Use of the Palmaz stent in the treatment of severe tracheomalacia.

To present our experience with the use of the Palmaz stent in treating cases of severe, life-threatening tracheomalacia, and to report our experience with the use of tracheal stents in patients who have concomitant tracheotomies, we performed a retrospective study in a tertiary-care children's hospital. Nine patients with multiple congenital anomalies including severe tracheomalacia required placement of a Palmaz stent to prolong life. The congenital anomalies included congenital heart disease, congenital lung disease, meningomyelocele, laryngotracheoesophageal cleft, and tracheoesophageal fistula. Three of the patients had concomitant tracheotomies. Each patient had placement of one or more Palmaz stents in the trachea and/or bronchus. Four patients died, and 5 patients are still alive. Three of the 4 patients who died had concomitant tracheotomies and died of complications associated with significant tracheal hemorrhage. The fourth died of pulmonary complications following repeated episodes of pneumonia. None of the 5 patients who are still alive had a concomitant tracheotomy. The Palmaz stent is a useful tool for treating life-threatening tracheomalacia as a final resort in this difficult patient population; however, the use of these stents may lead to subsequent hemorrhage and death, especially in patients with tracheotomies, so their use must be carefully considered.

Thyroglossal duct cyst and sinuses: a 20-year Los Angeles experience and lessons learned.

BACKGROUND: First described in 1920 and later modified in 1928, the Sistrunk procedure substantially reduced the incidence of recurrence of midline neck cysts compared with a local excision or cystectomy. The purpose of this study was to determine if the rate of recurrence was influenced by performing either a 'classic' or a 'modified' Sistrunk procedure, if the recurrence rate was influenced by the physician's training, how successful we have been in managing patients with a recurrence? Finally, is outpatient surgery safe for Sistrunk procedures? METHODS: We performed a retrospective review of all patients with a thyroglossal duct remnant (TGDR) who were seen at the Children's Hospital Los Angeles (CHLA) from 1990 to 2010. The following data were collected: patient age, gender, presence or absence of a pre-operative infection, imaging studies, type of procedure performed, the attending surgeon's training background, inpatient or outpatient status, and complications. RESULTS: A total of 128 patients (61% male, 39% female) met the inclusion criteria. The age ranged from 2 months to 14 years (mean of 5.1 years). A total of 137 procedures were performed; 114 (83.2%) for primary and 23 (16.8%) for secondary disease. Complications included post-operative infection (10.9%), recurrence of disease (6.6%), undesirable scar (5.8%), and fistula (2.9%). Surgeons with fellowship-training in pediatric otolaryngology had a recurrence rate of 4.0% and surgeons with fellowship-training in pediatric surgery or pediatric plastic surgery had a recurrence rate of 30.1%. Twenty patients had a 'classic' Sistrunk (14.6%) and 117 (85%) had a 'modified' procedure. Patients were admitted after surgery in 78 cases (56.9%) and 59 patients (43.1%) had an outpatient (OPD) procedure. CONCLUSIONS: There is no place for cystectomy in the treatment of TGDR. A 'modified' Sistrunk procedure is the procedure of choice in both primary and revision cases. Wide local excision of recurrences is required and a 'classic' Sistrunk should be considered. Specific training to gain an intimate knowledge of the anatomy in and around the larynx and experience with multiple cases reduces the incidence of recurrence. Outpatient surgery is safe and effective for selected patients who undergo a Sistrunk procedure.

Age specific differences in pediatric obstructive sleep apnea.

BACKGROUND: Some have suggested that younger children have a more severe form of obstructive sleep apnea than older children and therefore are at a higher risk for respiratory compromise after tonsillectomy and adenoidectomy. However, at present there are few studies that have identified any significant correlation between age and severity of obstructive sleep apnea. OBJECTIVE: To determine if age specific differences in obstructive sleep apnea are present in children. DESIGN: Retrospective chart review. SETTING: Tertiary care children's hospital. PATIENTS: The records of children (1-18 years of age) with obstructive sleep apnea diagnosed by overnight polysomnography between January 1998 and January 2001 were reviewed. Children included in the study also had evidence of adenotonsillar hypertrophy and had no other co-existing medical problems. MAIN OUTCOME MEASURES: Overnight polysomnography was performed in all children. Apnea-hypopnea index (AHI), baseline and lowest O(2) saturation, baseline and peak end tidal CO(2), and total number of obstructive apneas, hypopneas, central apneas and mixed apneas were measured during each polysomnogram. Children were subdivided into the following age groups: 1-2, 3-5, 6-11 and 12-18 years. Polysomnograms were classified into normal, mild, moderate and severe categories. RESULTS: Three hundred and sixty-three children were studied; 45 children were ages 1-2 years, 159 children were ages 3-5 years, 137 children were 6-11 years and 22 children were 12-18 years. Although there appears to be a trend towards a greater mean number of obstructive apneas, hypopneas, central apneas, mixed apneas, a higher mean AHI, lower mean SaO(2) nadir, and a higher mean PETCO(2) in the younger age groups when compared to the older groups, a Student's t-test demonstrates that there is no statistical significance for most OSA parameters. An analysis of variance using the F-test reveals statistical significance (p<0.01) when children ages 1-2 were compared to those 3-5, 6-11 or 12-18 years of age for the variables AHI, mean number of central apneas, hypopneas and mixed apneas. When comparing patients in the various severity categories, children ages 1-2 years show a distinct distribution with a larger percentage in the moderate to severe categories. Chi square analysis reveals a significant difference between the frequency distribution of children in age group 1-2 years and that of the other age groups (p<0.01). CONCLUSION: There is a predilection for children less than 3 years of age to have more severe obstructive sleep apnea as documented by polysomnography. Central apnea also appears to be more common in this age group. These findings may be explained by anatomic and physiologic differences related to age and support a period of observation following adenotonsillectomy in younger children.

Histologic assessment of thermal injury to tonsillectomy specimens: a comparison of electrocautery, coblation, harmonic scalpel, and tonsillotome.

OBJECTIVES/HYPOTHESIS: To determine the extent of thermal injury to the tonsillar tissue following the use of various types of instrumentation. To determine if tonsillectomy specimens routinely contain tissue other than lymphoid tissue. STUDY DESIGN: Retrospective histologic analysis. METHODS: A histologic analysis performed on 228 tonsillectomy specimens removed by use of an electrocautery in 132 specimens, harmonic scalpel in 46, coblation device in 24, and a tonsillotome in 26. The specimens were evaluated for presence and percentage of skeletal muscle and depth of thermal tissue injury. RESULTS: The mean percentage of skeletal muscle present in the specimens was 0.79% for electrocautery, 1.74% for harmonic scalpel, 0.97% for coblation device, and 1.66% for the tonsillotome. Skeletal muscle was absent in only 8 of 228 specimens (3.5%). Electrocautery has a statistically significant (P < .05) lower percentage of muscle tissue compared to harmonic scalpel and the tonsillotome. There was no statistically significant difference in the mean depth of thermal injury among the harmonic scalpel (0.68 mm), electrocautery (0.58 mm), and coblation device (0.71 mm) specimens. The tonsillotome specimens had no thermal injury. CONCLUSIONS: Attempts to remove the entire tonsil results in a similar depth of thermal injury to tonsillectomy specimens when using the harmonic scalpel, electrocautery, and coblation device. Skeletal muscle is a nearly ubiquitous finding in routine tonsillectomy specimens. The use of an electrocautery with a needle point may allow for a more precise dissection as it results in tonsillectomy specimens with a smaller percentage of muscle present.