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1.
Ann Otol Rhinol Laryngol ; : 3489420912438, 2020 Mar 08.
Artigo em Inglês | MEDLINE | ID: mdl-32148067

RESUMO

OBJECTIVES: To introduce an inexpensive method for objectively evaluating otoscopic visualization of the tympanic membrane wherein learners match what they visualize in standardized patients to tympanic membrane photographs. METHODS: Two standardized patients had photographs taken of their tympanic membranes using a commercially-available digital otoscope. First- and third-year medical students were asked to perform an otoscopic examination on each patient using a conventional handheld otoscope and to match what they saw with the correct tympanic membrane image among distractor photographs belonging to other patients. The ability of students to match the standardized patients' tympanic membrane to the correct photographs was assessed before and after a didactic training session. These measurements were compared between the two cohort groups for construct validity. RESULTS: Fifty-one first-year medical students (with no previous otoscopy experience) and 44 third-year medical students (with otoscopy experience from completing pediatric and family medicine clinical clerkships) were recruited to voluntarily participate in this study. At baseline, a larger percentage of third-year students correctly matched both tympanic membranes compared to first-year students (27% vs 8%, P < .01). After otoscopy training, correct matching of both tympanic membranes significantly improved among both first-year students (8-31%, P < .01) and third-year students (27-54%, P < .01). CONCLUSION: The use of tympanic membrane photographs from standardized patients provides a novel technique for objectively assessing proficiency in otoscopic visualization of the middle ear. The concept is low cost, uses live patients, and can be easily implemented in pre-clinical instruction and beyond.

2.
Otolaryngol Head Neck Surg ; 160(2): 187-205, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30921525

RESUMO

OBJECTIVE: This update of a 2011 guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children <15 years of age, based on the most recent published data. This guideline is intended for all clinicians in any setting who interact with children who may be candidates for tonsillectomy. PURPOSE: The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections. Additional goals include the following: optimizing the perioperative management of children undergoing tonsillectomy, emphasizing the need for evaluation and intervention in special populations, improving the counseling and education of families who are considering tonsillectomy for their children, highlighting the management options for patients with modifying factors, and reducing inappropriate or unnecessary variations in care. Children aged 1 to 18 years under consideration for tonsillectomy are the target patient for the guideline. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of nursing, anesthesiology, consumers, family medicine, infectious disease, otolaryngology-head and neck surgery, pediatrics, and sleep medicine. KEY ACTION STATEMENTS: The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. (2) Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. (3) Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. The guideline update group made recommendations for the following KASs: (1) Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess. (2) Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. (3) Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (4) The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of obstructive sleep-disordered breathing. (5) Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography. (6) Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. (7) The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. (8) Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both). (9) Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). (10) Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually. The guideline update group made a strong recommendation against 2 actions: (1) Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. (2) Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. The policy level for the recommendation about documenting recurrent throat infection was an option: (1) Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus. DIFFERENCES FROM PRIOR GUIDELINE: Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply. There were 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials included in the current guideline update. Inclusion of 2 consumer advocates on the guideline update group. Changes to 5 KASs from the original guideline: KAS 1 (Watchful waiting for recurrent throat infection), KAS 3 (Tonsillectomy for recurrent infection with modifying factors), KAS 4 (Tonsillectomy for obstructive sleep-disordered breathing), KAS 9 (Perioperative pain counseling), and KAS 10 (Perioperative antibiotics). Seven new KASs: KAS 5 (Indications for polysomnography), KAS 6 (Additional recommendations for polysomnography), KAS 7 (Tonsillectomy for obstructive sleep apnea), KAS 12 (Inpatient monitoring for children after tonsillectomy), KAS 13 (Postoperative ibuprofen and acetaminophen), KAS 14 (Postoperative codeine), and KAS 15a (Outcome assessment for bleeding). Addition of an algorithm outlining KASs. Enhanced emphasis on patient and/or caregiver education and shared decision making.


Assuntos
Adenoidectomia/normas , Guias de Prática Clínica como Assunto , Melhoria de Qualidade , Apneia Obstrutiva do Sono/etiologia , Tonsilectomia/normas , Tonsilite/complicações , Adenoidectomia/métodos , Adolescente , Criança , Pré-Escolar , Medicina Baseada em Evidências , Feminino , Seguimentos , Humanos , Masculino , Medição de Risco , Apneia Obstrutiva do Sono/fisiopatologia , Tonsilectomia/métodos , Tonsilite/diagnóstico , Tonsilite/cirurgia , Resultado do Tratamento , Estados Unidos
3.
Otolaryngol Head Neck Surg ; 160(1_suppl): S1-S42, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30798778

RESUMO

OBJECTIVE: This update of a 2011 guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children <15 years of age based on the most recent published data. This guideline is intended for all clinicians in any setting who interact with children who may be candidates for tonsillectomy. PURPOSE: The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections. Additional goals include the following: optimizing the perioperative management of children undergoing tonsillectomy, emphasizing the need for evaluation and intervention in special populations, improving the counseling and education of families who are considering tonsillectomy for their children, highlighting the management options for patients with modifying factors, and reducing inappropriate or unnecessary variations in care. Children aged 1 to 18 years under consideration for tonsillectomy are the target patient for the guideline. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of nursing, anesthesiology, consumers, family medicine, infectious disease, otolaryngology-head and neck surgery, pediatrics, and sleep medicine. KEY ACTION STATEMENTS: The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. (2) Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. (3) Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. The guideline update group made recommendations for the following KASs: (1) Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess. (2) Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. (3) Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (4) The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of oSDB. (5) Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography. (6) Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. (7) The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. (8) Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both). (9) Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). (10) Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually. The guideline update group made a strong recommendation against 2 actions: (1) Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. (2) Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. The policy level for the recommendation about documenting recurrent throat infection was an option: (1) Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus. DIFFERENCES FROM PRIOR GUIDELINE: (1) Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply. (2) There were 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials included in the current guideline update. (3) Inclusion of 2 consumer advocates on the guideline update group. (4) Changes to 5 KASs from the original guideline: KAS 1 (Watchful waiting for recurrent throat infection), KAS 3 (Tonsillectomy for recurrent infection with modifying factors), KAS 4 (Tonsillectomy for obstructive sleep-disordered breathing), KAS 9 (Perioperative pain counseling), and KAS 10 (Perioperative antibiotics). (5) Seven new KASs: KAS 5 (Indications for polysomnography), KAS 6 (Additional recommendations for polysomnography), KAS 7 (Tonsillectomy for obstructive sleep apnea), KAS 12 (Inpatient monitoring for children after tonsillectomy), KAS 13 (Postoperative ibuprofen and acetaminophen), KAS 14 (Postoperative codeine), and KAS 15a (Outcome assessment for bleeding). (6) Addition of an algorithm outlining KASs. (7) Enhanced emphasis on patient and/or caregiver education and shared decision making.


Assuntos
Doenças Faríngeas/cirurgia , Apneia Obstrutiva do Sono/cirurgia , Tonsilectomia , Criança , Humanos , Tonsilectomia/efeitos adversos , Tonsilectomia/métodos
4.
Int J Pediatr Otorhinolaryngol ; 104: 29-31, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29287875

RESUMO

OBJECTIVE: To compare and contrast coblation and microdebrider with touch-up electrocautery (ME) for adenoidectomy in children. METHODS: Patients <18 years old undergoing adenoidectomy without tonsillectomy were selected for this prospective, single-blinded, randomized controlled trial. Participants were enrolled into one of two groups based on birth date: coblation or ME. The surgeons completed a standard survey about intraoperative factors for each method. Recovery nurses filled out a standardized survey postoperatively. A third standardized survey was completed via a phone interview with the parent or patient caregiver on postoperative day 3 to assess procedure outcomes. The survey results were then compared using ANOVA statistical analysis. RESULTS: 50 patients were enrolled in the coblation group and 51 were enrolled in the ME group. There was no significant difference in mean age between the coblation (4.96 years) and ME groups (4.58 years) (p = 0.525). The mean time (in minutes) for coblation (5.50) was significantly lower than ME (9.47) when controlling for the confounder: surgical site exposure (p < 0.001). The surgical time was significantly influenced by the quality of exposure/visualization (p = 0.037). The coblator method had significantly less intraoperative blood loss compared to ME (p < 0.001). There was a statistically significant difference between coblation (1.53) and ME (2.05) for days of pain (p = 0.045) when controlling for the confounder adenoid size. CONCLUSION: In our study we found that coblation demonstrated significantly less intraoperative time and less blood loss, as well as a shorter duration of postoperative pain, when compared to ME for adenoidectomy.


Assuntos
Técnicas de Ablação/métodos , Adenoidectomia/métodos , Eletrocoagulação/métodos , Técnicas de Ablação/efeitos adversos , Tonsila Faríngea/cirurgia , Criança , Pré-Escolar , Eletrocoagulação/efeitos adversos , Feminino , Humanos , Masculino , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Período Pós-Operatório , Estudos Prospectivos , Inquéritos e Questionários
5.
Int J Pediatr Otorhinolaryngol ; 103: 76-79, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29224770

RESUMO

OBJECTIVE: This prospective study aimed to survey pediatric patients and their parents after tonsillectomy to assess their pain management utilization and satisfaction. INTRODUCTION: Tonsillectomy is the second most common surgical procedure performed in pediatric patients. Postoperative recovery is often associated with high levels of pain and severe functional limitations. There is currently no consensus on pain control regimens. Additionally, a recent FDA Black Box Warning on narcotic use has caused more uncertainty in appropriate pain control regimens. METHODS: 111 pediatric patients (≤18 years) included in this study underwent tonsillectomy with or without adenoidectomy between October 2013 and August 2015. Postoperatively, each patient/parent was counseled to alternate on an over-the-counter regimen of acetaminophen and ibuprofen and given an additional as-needed acetaminophen with hydrocodone prescription. A survey was administered during the patient's 2-week follow-up that included questions regarding pain levels, worst post-op pain day, pain medications taken during recovery, and patient/parental perceived satisfaction of having the acetaminophen with hydrocodone prescription. RESULTS: 84 patients/parents (75.7%) felt that OTC medications were not adequate for pain control and used hydrocodone at least once. Between those who took hydrocodone versus those who did not, there was no significant difference in mean age (6.7 ± 2.9 vs. 6.0 ± 2.4 years), percentage of patients with severe pain (36.9% vs. 22.2%) and worst post-op pain day (4.3 ± 1.5 vs. 3.9 ± 1.9 days) (p > 0.05). However, regardless of pain control regimen followed, the majority of patients/parents found it valuable to have the hydrocodone prescription (p = 0.004). CONCLUSION: Post-tonsillectomy patients and their parents find being provided with an acetaminophen-hydrocodone prescription is therapeutically valuable, and many find it necessary in their postoperative pain management. However, further studies are needed to determine patient factors that influence narcotic utilization.


Assuntos
Analgésicos/uso terapêutico , Dor Pós-Operatória/tratamento farmacológico , Tonsilectomia/efeitos adversos , Adenoidectomia/efeitos adversos , Adenoidectomia/métodos , Analgésicos/efeitos adversos , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Manejo da Dor/métodos , Medição da Dor , Estudos Prospectivos , Inquéritos e Questionários , Tonsilectomia/métodos
6.
Int J Pediatr Otorhinolaryngol ; 100: 8-13, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28802392

RESUMO

OBJECTIVE: Examine trends in surgical instrument usage for pediatric adenotonsillectomy. METHODS: An online survey asking questions about current and previous surgical instrument use was created by the authors and distributed to 517 members of the American Society of Pediatric Otolaryngology in October 2015. The survey was designed to assess trends in the use of surgical instruments in pediatric adenotonsillectomy by comparing the results of our 2015 survey to data from a previously published 2005 study. RESULTS: 133 surveys were returned. The most common instruments for total tonsillectomy in 2015 were monopolar electrocautery (57.0%) and coblation (22.7%). The most common subtotal tonsillectomy instruments in 2015 were microdebrider with monopolar electrocautery (41.3%) and coblation (37.0%). The most common adenoidectomy instruments in 2015 were monopolar electrocautery alone (41.3%), coblation (15.1%), and microdebrider with electrocautery (15.1%). CONCLUSION: As compared to our 2005 study, our 2015 study demonstrates that the instrument choice for total tonsillectomy, sub-total tonsillectomy, and adenoidectomy have shifted away from cold techniques toward monopolar electrocautery and coblation.


Assuntos
Adenoidectomia/instrumentação , Instrumentos Cirúrgicos/estatística & dados numéricos , Tonsilectomia/instrumentação , Adenoidectomia/estatística & dados numéricos , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Otolaringologia , Instrumentos Cirúrgicos/tendências , Inquéritos e Questionários , Tonsilectomia/estatística & dados numéricos
7.
Int J Pediatr Otorhinolaryngol ; 85: 112-4, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27240508

RESUMO

Persistent tracheocutaneous fistulae (PTCFs) are sequelae of long-term tracheostomy tube use, and while many procedures exist to correct this issue, several are invasive and incur risk to the patient. This case study discusses a minimally invasive approach to closure of small PFTFs with a coblator device that may reduce the risks associated with other closure procedures. We demonstrated successful tracheocutaneous fistulae closure after coblation in all 4 patients that the operation was performed. We believe this technique can be considered for patients under select circumstances and can be part of a surgeon's armamentarium for the treatment of small PTCFs.


Assuntos
Fístula Cutânea/cirurgia , Fístula/cirurgia , Terapia por Radiofrequência , Fístula do Sistema Respiratório/cirurgia , Doenças da Traqueia/cirurgia , Criança , Pré-Escolar , Fístula Cutânea/etiologia , Fístula/etiologia , Humanos , Lactente , Fístula do Sistema Respiratório/etiologia , Doenças da Traqueia/etiologia , Traqueostomia/efeitos adversos
8.
Laryngoscope ; 126(7): E255-60, 2016 07.
Artigo em Inglês | MEDLINE | ID: mdl-26403138

RESUMO

OBJECTIVES/HYPOTHESIS: To assess the safety and feasibility of using ß-tricalcium phosphate grafts in airway reconstruction in rabbits. STUDY DESIGN: Interventional animal study. METHODS: Ten New Zealand White rabbits underwent division of the anterior cricoid cartilage with interposition of a graft sculpted from ß-tricalcium phosphate blocks. Grafts were secured with sutures or were self-retaining. Rabbit larynges were harvested according to the following schedule: one at 1 week, one at 3 months, and two each at 2 weeks, 4 weeks, 6 months, and 1 year after graft implantation. Specimens were evaluated grossly for overall graft incorporation. Sections through the graft substance were prepared for histology. All sections were reviewed by a pathologist for evidence of vascular ingrowth, granulation tissue, inflammation, epithelialization, and graft resorption. RESULTS: There were no major postoperative complications. Gross examination revealed persistent widening of the airway at the level of graft placement. Histologic evaluation of the larynges showed growth of new blood vessels within all specimens and absence of significant granulation tissue near the airway lumen. The graft was at least partially covered by an epithelium in seven of the 10 specimens. Evidence of graft resorption was present as early as 4 weeks after implantation, with replacement of the graft substance by fibrous tissue, fatty tissue, bone, or cartilage. CONCLUSIONS: ß-tricalcium phosphate grafts can be used safely in airway reconstruction procedures in rabbits. Further research is necessary to demonstrate its safety in human airway reconstruction in addition to further clarifying the processes of graft resorption and integration. LEVEL OF EVIDENCE: NA Laryngoscope, 126:E255-E260, 2016.


Assuntos
Manuseio das Vias Aéreas/instrumentação , Fosfatos de Cálcio , Implantes Experimentais , Procedimentos Cirúrgicos Reconstrutivos/instrumentação , Manuseio das Vias Aéreas/métodos , Animais , Cartilagem Cricoide/cirurgia , Estudos de Viabilidade , Laringe/cirurgia , Masculino , Projetos Piloto , Coelhos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Resultado do Tratamento
9.
Ann Otol Rhinol Laryngol ; 124(10): 803-7, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25944597

RESUMO

OBJECTIVE: While generally well tolerated for the treatment of severe laryngomalacia, bilateral supraglottoplasty has potential complications including supraglottic stenosis and aspiration. We report a more conservative staged supraglottoplasty in infants with severe laryngomalacia. METHODS: A retrospective review was performed of our patients who underwent staged supraglottoplasty from June 2007 to June 2012. Fifteen infants were identified and scored based on stridor, retractions, oxygen saturation, and feeding quality. Outcomes were compared with those reported in the literature for conventional bilateral supraglottoplasty. RESULTS: Seventy-three percent had significant improvement or resolution of stridor following the first stage of surgery and 100% in those undergoing a second stage. Twelve patients (80%) had mild to no retractions following one procedure and 100% had resolution after a second surgery. All 6 patients with recurrent preoperative desaturations had resolution after the first stage of surgery. Of the 11 infants who had preoperative moderate-severe feeding problems, 9 of them (82%) had resolution after one surgery and the remaining 2 had resolution after a second surgery. There were no complications in any of the patients. CONCLUSIONS: Staged supraglottoplasty appears to be an effective, low-risk method to treat severe laryngomalacia. A second procedure was only required in 40% of patients.


Assuntos
Laringomalácia , Laringoplastia , Epiglote/patologia , Epiglote/cirurgia , Métodos de Alimentação , Feminino , Glote/patologia , Glote/cirurgia , Humanos , Lactente , Laringomalácia/complicações , Laringomalácia/congênito , Laringomalácia/metabolismo , Laringomalácia/fisiopatologia , Laringomalácia/cirurgia , Laringoplastia/efeitos adversos , Laringoplastia/métodos , Masculino , Consumo de Oxigênio , Período Pós-Operatório , Sons Respiratórios/etiologia , Sons Respiratórios/fisiopatologia , Estudos Retrospectivos , Índice de Gravidade de Doença , Resultado do Tratamento
10.
Laryngoscope ; 124(11): 2636-9, 2014 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-24622964

RESUMO

Nontoxic adenomatous multinodular goiter (AMNG) in infants is a rare condition. We discuss an extremely rare case of a nontoxic AMNG in a 3-month-old female presenting with airway obstruction. Surgical resection of the mass was performed to reduce the burden on the airway and for diagnosis. The literature is reviewed, and the clinical characteristics, pathology, and surgical treatment are discussed.


Assuntos
Adenoma/complicações , Obstrução das Vias Respiratórias/etiologia , Bócio Nodular/complicações , Bócio Nodular/patologia , Neoplasias da Glândula Tireoide/complicações , Adenoma/diagnóstico , Adenoma/cirurgia , Obstrução das Vias Respiratórias/patologia , Obstrução das Vias Respiratórias/cirurgia , Biópsia por Agulha , Feminino , Seguimentos , Bócio Nodular/cirurgia , Humanos , Imuno-Histoquímica , Lactente , Laringoscopia/métodos , Doenças Raras , Medição de Risco , Índice de Gravidade de Doença , Neoplasias da Glândula Tireoide/patologia , Neoplasias da Glândula Tireoide/cirurgia , Tireoidectomia/métodos , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento
11.
Ann Otol Rhinol Laryngol ; 122(4): 277-82, 2013 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-23697327

RESUMO

OBJECTIVES: Postoperative bleeding is a well-recognized complication after tonsillectomy. We believe significant variation exists in how bleeding following tonsillectomy is reported and that a standardized system is needed. Our goal was to develop such a system. METHODS: Relevant literature was found on Ovid Medline. Studies published from 1996 to 2009 involving post-tonsillectomy bleeding were analyzed, and data were collected on the basis of strict criteria. A standardized system for reporting post-tonsillectomy bleeding was then developed. RESULTS: A review of the literature found variation in the reporting of post-tonsillectomy bleeding and found that categorization systems for reporting bleeding are often not used. The following standardization system is proposed. Type I is bleeding, historical or observed, that does not require any intervention or control of the bleeding (except for oral rinses or intravenous administration of fluids). Type II is bleeding that requires control with local measures under topical or local anesthesia. Type III is bleeding that requires control with local measures, suture ligation, and/or aggressive cauterization in the operating room. Type IV is bleeding that requires control that includes external carotid artery ligation or embolization. Type V is bleeding that leads to the patient's death. The postoperative day on which the bleeding occurs is also reported. CONCLUSIONS: The literature on tonsillectomy varies greatly in describing and reporting post-tonsillectomy bleeding. We propose a system to standardize the reporting of post-tonsillectomy bleeding.


Assuntos
Registros Médicos/normas , Hemorragia Pós-Operatória/classificação , Tonsilectomia/efeitos adversos , Humanos , Hemorragia Pós-Operatória/etiologia
12.
Laryngoscope ; 122(10): 2330-6, 2012 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-22833366

RESUMO

OBJECTIVES/HYPOTHESIS: To evaluate the intraoperative and postoperative bleeding rate utilizing the Coblation device for total tonsillectomy in children. STUDY DESIGN: Prospectively designed clinical study. METHODS: Institutional review board approval was obtained to study patients undergoing Coblation tonsillectomy. Records of all children 1 to 18 years of age undergoing tonsillectomy or adenotonsillectomy from April 2003 to April 2010 were reviewed. All children underwent total tonsillectomy utilizing the Coblation device, and the intraoperative and postoperative bleeding complications were analyzed. The data were also analyzed to determine whether surgeon experience with the technique influenced the bleeding rate. RESULTS: A total of 1,918 patients were evaluated. Intraoperative blood loss was <5 mL in >90% of the patients, with no patients experiencing >20 mL of blood loss. The postoperative bleeding rate was consistent with the literature (n = 87, 4.5%). Of the patients with bleeding following surgery, five (5.7%) experienced primary bleeding and 82 (94.3%) secondary bleeding. Postoperative bleeding that ceased spontaneously and did not require intervention was present in 56 (2.9%). The number of patients who actually required intervention to control postoperative bleeding was 31 (1.6%). The majority of bleeding occurred by postoperative day 7. There was no statistically significant difference in bleeding rates by age, and there was no evidence found to support a surgeon learning curve for performing Coblation tonsillectomy. CONCLUSIONS: This study provides further support that Coblation total tonsillectomy in children is a reliable and safe procedure with a relatively low incidence of intraoperative and postoperative bleeding.


Assuntos
Perda Sanguínea Cirúrgica/estatística & dados numéricos , Hemorragia Pós-Operatória/epidemiologia , Tonsilectomia/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Incidência , Lactente , Laringismo/epidemiologia , Masculino , Fatores de Risco , Tonsilectomia/instrumentação , Tonsilectomia/métodos
13.
Int J Pediatr Otorhinolaryngol ; 76(6): 869-72, 2012 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-22445797

RESUMO

OBJECTIVE: To determine if and how the preoperative peak airway pressure and oxygen requirement of an infant (less than 6 months of age) who requires mechanical ventilation influences the physician's decision to perform a tracheostomy on that infant. STUDY DESIGN: Nationwide survey. SUBJECTS: Pediatric Otolaryngologists. METHODS: A web-based survey was developed and sent to all members of the American Society of Pediatric Otolaryngology. RESULTS: 150 of the 348 surveys were returned (43%). The majority of respondents do not consider the patient's requirement for elevated peak airway pressure (PAP) or the patient's requirement for a high percentage of oxygen as a contraindication to performing a tracheostomy in that patient (54.7 and 72.1% respectively). The presence of preoperative high PAP influenced 68.2% of respondents to consider using a cuffed tracheostomy tube. In the immediate postoperative period, the most common complication resulting in significant morbidity or mortality was mucous plugging, and the majority of respondents attributed postoperative morbidity and mortality to preoperative pulmonary comorbidity. CONCLUSIONS: Preoperative PAP and the patient's oxygen requirement do not influence the surveyed otolaryngologists' decision whether or not to perform a tracheostomy in the infant population. However, PAP do influence whether or not a cuffed tracheostomy tube is used.


Assuntos
Tomada de Decisões , Consumo de Oxigênio/fisiologia , Pico do Fluxo Expiratório , Inquéritos e Questionários , Traqueostomia/métodos , Atitude do Pessoal de Saúde , Feminino , Pesquisas sobre Serviços de Saúde , Humanos , Unidades de Terapia Intensiva Neonatal , Masculino , Otolaringologia/normas , Otolaringologia/tendências , Padrões de Prática Médica , Cuidados Pré-Operatórios/métodos , Pressão , Respiração Artificial/métodos , Testes de Função Respiratória , Gestão da Segurança , Estados Unidos
14.
Laryngoscope ; 122(2): 429-35, 2012 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-22252780

RESUMO

OBJECTIVES/HYPOTHESIS: Evaluation of safety and postoperative outcomes of the laryngeal mask airway (LMA) during pediatric tonsil surgery compared to use of the endotracheal tube (ETT). STUDY DESIGN: Randomized controlled trial. METHODS: A population-based sample of 117 patients ages 2 to 18 years requiring adenotonsillectomy, adenoidectomy, or tonsillectomy was studied. Evaluation forms covering 36 safety, surgery duration, and patient comfort variables were given to the surgeon, anesthesiologist, and phase I and phase II recovery nurses to collect data on the intra- and postoperative course. A phone survey was conducted 24 hours after surgery. RESULTS: At the α level following Bonferroni correction, LMA showed less coughing or gagging during the anesthesia phase for all surgeries combined (48% for ETT vs. 20% for LMA; χ(2) = 10.153, P = .002), and for ETT nontonsillectomy vs. LMA nontonsillectomy (48% for ETT vs. 3% for LMA; χ(2) = 15.196, P = .000), spontaneous ventilation was used more often in the LMA group when comparing all surgeries (χ(2) = 19.493, P = .000), and when comparing ETT tonsillectomy and LMA tonsillectomy (χ(2) = 11.131, P = .000). CONCLUSIONS: Use of the LMA during pediatric tonsil surgery does not appear to have any major disadvantages compared to use of the ETT. In fact, analysis of safety, comfort, complications, and postoperative problems suggests that LMA may be superior for some outcome variables such as coughing and gagging. Use of spontaneous ventilation is more common among LMA patients, although the significance of this finding is uncertain.


Assuntos
Adenoidectomia/métodos , Intubação Intratraqueal/instrumentação , Máscaras Laríngeas , Laringismo/prevenção & controle , Tonsilectomia/métodos , Adenoidectomia/efeitos adversos , Adolescente , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Incidência , Período Intraoperatório , Laringismo/epidemiologia , Masculino , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Tonsilectomia/efeitos adversos , Resultado do Tratamento , Estados Unidos
16.
Int J Pediatr Otorhinolaryngol ; 75(2): 282-5, 2011 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-21168225

RESUMO

OBJECTIVE: To report trends in the indications for pediatric tonsillectomy or adenotonsillectomy. METHODS: To identify current indications, (1) a retrospective chart review analyzed all indications for procedures performed by a pediatric otolaryngologist on patients aged 0-3, 4-10, or 11-18 years, and (2) a cross-sectional survey to members of the American Society of Pediatric Otolaryngology asked for approximate percentages of children in the same age groups receiving procedures for obstruction, infection, or another indication. To assess changing indications over time, (3) a literature review was performed. RESULTS: (1) Chart review: 302 patients aged 5 months to 18 years (average: 6.34; median: 6) were analyzed. For the 0-3-year age group, obstruction was an indication in 100.0% of cases, and infection in 2.6%. For the 4-10-year age group: 91.9% and 13.4%, respectively. For the 11-18-year age group: 84.6% and 33.3%. (2) SURVEY: 120 surveys were returned (40% response rate), and 63 surveys were appropriate for analysis (21% completion rate). For the 0-3-year age group, obstruction was the primary indication in 91.8% of procedures and infection in 7.5%. For the 4-10-year age group: 73.2% and 25.3%, respectively. For the 11-18-year age group: 43.0% and 54.2%. (3) LITERATURE REVIEW: 11 articles consistently illustrated a rise in obstruction and a decline in infection as an indication since 1978. CONCLUSIONS: Obstruction has become a more prominent indication than infection for pediatric tonsillectomy or adenotonsillectomy in children, especially younger children. Infection becomes a more prominent indication as age increases. Data may not be absolutely reflective of all pediatric otolaryngologists or other otolaryngologists that treat children. Comparing studies is difficult owing to the variety of surgical procedures focused upon and terms used to define indications.


Assuntos
Adenoidectomia/tendências , Tonsilectomia/tendências , Tonsilite/cirurgia , Adenoidectomia/estatística & dados numéricos , Adolescente , Fatores Etários , Criança , Pré-Escolar , Estudos Transversais , Feminino , Seguimentos , Humanos , Incidência , Lactente , Masculino , Otolaringologia/tendências , Estudos Retrospectivos , Medição de Risco , Fatores Sexuais , Tonsilectomia/estatística & dados numéricos , Tonsilite/diagnóstico , Resultado do Tratamento
17.
Int J Pediatr Otorhinolaryngol ; 74(6): 704-6, 2010 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-20398948

RESUMO

The most common etiologies for acute infectious airway obstruction include epiglottitis, croup, and bacterial tracheitis. We present a unique cause of upper airway obstruction in a child not previously described. To our knowledge this is the first case in the literature of membranous laryngitis in a child due to Methicillin-resistant Staphylococcus Aureus (MRSA). The diagnosis was made by endoscopy and culture and treated with culture directed antibiotics and debridement of membranes from the larynx. The patient did not present with clinical symptoms consistent with epiglottitis as the disease course was not abrupt, and the patient did not present with classic posturing and drooling. Croup-like symptoms were described, but there was no evidence of subglottic involvement radiographically or on endoscopy. Additionally, there was no evidence of membranous plaques within the trachea or subglottis which would be suggestive of bacterial tracheitis. This unique finding is likely the result of MRSA superinfection in a child with Influenza type B.


Assuntos
Laringite/microbiologia , Laringite/patologia , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Infecções Estafilocócicas/complicações , Anti-Infecciosos/uso terapêutico , Migração de Corpo Estranho/diagnóstico , Humanos , Lactente , Recém-Nascido , Intubação , Laringite/cirurgia , Laringoscopia , Masculino , Síndrome do Desconforto Respiratório do Recém-Nascido/tratamento farmacológico , Síndrome do Desconforto Respiratório do Recém-Nascido/microbiologia , Infecções Estafilocócicas/tratamento farmacológico , Vancomicina/uso terapêutico
18.
Laryngoscope ; 119(4): 734-9, 2009 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-19266589

RESUMO

OBJECTIVES: To evaluate basic fibroblast growth factor-2 (BFGF) and hyaluronic acid (HA) effects on a surgically produced tracheal defect. STUDY DESIGN: Animal model. METHODS: Anterior punch lesions were created on 33 male rabbits divided into three equal groups. Group 1 (Control) received a normal saline (NS)-soaked collagen sponge directly on the defect, group 2 (HA alone) a NS-soaked HA sponge, and group 3 (BFGF+HA) a 10 ng/mL BFGF-soaked HA sponge. Sponge fixation and surgical closure were followed by a 90-day healing period, then animal sacrifice. Harvested tracheas were fixed, imbedded, sectioned, and stained with hematoxylin and eosin or safranin-O. Histopathological measures included: chondrocyte death, chondrocyte proliferation (both reported as number of rabbits displaying death or proliferation per group/total rabbits per group [%]), connective tissue (CT) organization (graded on a scale), epithelial closure (1-3 scale), and inflammation (1-4 scale). The final three measures are reported as an average grade per group, where values closer to 1 signify improved healing, whereas higher values signify poorer healing. RESULTS: Chondrocyte death: Control, 8/11 (72.7%); HA alone, 5/11 (45.5%); BFGF+HA 5/11 (45.5%). Chondrocyte proliferation: 3/11 (27.3%), 7/11 (63.6%), and 9/11 (81.8%), respectively. CT organization: 2.00, 1.82, 1.64. Epithelial closure: 1.18, 1.09, and 1.00. Inflammation: 2.82, 1.82, and 1.73. Statistical comparisons: significantly improved chondrocyte proliferation for BFGF+HA (P = .015) and reduced inflammation for HA alone (P = .011) and BFGF+HA (P = .004) compared to controls. CONCLUSIONS: BFGF+HA applied to an anterior tracheal defect significantly improves chondrocyte proliferation; HA alone and BFGF+HA significantly reduce inflammation. BFGF+HA and HA alone may improve tracheal wound healing.


Assuntos
Anti-Inflamatórios/farmacologia , Fator 2 de Crescimento de Fibroblastos/farmacologia , Ácido Hialurônico/farmacologia , Traqueia/lesões , Cicatrização/efeitos dos fármacos , Animais , Proliferação de Células , Condrócitos/patologia , Modelos Animais de Doenças , Fator 2 de Crescimento de Fibroblastos/metabolismo , Ácido Hialurônico/metabolismo , Masculino , Coelhos , Traqueia/metabolismo , Traqueia/patologia , Cicatrização/fisiologia
19.
Arch Otolaryngol Head Neck Surg ; 134(3): 272-7, 2008 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-18347252

RESUMO

OBJECTIVE: To describe a previously unreported condition of the neonatal larynx. DESIGN: Case series of 4 neonates with an uncommon laryngeal lesion. SETTING: Tertiary care children's hospital. PATIENTS: Four neonates in the first 10 days of life with stridor, hoarseness, and respiratory distress. INTERVENTION: The patients were examined using flexible fiberoptic laryngoscopy, and laryngeal lesions were identified and subsequently removed using microlaryngoscopy. Photodocumentation of the lesions was performed. Microscopic evaluation of biopsy specimens by a pathologist followed. MAIN OUTCOME MEASURES: Each patient's medical record was carefully reviewed for prenatal history, birth history, neonatal history, pathologic findings, and office follow-up. RESULTS: All 4 neonates were delivered atraumatically and developed symptoms of upper airway obstruction within the first few minutes to days of life. Each neonate was found to have an obstructive laryngeal lesion requiring surgical intervention. No child had other congenital abnormalities or a history of obvious laryngeal trauma. Pathologic review of each laryngeal specimen revealed inflammatory lesions with characteristic features of a lobular capillary hemangioma (or a pyogenic granuloma). CONCLUSIONS: The diagnosis of a lobular capillary hemangioma of the larynx should be considered in the differential diagnosis of a newborn with stridor, hoarseness, or respiratory distress. The cases seem to be of congenital origin, although acquired pathogenesis cannot be ruled out. Treatment of these lesions includes microscopic surgical excision.


Assuntos
Hemangioma/diagnóstico , Hemangioma/cirurgia , Neoplasias Laríngeas/diagnóstico , Neoplasias Laríngeas/cirurgia , Feminino , Hemangioma/patologia , Humanos , Recém-Nascido , Neoplasias Laríngeas/patologia , Laringoscopia , Masculino
20.
Otolaryngol Head Neck Surg ; 137(3): 465-70, 2007 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-17765777

RESUMO

OBJECTIVE: Study the effects of vascular endothelial growth factor (VEGF) on laryngeal wound healing in a rabbit model. STUDY DESIGN: Prospective, randomized, blinded. METHODS: The anterior cricoid cartilage of 10 rabbits was split and a VEGF-soaked collagen sponge was sewn between the cut edges. In 10 control animals, the collagen sponge was soaked with phosphate-buffered saline solution. The larynx was harvested on day 10. The degree of epithelial closure, the degree of soft tissue closure, and the presence of inflammatory cells was graded. RESULTS: There was complete epithelial closure in the control group. There was a slightly higher, but not statistically significant, grade of soft tissue closure in the experimental group. The experimental group had a lower but not statistically significant acute inflammatory response score. CONCLUSIONS: The topical application of VEGF through an implanted collagen sponge to an anterior, subglottic incision in a rabbit has no significant effect on tracheal luminal epithelial closure, acute inflammatory response, or soft tissue repair at postsurgical day 10.


Assuntos
Cartilagem Cricoide/efeitos dos fármacos , Cartilagem Cricoide/cirurgia , Fator A de Crescimento do Endotélio Vascular/administração & dosagem , Cicatrização/efeitos dos fármacos , Administração Tópica , Animais , Colágeno , Cartilagem Cricoide/fisiopatologia , Implantes de Medicamento , Masculino , Coelhos , Tampões de Gaze Cirúrgicos , Fatores de Tempo
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