative coagulation screening in patients undergoing tonsillectomy and/or adenoidectomy (T and A) is considered by some to be mandatory. T and A is often the first hemostatic challenge in children; therefore, screening is thought to be useful in predicting patients who may experience postoperative hemorrhage. On the other hand, in today's cost-conscious medical environment, routine screening is considered by some to be an unnecessary added expense. At our institution, among 4373 patients who underwent T and A between 1989 and 1994, 43 returned with postoperative bleeding (0.98%). We retrospectively evaluated the usefulness of prothrombin time (PT) and activated partial thromboplastin time (PTT) in predicting intraoperative and postoperative bleeding. All children had extensive bleeding histories taken; however, preoperative laboratory screening was left to the discretion of the attending physician. Preoperative PT/PTT did not predict intraoperative or postoperative bleeding. In our experience, laboratory screening has a very low positive predictive value in detecting occult bleeding disorders or perioperative hemorrhage; thus, we feel it should be used selectively. Routine preoperative PT/PTT is not recommended to screen T and A patients and does not appear to be cost-effective.