Tonsillectomy and adenoidectomy in pediatric patients: A current experience.

Objective: To review experiences with tonsillectomy and/or adenoidectomy in pediatric patients. Methods: Retrospective chart study was done in pediatric patients who underwent tonsillectomy and/or adenoidectomy under supervision of the authors from August 1999 to March 2005 at the Department of Otolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University. Results: One hundred and twenty-three charts were retrieved from the total number of 129 pediatric patients who were operated during the study period. Obstructive sleep apnea syndrome (OSAS) was the most common indication for surgery (86%). Seventy percent of patients were between three to eight years old. Obesity was the most common co-morbidity (17.9%) followed by otitis media with effusion (13.8%) and allergic rhinitis (8.1%). Six patients (4.9%) had minor complications which were two cases (1.6%) of postoperative bleeding, three cases (2.4%) of loosening deciduous teeth, and one case (0.8%) of lip ulceration. Postoperative fever and inadequate oral intake prolonged hospitalization in twenty patients (16.3%). However, all patients improved and discharged within 48 hours postoperatively. All parents were satisfied with the final results of the procedures. Conclusion: Tonsillectotmy and adenoidectomy were safe, effective procedures in pediatric patients. The most common indication was OSAS. Obesity was the most common co-morbidity found in the patients with OSAS. Complications were rare, easily detected and treated.

Identification of high-risk tonsillectomy and adenoidectomy.

Objective: To identify children who were at risk to postoperative complications after tonsillectomy and/or adenoidectomy, and to propose a guideline for care giving of this group of patients. Methods: Retrospective chart study of children who underwent tonsillectomy and/or adenoidectomy and required special postoperative care was performed from August 1999 to March 2005. All children were treated under supervision of the authors at the Department of Otolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University. Results: One hundred and twenty-nine children were operated during the study period. One hundred and twenty-three charts were retrievable. Forty-seven children were included in the series. Four categories of patients, i.e., very young-age group, intensive care unit group, extended admission group, and postoperative bleeding group, were identified. Eleven children (23.4%) whose ages were less than 36 months were observed in post-anesthetic recovery unit (PACU) for 5-6 hours with oxygen saturation monitoring and oxygen supplementation. Fourteen children (29.8%) were admitted to pediatric intensive care unit (PICU) with the most common indication of morbid obesity (64.3%). Four children needed interventions, which were two intravenous dexamethasone injections and two temporary continuous positive airway pressure (CPAP) administrations in PICU. Twenty children (42.6%) had extended admission because of postoperative fever and inadequate oral intake. However, every one of them improved within 48 hours postoperatively. Two children (4.2%) had minor postoperative bleeding and one of them needed bleeding control. Conclusion: Tonsillectomy and adenoidectomy are procedures of low morbidity in healthy children. However, very young patients and those with high-risk of co-morbidities are considered to have high chance of compromised airway and inadequate oral intake. Besides our routine admission, we suggest that children under the age of 36 months need close observation for 5-6 hours in PACU. Admission in PICU is probably necessary for children who have high-risk of co-morbidities such as morbid obesity, asthma, cardiac diseases, neuromuscular disorders, craniofacial anomalies. Adequate oral intake is needed before removing intravenous fluid line and a consideration of discharge. Extended admission is unnecessary for postoperative fever, which mostly disappears within 48 hours.

How to overcome laryngotracheal stenosis.

OBJECTIVES: To review and evaluate the outcome of the treatment of laryngotracheal stenosis (LTS). DESIGN: Descriptive review cases. SETTING: Tertiary care university hospital. PATIENTS: Series of LTS patients who were treated by the first author (TW) from January 2000 to January 2003. MAIN OUTCOME MEASURES: Leading causes of LTS, details of the lesions, therapeutic procedures, complications of treatment, time to and success in decannulation. RESULTS: Twenty-one patients (9 females and 12 males), ranging in age from 1 to 32 years old were included in the present study. Half of the patients were under 10 years old. The most common site of the lesion was the subglotic lumen (14 cases), followed by the cervical trachea (5 cases). Patients were treated using endoscopic methods (6 cases), laryngotracheal reconstruction (LTR) (9 cases), tracheal resection (3 cases), and partial cricotracheal resection (3 cases). Decannulations were achieved in 19 patients (90.5%). Endoscopic treatment succeeded within 2-4 procedures in properly selected cases. Despite LTR, multiple sessions of endoscopic laser surgery, and arytenoidectomy, decannulation was not achieved in two of the cases, both of whom had all-level laryngeal stenosis. Time to decannulation ranged from 2 to 210 days. The major causes of delayed decannulation were the presence of a large bare area of cartilaginous grafts and restenosis with granulation tissue formation CONCLUSION: Appropriate LTS treatment, which is based on the description of the lesion, results in a high decannulation rate within a proper time. Multilevel LTS, especially in the supraglottic and glottic area, is refractory to various treatment modalities, and full function of the larynx may not be restored.

Nasal granuloma gravidarum presenting with recurrent massive epistaxis.

Nasal granuloma gravidarum is a rare condition associated with pregnancy and minor trauma. This condition presents with a nasal mass with varying degree of bleeding and obstruction. We report a patient with nasal granuloma gravidarum in the third trimester of pregnancy. Surgical excision is the definite treatment for this condition in order to stop the vicious cycle of recurrent massive bleeding. Possible etiology, clinical features and management are discussed.

Ear diseases and hearing in the Thai elderly population. Part I. A comparative study of the accuracy of diagnosis and treatment by general practitioners vs ENT specialists.

The prevalence of ear disease and hearing disability in elderly Thais in 14 urban communities around Siriraj Hospital was studied. The accuracy of diagnosis and treatment of common ear diseases and of screening for hearing loss in the elderly between general practitioners (GP) and Ear, Nose and Throat (ENT) specialists was also compared. Elderly people aged 60 years or more who had registered with the health care program had their ear and hearing check-up performed by GPs and ENT specialists from mobile team. Altogether, 980 subjects were included, 332 were males, 648 were females, (male:female ratio 1:2). Their ages ranged from 60-96 years with an average age of 68.5 years. The prevalence of ear disease diagnosed by ENT specialists was 16.3 per cent (95% CI = 14.0-18.6), 12.5 per cent was external ear disease and 2.7 per cent middle ear disease. The most common ear problem was impacted ear wax (8%), the second most common problem was otitis externa (4.3%). Compared with an ENT specialist, the ability of a GP to diagnose ear diseases had a sensitivity of 46.5 per cent and a specificity of 80.3 per cent, the positive predictive value of their diagnoses was 31.5 per cent. The efficacy of the treatment of ear diseases in 51 elderly people by GPs and in 63 elderly people by ENT specialists was statistically significantly different (p = 0.02). Hearing screening by the GP using whisper or the watch test performed in 650 elderly people revealed abnormal findings (could not hear) in 70 cases or 10.8 per cent. Hearing screening using pure tone audiometry in 980 elderly people showed abnormal hearing level in 508 cases (52.4%). 9.5 per cent of them had a bilateral moderate to severe degree of hearing impairment. There was no difference in the level of hearing impairment between males and females or between right and left ears. The prevalence of hearing loss increases with increasing age. Tympanometry performed by an acoustic impedance machine in 980 of the elderly showed a conductive hearing loss in 85 cases (9.1%). The authors conclude that the prevalence of ear disease in elderly people living in the urban community around Siriraj Hospital is quite high. Although the ear diseases commonly encountered were not serious, if left untreated they may lead to complication and decreased hearing. Therefore, the proficiency of GPs in the management of common ear diseases in every community should be regularly maintained. Hearing impairment is very prevalent and increases with age. Thus, screening for hearing loss using an audiometer and/or acoustic impedance is recommended for all senior citizens in their community at least once a year. Early detection of elderly persons who could benefit from a properly fitted hearing aid will certainly improve the quality of life and may prevent psychiatric and functional impairment of the Thai elderly population.

Ear diseases and hearing in the Thai elderly population. part II. A one year follow-up study.

The ear and hearing survey of the Thai elderly in 14 urban communities around Siriraj Hospital was repeated one year after the first survey in order to detect any changes. Altogether 556 elderly people came for follow-up examination, 191 were males, 365 were females, the average age was 68.2 years (60-88 years). Ear disease was diagnosed by ENT specialists in 80 cases which implied that the prevalence of ear disease was 14.4 per cent. This was not statistically significantly different from the prevalence of ear disease in the survey conducted in the previous year and although the elderly who had ear diseases in the first survey had already been treated, the prevalence did not decrease. Some elderly people only had ear diseases in this survey. Hearing evaluation by pure tone audiometry was performed in 549 elders. There were 12.4 per cent who had bilateral, moderate to severe hearing loss which was 2.9 per cent higher than in the previous survey. The hearing level had also deteriorated in 14.3 per cent of the elderly people. Tympanometry was performed in 556 cases and showed that 10.5 per cent had a conductive hearing loss. When audiometry and tympanometry of the same elderly people were evaluated together, 49.2 per cent of them had a sensorineural hearing loss, 3 per cent had a conductive hearing loss and 6.5 per cent had a conductive or mixed type hearing loss. When the results of audiometry were compared with the self identification/perception of their hearing reported by the elderly in the questionnaires, they were not reliable. In conclusion, a one-year follow-up study of the prevalence of ear disease and hearing impairment in the elderly showed that the prevalence of ear disease was still high and had not changed significantly. Concerning hearing impairment, not only had the prevalence increased, but also the severity of hearing loss. Therefore, the authors stress the need to implement the "Ear and Hearing Care" program for the elderly both in rural and urban communities at least once a year in order to improve quality of life of the elderly Thai people and to prevent complications of ear disease.

Primary ciliary dyskinesia: A case presentation and A current review.

We present a 14 year-old girl with a history of chronic rhinorrhoea and nasal obstruction. Physical findings showed huge nasal polyp with broadening of the nasal bridge, perforation of the left ear drum and a right middle ear effusion. Despite a strict program of nasal saline toilet, broad-spectrum antibiotics covering beta-lactamase producing organisms, and meticulous technique of endoscopic sinus surgery, the patient's symptoms and nasal polyp reappeared very quickly. A set of investigations had been done in order to confirm and rule out suspected diseases. The electron microscopic study of the patient's nasal mucosa revealed partial absence of inner dynein arms and extra singlet at the center in some axoneme compatible with Primary ciliary dyskinesia.

Broncho-alveolar lavage: An aid to diagnosis in immuncompromised children with pulmonary lesion.

Conventional broncho-alveolar lavage with flexible bronchoscope has proven to be an effective method for the diagnosis of pulmonary lesions, especially in immunocompromised patients. The disadvantage of flexible endoscopy is that it can not be performed safely in pediatric patients with compromised airway due to the lack of ventilating channel. We designed an alternative method for broncho-alveolar lavage by target bronchus and secure the airway at the same time. We performed brocho-alveolar lavage via that method in 15 immunocompromised paediatric patients with signs and symptoms of pneumonia from December 1995 to September 1997. The group comprised eight males and seven females with a mean age of 30.35+24.60 months. Most of the patients had positive HIV titre (86.67 percent). Causative agents were identified in 11 of 15 patients (77.33 percent) Pneumocystis carinii was found in four cases (26.7 percent) followed by fungus (four cases, 26.7 percent), Mycobacterium tuber culosis (one cases, 6.7 percent) and Respiratory syncytial virus (one cases, 6.7 percent). No complications were reported. Compared to the literature control which gave an average yield of 45-84 percent, this technique of brocho-alveolar lavage was proven to be an effective, safe diagnostic method which gave satisfactory results.

Upper aerodigestive tract endoscopy during the first year of life: A current review.

A five-year retrospective review of 52 infants who underwent 67 endoscopic procedures of the upper aerodigestive tract was performed. The ages of the patients ranged from one day to one year with a mean of 157 days. The most common indication of endoscopy was stridor/respiratory distress (46.3 per cent) and persistent wheezing (16.4 per cent). Congenital anomalies were the causes of airway problems in more than half of the patients and laryngomalacia was the most common diagnosis (34.6 per cent), followed by congenital subglottic stenosis (7.6 per cent). There were 19.2 per cent of cases who had more than one airway lesion. Diagnosis was obtained from endoscopy in90.4 per cent of cases. There were two cases of gastroesophageal reflux (GER) diagnosed by nuclear scintigraphy. Therapeutic procedures during and after endoscopy were also reviewed. Only minor complications were found in three cases (4.5 per cent) (one bronchospasm, two subglottic oedema ). Endoscopy was found to be a safe, accurate diagnostic method which also offered useful therapeutic interventions.