Epidermal inclusion cyst versus thyroglossal duct cyst: sistrunk or not?

Epidermal inclusion cyst (EIC) is a recognized cause of an anterior neck mass in children. Controversy exists as to the proper surgical management of an anterior neck EIC: is simple excision adequate treatment, or is a Sistrunk procedure necessary? A retrospective review of the operative logs of the two senior authors (M.M.A., R.F.W.) from 1993 to the present revealed 16 children, ages 6 months to 9 years (mean, 4.5 years), with a diagnosis of anterior neck EIC. An accurate intraoperative diagnosis of an EIC in all cases allowed for a simple excision of the mass rather than a Sistrunk procedure. The final histologic diagnosis was EIC in all 16 patients. Follow-up of these 16 patients for a mean of 4.5 years revealed no recurrences or complications. When the diagnosis of EIC can be made confidently in the operating room, simple excision is an adequate surgical treatment.

Atypical indications for OtoScan laser-assisted myringotomy.

OBJECTIVE: To describe the role of OtoScan laser-assisted myringotomy (OtoLAM) for indications other than chronic otitis media or recurrent acute otitis media. STUDY DESIGN: Cross-sectional review. METHODS: Twenty-seven office-based OtoLAM procedures were performed in 21 patients for "atypical" reasons. The indications included middle ear dysfunction with necessary air travel (n = 10) or hyperbaric oxygen treatment (n = 6), mastoiditis with postauricular cellulitis (n = 2), canal exostosis prohibiting tympanostomy (n = 1), acute otitis media accompanied by seizures (n = 1), and chronic middle ear effusion in a patient with hemophilia (n = 1). RESULTS: In each of the 20 cases available for follow-up, middle ear disease resolved with closure of the laser-assisted myringotomy. At a later date, two patients (10%) underwent another OtoLAM in the opposite ear and four patients (20%) required repeat OtoLAM in the same or both ears. Three patients (15%) ultimately underwent myringotomy tube placement because of recurrent middle ear dysfunction. CONCLUSIONS: Although this report contains preliminary data, the data suggest that OtoLAM may provide an additional option in the care of certain patients who have previously been treated with myringotomy tubes.

Superior adenoidectomy in children with palatal abnormalities.

When treating a child with a palatal abnormality for otitis media or a nasal obstruction, otolaryngologists often face the question of whether the benefits of adenoidectomy are worth the risk of the development of velopharyngeal insufficiency. Treatment options for these patients include a complete adenoidectomy, a partial adenoidectomy, or no surgical intervention. In this retrospective study, we describe the outcomes of 22 such patients who were treated with a superior adenoidectomy performed with a St. Clair adenoidforceps under indirect vision with a laryngeal mirror. All patients experienced a complete or near-complete resolution of their nasal obstruction, and none developed permanent velopharyngeal insufficiency. Only three patients experienced a recurrence of otitis media. Our experience suggests that superior adenoidectomy is a safe and effective procedure.

Role of otoscan-assisted laser myringotomy in hyperbaric oxygen therapy.

Patients undergoing hyperbaric oxygen (HBO2) therapy often experience middle ear barotrauma. Not infrequently this disrupts therapy and may require myringotomy tube placement. A new, simple, office-based procedure known as OtoScan Laser Assisted Myringotomy (OtoLAM) provides temporary middle ear ventilation, which offers significant potential benefis for HBO2 patients. Five patients whose middle ear disease complicated their HBO2 therapy have undergone nine OtoLAM procedures in 11 ears. All patients tolerated the procedure without complications and immediately returned to HBO2 treatment. Based on this preliminary experience, we recommend OtoLAM for selected HBO2 patients with problematic middle ear dysfunction.

Mitomycin-C in the treatment of tracheal cicatrix after tracheal reconstruction.

OBJECTIVE: To demonstrate the potential use of Mitomycin-C (MMC) in the treatment of difficult and recurrent tracheal stenosis. DESIGN: Case series. SETTING: Tertiary care setting. PATIENTS: A retrospective chart review was performed on five pediatric patients with severe, recurrent tracheal granulation and cicatrix after tracheal reconstruction who were treated with topical MMC as an adjunct to bronchoscopy and laser treatment. MMC was applied intraoperatively on saturated pledgets at a dose of 0.1 mg/ml for 2 min to the area where the cicatrix had been lysed. The five patients were able to be decannulated. DISCUSSION: Mitomycin-C is an anti metabolite known to inhibit fibroblast proliferation in vitro. This agent has been used with a high success rate in glaucoma filtration surgery to promote patency of the trabecula. The results of this preliminary application in the pediatric airway as well as the mechanism of action will be discussed.

Diagnosis, management, and follow-up of congenital head and neck teratomas.

OBJECTIVE: To describe our clinical experience with congenital teratomas of the head and neck. STUDY DESIGN: A retrospective review of the six patients as well as a review of the literature in the setting of academic referral centers. METHODS: In six infants with teratomas, four in the cervical region and two arising from the nasopharynx, surgical excision of all tumors was performed. Outcome measures were clinical and radiographic follow-up and the use of a-fetoprotein (AFP) for postoperative monitoring. RESULTS: There was no recurrence of teratomas. CONCLUSIONS: Surgical excision is the treatment for congenital teratomas. Postoperative monitoring for recurrences should include AFP levels in difficult cases.

Modifications of airway reconstruction in children.

We review our treatment experience of subglottic stenosis in 66 children. Sixty-one of these children required some form of airway expansion using cartilage grafts. Eight children had grade I (Cotton classification), 15 grade II, 28 grade III, and 15 grade IV stenosis. All patients with grade I and II lesions were decannulated. Ninety-three percent of grade III patients and 67% of grade IV patients were also ultimately decannulated. Laryngotracheal reconstruction with costal cartilage grafting has become widely accepted for treatment of severe laryngotracheal stenosis. Several modifications of this technique have been employed to treat our patients. Recently, we have used a modified single-stage technique with an endotracheal tube stent, externally secured for 1 week, to avoid postoperative intensive care unit admission for sedation and/or paralysis, and its related complications. Posterior graft design and placement without sutures was also performed in 20 cases. A two-surgeon technique that involves a simultaneous endoscopic control of incision of the stenotic area was employed. These modifications will be described in detail.

Growth factors in subglottic stenosis.

We sought to define the role of fibrogenic peptides in subglottic stenosis (SGS). Biopsy specimens were obtained from patients with stenosis following endotracheal intubation (group 1, n = 5, mean age 5), patients without a history of any precedent trauma, ie. idiopathic stenosis (group 2, n = 3, mean age 40), and those without stenosis (group 3, n = 3, mean age 70). Formalin-fixed biopsy specimens were analyzed following immunohistochemical staining to determine if epidermal growth factor (EGF), platelet-derived growth factor-AA and -BB (PDGF-AA/BB), transforming growth factor-beta 1 and -beta 2 (TGF-beta 1, beta 2), or basic fibroblast growth factor (bFGF) was deposited in these tissues. Blinded analysis revealed TGF-beta 2 and PDGF-AA to be present in seven of eight biopsy specimens from SGS and absent in controls. Staining for PDGF-BB was observed in the mucosa and submucosa and occasionally within vessel walls. Staining of individual growth factors appeared to correlate closely with the presence of granulation tissue. Essentially no bFGF or TGF-beta 1 was observed. Differences were found between patients in groups 1 and 2; tissue from group 1 revealed deposition of EGF and PDGF-BB in submucosa, epithelium, and vasculature. In summary, our experimental findings implicate PDGF and TGF-beta 2, perhaps acting in concert, in mediating the pathologic fibrotic process observed in subglottic stenosis. Epidermal growth factor, in conjunction with TGF-beta and PDGF, may also have a role, but further investigation is needed to more precisely define it.

Reverse transcriptase in situ polymerase chain reaction in atypical mycobacterial adenitis.

OBJECTIVE: To determine whether reverse transcriptase (RT) in situ polymerase chain reaction (PCR) can facilitate the diagnosis of nontuberculous ("atypical") mycobacterial (NTM) cervical adenitis. DESIGN: Retrospective review of 12 patients with neck masses clinically diagnosed as NTM cervical adenitis. SETTING: University medical center caring for both ambulatory and hospitalized children. PATIENTS: Twelve pediatric patients (all younger than 9 years) with cervicofacial masses. INTERVENTION: Surgical excision of the presenting mass. MAIN OUTCOME MEASURES: Reverse transcriptase in situ PCR was used to detect mycobacterial RNA in excised tissue. All specimens were also cultured and stained for acid-fast bacilli. RESULTS: Reverse transcriptase in situ PCR was positive for NTM in 7 of 12 cases. CONCLUSIONS: Infection with NTM may be an extremely indolent process, and the success of RT in situ PCR depends on the presence of mycobacterial nucleic acids. Even in cases in which the findings of RT in situ PCR were positive, infected cells were few in number. Because of the sparsity of infection in the positive cases, NTM may be even more rare in the negative cases, ie, those in which mycobacterial nucleic acids do not exist and cannot be detected by any means, including RT in situ PCR. Although RT in situ PCR, cultures, stains for acid-fast bacilli, and tuberculin tests using purified protein derivative are all helpful in diagnosing NTM cervical adenitis, when nucleic acids are present RT in situ PCR is the simplest, most reliable, and quickest to perform and the results are easiest to interpret.

Polysomnography after adenotonsillectomy in mild pediatric obstructive sleep apnea.

OBJECTIVES: a) To determine the need for intensive monitoring on the first operative night of surgery in children undergoing adenotonsillectomy for mild obstructive sleep apnea; b) to examine the effect of narcotics on postoperative obstructive sleep apnea. DESIGN: Randomized, prospective study. SETTING: University hospital. PATIENTS: Children, ranging in age between 1 and 18 yrs, presented to the Pediatric Otolaryngology Clinic for adenotonsillectomy for mild obstructive sleep apnea defined as from one to 15 obstructive apnea events per hour on preoperative polysomnogram. INTERVENTIONS: Patients were assigned to receive either a narcotic- or a halothane-based anesthetic for adenotonsillectomy. A postoperative polysomnogram was performed in the pediatric intensive care unit on the first operative night. MEASUREMENTS AND MAIN RESULTS: Eighteen patients were recruited, 15 of whom met inclusion criteria: nine patients received a halothane-based anesthetic and six patients received a fentanyl-based anesthetic. When the data were analyzed by pooling both groups, the differences between pre- and postoperative sleep studies demonstrated a reduction in the number of obstructive events and less severe oxygen desaturations on the operative night. Total sleep time between the two sleep studies decreased from 371 +/- 13 to 304 +/- 14 mins. The number of obstructive apnea events/hr decreased as well. The lowest oxygen saturation measured during rapid eye movement sleep was 78 +/- 5% preoperatively and 92 +/- 1% postoperatively. CONCLUSIONS: Our data suggest that children without underlying medical conditions, neuromotor diseases, or carniofacial abnormalities, 1 to 18 yrs of age, who suffer from mild obstructive sleep apnea, have improvements documented by polysomnography on the night of surgery following adenotonsillectomy and do not necessarily need to be monitored intensively. These findings were not significantly affected by the choice of intraoperative anesthetic.

The effect of intravenous dexamethasone in pediatric adenotonsillectomy.

OBJECTIVE: To determine whether the intravenous administration of dexamethasone sodium phosphate before tonsillectomy and adenoidectomy can reduce the morbidity from, and increase the safety of, this procedure. DESIGN: Prospective, randomized, double-blind, placebo-controlled clinical trial. SETTING: A university medical center, caring for both ambulatory and hospitalized children. PATIENTS: Eighty children aged 3 to 15 years undergoing tonsillectomy and adenoidectomy for either chronic tonsillitis or adenotonsillar hypertrophy (obstructive sleep apnea and/or upper airway obstruction). INTERVENTIONS: Forty-one children received intravenous dexamethasone sodium phosphate (1 mg/kg up to 16 mg) and 39 received placebo before undergoing an electrocautery dissection tonsillectomy and adenoidectomy. MAIN OUTCOME MEASURES: Postoperative oral intake, pain, vomiting, temperature, and complications. RESULTS: Patients who received intravenous dexamethasone had significantly less trismus, vomiting, and elevations of temperature 6 hours after surgery and more oral intake (liquids and soft solids) at 24 hours. Three children, all of whom were in the placebo group, had emergency department visits for pain and dehydration. Each group had one child who had a secondary hemorrhage (no surgery needed), one child who had pneumonia, and one child who had night terrors. CONCLUSIONS: Treatment with intravenous dexamethasone before electrocautery tonsillectomy and adenoidectomy is safe, increases early postoperative oral intake, and decreases morbidity.

Self-induced pneumoparotitis.

Pneumoparotitis is a rare cause of enlargement of the parotid gland; it is often misdiagnosed and therefore incorrectly treated. We report three pediatric cases of self-induced pneumoparotitis and detail the clinical presentation, pathogenesis, radiographic findings, and treatment options. We also review the literature on the subject. In children, inflammatory swelling of the parotid gland is usually due to acute viral or bacterial infection, juvenile recurrent parotitis, or allergic, autoimmune, or systemic disease. Infrequently, swelling may result from air being forced through Stensen's duct, resulting in pneumoparotitis. This may occur as a transient or recurrent phenomenon. Recurrent parotid insufflation is not entirely benign and may predispose to sialectasias, recurrent parotitis, and even subcutaneous emphysema.

Pediatric otolaryngology: isolated cervical subcutaneous emphysema.

Two cases of pediatric isolated cervical emphysema caused by foreign bodies are presented. This report emphasizes the need for roentgenograms, flexible nasolaryngoscopy, and situational barium swallows to identify the exact location of a tear and to determine whether the situation requires direct laryngoscopy and esophagoscopy to remove a foreign body, or an open surgical repair of a mucosal disruption. The treatment of this self-limited condition usually requires only antibiotics, fasting, intravenous fluid, and most importantly, close observation for signs of perforation.

Massive cystic heterotopic brain tissue.

The differential diagnosis of large cystic masses in the newborn should include heterotopic brain tissue. This lesion is attributed to early displacement of pluripotential cells and cyst formation may result from cerebrospinal fluid production by choroid plexus-like structures. Treatment consists of surgical excision.

Coronal CT scan abnormalities in children with chronic sinusitis.

Coronal computed tomography (CT) scans are currently the optimal study to display the normal and abnormal anatomy in children with chronic and recurrent acute sinusitis after failure of medical therapy. To assess the extent and distribution of disease as well as associated anatomic abnormalities in this pediatric population, 74 coronal CT scans of children with continued symptoms of sinusitis after failure of extensive medical therapy were reviewed retrospectively. Twelve children with cystic fibrosis showed the characteristic features of medial displacement of the lateral nasal wall in the middle meatus and uncinate process demineralization, creating the appearance of a maxillary sinus mucocele. Nine of these 12 children had increased attenuation in the maxillary sinus on soft-tissue windows. In the remaining 62 children, a significantly greater frequency of disease, when compared with that reported for adults, was seen in the maxillary, anterior ethmoid, posterior ethmoid, and frontal sinuses. Children with asthma (n = 33) had more extensive disease. Bony anatomic abnormalities were similar to those reported for adults, except for a lower incidence of septal deformity.