Laryngotracheal reconstruction and cricotracheal resection in children: recent experience at Great Ormond Street Hospital.

BACKGROUND: Surgery for paediatric airway stenosis is constantly evolving. Surgery is the primary treatment modality via either an open or endoscopic approach. The objective of this study was to review the results of laryngotracheal reconstruction (LTR) and cricotracheal resection (CTR) procedures performed at Great Ormond Street Hospital over the past 10 years. METHODS: All patients who underwent open airway reconstruction surgery from January 2000 to December 2010 were included in this study. Patients treated entirely endoscopically were excluded. The data was collected using the electronic operating theatre database and the discharge summary database. RESULTS: Complete data was available for 199 patients who underwent open airway reconstruction from January 2000 to December 2010. The procedures included single stage LTR (57, 28.6%), two stage LTR (115, 57.7%), single-stage stomal reconstruction (14), single-stage CTR (8) and two-stage CTR (5). The diagnoses at the initial airway endoscopy were laryngeal web (22), subglottic stenosis (151), posterior glottic stenosis (9), suprastomal collapse (15), supraglottic stenosis (1) and tracheal stenosis (1). For those with subglottic stenosis, the stenosis was grade 1 in 1 patient, grade 2 in 26 patients, grade 3 in 117 patients and grade 4 in 6 patients. At the completion of intervention 175/199 (87.9%) patients reported improvement in their symptoms. Amongst the subglottic stenosis group, post LTR success was achieved in 100% with grade 1 stenosis, 92.3% with grade 2 stenosis, 88.1% in grade 3 stenosis and 83.3% in grade 4 stenosis. Of the two-stage LTR procedures, 100/115 (86.9%) had their tracheostomy removed and 15/115 (13.1%) have failed decannulation. Of the single-stage LTR group, 50/57 (87.7%) patients were better both on airway examination and symptomatically postoperatively. Of the single-stage stomal reconstruction group, 13/14 (92.8%) were better symptomatically and on airway examination. Patients who underwent single-stage CTR had a better airway on examination and were symptomatically improved in all cases (8/8). For the patients who underwent two stage CTR, the tracheostomy was removed in 3/5 (60%) and retained in 2/5 (40%). For the whole group, 15/199 (7.5%) patients underwent a revision LTR. On further analysis, revision LTR was required in 4/57 (7.1%) single-stage LTR, 9/115 (7.8%) two-stage LTR, 1/5 (20%) two-stage CTR and 1/8 (12.5%) single-stage CTR. In this study complications occurred in 13/199 (6.5%). CONCLUSIONS: Subglottic stenosis in children needs to be approached on the basis of the nature and severity of stenosis and the individual patient's general health. Good outcomes are achieved with both LTR and CTR. Good results are obtained both with single-stage and two-stage LTR, but restenosis remains a problem. An individual approach is required for treatment of paediatric airway stenosis to achieve good final outcomes. The overall success rate has increased only marginally in our institution over the last 20 years.

Trends in paediatric airway surgery: a move towards endoscopic techniques.

The endoscope has long been an invaluable tool in assessment of the paediatric airway. Recently, its applications for definitive surgery of the airway have greatly increased, due to innovative surgical techniques, development of new instruments, improvements in anaesthesia and availability of new medications for endoscopic use. This review discusses the move towards endoscopic techniques in the management of paediatric airway disorders.

Treatment of piriform fossa sinuses with monopolar diathermy.

INTRODUCTION: Embryological remnants of third or fourth branchial pouches are a rare but important cause of recurrent neck abscesses in children. They are characterised by an internal opening in the piriform fossa. Traditional management involves surgical excision of the entire tract. We present our experience with the use of monopolar diathermy applied to the internal sinus opening as a treatment modality for this condition. MATERIALS AND METHODS: A retrospective, case report review was performed. RESULTS: Four cases of piriform fossa sinus were treated with monopolar diathermy to the sinus opening via an endoscopic approach. The first three cases were treated in this way for recurrence, following external tract excision, while the fourth case had simultaneous excision of the tract and diathermy to the piriform fossa opening. There were no serious complications and no recurrence within a follow-up period ranging from nine to 27 months. DISCUSSION: Obliteration of the internal opening of these sinuses by endoscopic diathermy is a safe and effective management option for this condition, either as an alternative to or as an adjunct to external surgical excision of the tract.

The Great Ormond Street Hospital paediatric cochlear implant programme 1992-2004. A review of surgical complications.

The authors present a review of surgical complications following cochlear implantation at Great Ormond Street Hospital, since inception of the programme in 1992 until June 2004. Complications are defined as major (resulting in re-operation, explantation, re-implantation or which resulted in permanent serious morbidity or mortality) or minor (where the implant was not threatened). A comparison of surgical complication rates is made both with an earlier study in the same institution and also with other cochlear implantation centres worldwide. The decrease in surgical complication rates is discussed along with the difficulties inherent in cochlear implantation in the paediatric population with coexisting medical complaints.

Updated surgical experience with bone-anchored hearing aids in children.

BACKGROUND: We present the results of a retrospective review of children undergoing implantation with bone-anchored hearing aids (BAHAs) at the Great Ormond Street Hospital for Children. METHODS: The case notes of 71 children undergoing BAHA placement at the Great Ormond Street Hospital for Children between December 1990 and August 2002 were reviewed. Outcome measures included hearing thresholds, incidence of fixture loss, skin reaction and need for revision. Quality of life outcomes were also measured. RESULTS: Eighty-five ears had been implanted. Fifty-four per cent of children had experienced no complications, 42 per cent had required revision surgery and 26 per cent had experienced fixture loss at some point. Young age at implantation was associated with an adverse outcome. Trauma and failure of osseointegration had been the commonest reasons for failure. A skin reaction around the abutment had occurred at some point in 37 per cent of children but had persisted for longer than six months in only 9 per cent; this had been associated with fixture loss. The use of fixture site split skin grafts had reduced problems with skin hypertrophy and hair overgrowth. Hearing thresholds when using BAHAs had been comparable to those when using bone conduction hearing aids. However, BAHAs had significant additional benefits in terms of sound quality, ease of use and overall quality of life. CONCLUSION: Bone-anchored hearing aids provide significant benefits over other types of hearing aid, both audiologically and in terms of quality of life. Careful selection of candidates and meticulous follow up are required in order to minimize complications.

Subglottic haemangioma in children: experience with open surgical excision.

Subglottic haemangioma is a potentially life-threatening condition for which various treatment modalities are available. The objective of this study was to evaluate our results for open excision of subglottic haemangioma. The study assessed 18 patients who had been treated at a paediatric tertiary referral centre. Most of these patients (83.3 per cent) had undergone open surgical excision without post-operative tracheostomy and had been intubated for several days post-operatively (single-stage procedure). In most of these patients (66.7 per cent), an anterior cartilage graft had been used for reconstruction. The average follow up in this study was 25 months. All the patients in this series had achieved an adequate airway after the procedure. One patient had developed a recurrence of haemangioma in the trachea at a later date. The results of open surgical excision in this study were very encouraging. Seventeen out of 18 (94.4 per cent) patients had avoided tracheostomy or had been decannulated as a direct result of surgery. One of these 18 patients (5.6 per cent) had required a temporary post-operative tracheostomy for 13 months as the subglottis cleared; this was classed as a partial success. Our experience is that open excision is a highly successful 'one stop' treatment for subglottic haemangioma, which avoids prolonged use of steroids and multiple endoscopic procedures. No patient in this series developed subglottic stenosis, which can be a significant complication of laser application.

The midfacial degloving approach to sinonasal tumours in children.

The midfacial degloving approach was originally described by Denker and Kahler in 1926 but has been little used in the paediatric population. The procedure allows access to benign and malignant lesions of the sinonasal region with the avoidance of an external scar. The advantages and application of this technique are presented in 9 paediatric patients, ranging from 3 months to 15 years of age with a mean follow-up of 7 months. Eight children had benign pathology. There were two juvenile angiofibromas, two nasal gliomas, one ossifying fibroma, one fibroma, one fibrous dysplasia and one benign myofibroblastic proliferation. One child had malignant disease in the form of recurrent embryonal rhabdomyosarcoma. All had excellent cosmetic results and no complications were encountered during follow-up.

Chronic suppurative otitis media following paediatric cochlear implantation.

The objective of this study was to report and discuss the management of chronic suppurative otitis media (CSOM) following cochlear implantation in children. The study was a retrospective review of 650 patients receiving an implant at two paediatric tertiary referral centres for cochlear implantation. Nine patients were identified who developed CSOM following cochlear implantation (incidence 1.38%). The mean time interval between implantation and symptom development was 3.66 years (range 2-8 years) and the mean time interval between implantation and CSOM surgery was 5.02 years (range 2.2-8 years). All patients presented with otorrhoea and/or abscess formation over the implant site. Two patients underwent a modified radical mastoidectomy and seven underwent a combined approach tympanoplasty, three of whom required posterior canal wall reconstruction with cortical bone and one with cartilage. In four cases it was possible to remove the cholesteatoma without removing the implant. All but two patients were fitted with a contralateral implant. In the explanted ears the cochlear implant electrode was cut at the cochleostomy site, which was then covered with muscle. Chronic suppurative otitis media following cochlear implantation may occur either as a result of a posterior canal wall defect related to surgery or possibly de novo. Attempts should be made to save the implant, but explantation with reimplantation of the contralateral ear may be the only option. In these cases the intracochlear part of the electrode array should be left in situ to facilitate possible future reimplantation. Surgical options for management of CSOM should be individualized and may include both canal-wall up and canal-wall down techniques. To reduce the incidence of CSOM following implantation the authors recommend: (1) prompt treatment and careful follow-up of patients with a history of otitis media with effusion, (2) avoidance of excessive thinning of the posterior canal wall during mastoidectomy and (3) reconstruction of any accidental trauma to the annulus or posterior canal wall during posterior tympanotomy.

How we do it: BAHA positioning in patients with microtia requiring auricular reconstruction.

Keypoints * Bilateral microtia is a challenging problem as these patients require both reconstruction of the auricle and rehabilitation of hearing. * Our aim was to find the optimal position for bone-anchored hearing aids (BAHA) in patients requiring reconstruction of the auricle on the same side. * From an analysis of five such operated patients, it was found that siting a BAHA 6.5-7.0 cm from the position of the external auditory meatus is probably the correct distance to facilitate optimal auricular reconstruction. * Using these criteria, a group of another five patients with BAHA awaiting auricular reconstruction were reviewed. Of these only three (60%) have been satisfactorily sited.

Laryngeal ultrasound to assess vocal fold paralysis in children.

The purpose of this study was to assess the practicality and validity of laryngeal ultrasound to establish vocal fold movement in children with suspected vocal fold palsy. Fifty-five consecutive patients (age range three days to 12 years) with suspected vocal fold palsy underwent both laryngoscopy and laryngeal ultrasound. Ultrasonographic findings correlated with endoscopic findings in 81.2 per cent of cases. This, however, rose to a concordance rate of 89.5 per cent in patients aged over 12 months. Laryngeal ultrasound is well-tolerated, safe and non-invasive and the authors feel that it is a useful adjunct to endoscopy in the diagnosis of vocal fold palsy.

An update on choanal atresia surgery at Great Ormond Street Hospital for Children: preliminary results with Mitomycin C and the KTP laser.

We present the results of transnasal choanal atresia correction in 46 children, as an update to the published Great Ormond Street Hospital series. Females outnumbered males 2-1, and half the cases in our series were bilateral. Eight of the children with bilateral atresia had the CHARGE association. The median number of procedures required was three over a period of up to 3 years. Eighty-two percent of children with unilateral atresia and 78% of those with bilateral atresia were asymptomatic at the time of their last follow up. Four deaths occurred, all but one in children with CHARGE association. We were not able to demonstrate any benefit from the use of Mitomycin C, the KTP laser, betamethasone nasal drops or (in unilateral cases) stents.

Third and fourth branchial pouch anomalies.

Congenital sinuses arising from the pyriform fossae are rare. They may present as neck cysts, recurrent neck abscesses, thyroiditis or neonatal stridor. Children typically undergo multiple surgical procedures before the diagnosis is made. We present our recent experience of five third-pouch sinuses and four fourth-pouch sinuses, including one bilateral case. The median age at presentation was four years. The mean number of operations prior to diagnosis was six (range 0-13), with a mean delay to diagnosis of six years. The diagnosis was made by barium swallow, by ultrasound, at pharyngoscopy or at open surgery. The median age at definitive surgery was 10 years. Definitive treatment involved complete excision of the sinus and neck mass in seven cases. Two sinuses were treated with endoscopic diathermy to their internal opening. Adoption of the correct nomenclature, diagnostic tools and operative requirements for these cases will help reduce the significant morbidity.

A 10-year serial, prospective study of laparoscopic cholecystectomy training in a single region.

AIM: To determine how surgical registrar training in laparoscopic cholecystectomy evolved in a single region in the 10 years since the introduction of this technique. METHODS: In 1993, 1996, and 2001, identical, standardised postal questionnaires were sent to all general surgical registrars in the Oxford region. The questionnaire enquired about the number of laparoscopic cholecystectomies performed, performed with supervision or simply assisted at within a set time period. RESULTS: There has been a significant increase in the number of procedures performed by trainees between 1993 and 2000, in comparison to the number purely assisted at. CONCLUSIONS: After an initial learning period for the consultant trainers, laparoscopic cholecystectomy has been rapidly adopted, and is now a major training operation, much as open cholecystectomy was in the past.

The incidence and causes of permanent stoma after anterior resection.

AIMS: Defunctioning stomas are used following anterior resection to guard against the serious consequences of anastomotic leak such as pelvic sepsis and generalized peritonitis. This study aims to determine what proportion of patients undergoing anterior resection have a defunctioning stoma, how many of these patients do not have their stoma closed, and the reasons for this. METHODS: All patients undergoing a resection for rectal cancer in our institution in a five year period (January 1995 to December 1999) are included in the study. Anterior resection was performed on 154 patients, divided into 76 anterior resections (AR) and 78 low anterior resections (defined as the anastomosis within 6 cm of the anal verge). The data from these patients were analysed retrospectively. RESULTS: Of the total of 154 patients undergoing anterior resection, 59 (38%) were defunctioned, divided into 33 with loop ileostomy and 26 with loop colostomy. Five of these patients had not had their stoma closed at a median follow up of four years (range 1.5-6.5 years). The reasons for non closure were anastomotic stricture (2), metastatic disease (2), and patient choice (1). When comparing AR and LAR, 16% of patients had a defunctioning stoma after AR, compared with 60% after LAR (P < 0.01). CONCLUSION: Anterior resection is being performed for very low rectal tumours in order to avoid a permanent stoma. However we have found that 8% of patients who are defunctioned with a stoma at anterior resection will not have their stoma closed, and conclude that patients should be warned of this pre-operatively.

A 1 year prospective study of management and outcome of patients presenting with critical lower limb ischaemia.

OBJECTIVES: to determine management of patients with critical lower limb ischaemia (CLI) from first presentation to investigation and treatment. DESIGN: prospective study of critical ischaemia patients. METHODS: one-year prospective survey (May 2000-May 2001). Follow-up 3-15 months. RESULTS: some 873 arterial cases presented, 134 patients had CLI. Of the latter 49% were men, 30% diabetic, the median age was 81 years. Only 15 (24%) of 62 cases were referred to outpatients as urgent. Patients waited a median of 25 days (range 1-100) to be seen in outpatients, and had symptoms for a median of 8 weeks. Treatment was conservative for 70 patients, and 11 primary amputations, six secondary amputations, and 62 revascularisation procedures (34 operative, 28 percutaneous transluminal angioplasty) were performed. At follow-up (3-15 months, median 9 months), rates of major amputation and death were 12 and 27% respectively. Significantly more diabetics underwent major amputation (p < 0.02) than non diabetics. Patients presenting with ulceration or gangrene were at greater risk of death than those with rest pain alone (p < 0.01). CONCLUSION: patients with CLI often have symptoms for many weeks before being seen by a specialist, and 76% are referred as non-urgent cases. This compares with patients with suspected malignant disease in the U.K. who are required to be seen within 2 weeks.

Avoiding inappropriate surgery for secondary rectal cancer.

AIMS: Secondary rectal carcinoma occurs by invasion of the rectum by local primaries or by metastatic spread from a distant primary. The principle management of primary rectal carcinoma is surgery, but this is not usually the case for secondary carcinoma. This study investigates how these two may be differentiated and inappropriate surgery, in particular inappropriate abdominoperineal excision, can be avoided. METHODS: There were six patients with secondary carcinoma of the rectum. The primary tumours were: prostate (three), endometrium (two), breast (one). RESULTS: All the patients presented with lower gastrointestinal symptoms and four had a palpable mass on rectal examination. The diagnosis was made on histology and immunohistochemistry. Treatment was with endocrine therapy, chemotherapy, radiotherapy, and surgery. Three patients had palliative surgical procedures, and one had a curative anterior resection. The median survival was 7.5 months. CONCLUSIONS: This study has found that the presentation of primary and secondary rectal carcinoma is similar, and the method for distinguishing between the two is histology and immunohistochemistry. Staining for prostate-specific antigen was 100% accurate in the diagnosis of secondary rectal carcinoma arising from a prostate primary. The treatment of secondary rectal carcinoma is with systemic therapy and surgery is usually palliative, and therefore abdominoperineal excision should be avoided.

Type IV laryngotracheoesophageal clefts -- recent 5 year experience at Great Ormond Street Hospital for Children.

This article summarises a 5 year experience of type IV laryngotracheoesophageal clefts from Great Ormond Street Hospital for Children, London. We present six infants who had type IV clefts, two of whom are long-term survivors, and we review the literature. The recognition of specific complicating issues may lead to a standardised approach, which can result in successful repair and long-term survival. Increased awareness of the condition and early diagnosis combined with aggressive, planned surgical intervention in centres of paediatric expertise should result in a significant reduction of current mortality.

Aryepiglottoplasty for laryngomalacia: 100 consecutive cases.

A retrospective review of the notes of 100 consecutive patients who had undergone aryepiglottoplasty for laryngomalacia, at Great Ormond Street Hospital for Children, was undertaken. Fifty-six were male, 44 female and 47 were under three months of age. Indications for surgery were oxygen desaturation below 92 per cent and feeding difficulties causing failure to thrive. Forty-seven patients had other pathology contributing to their airway compromise or feeding problems. Improvement in stridor after one month was achieved in 86/91 (94.5 per cent) being abolished completely in 50/91 (55 per cent). Of the 25 per cent of patients whose symptoms took more than one week to resolve, 16/22 (63.6 per cent) were later found to have a serious neurological condition. Feeding was improved in 42 of 58 patients (72.4 per cent) who had a pre-operative feeding difficulty. The complication rate was low, with only five out of 86 (10 per cent) experiencing initial worsening of the airway and six per cent having aspiration of early feeds before improvement occurred. Endoscopic aryepiglottoplasty remains the operation of choice for patients with severe laryngomalacia, however, in the presence of neurological disease surgery is less likely to be successful.

Laparostomy for severe intra-abdominal infection complicating colorectal disease.

PURPOSE: The aim of this study was to evaluate the use of laparostomy in the management of patients with severe intra-abdominal infection resulting from colorectal disease. METHODS: Seven patients, four with inflammatory bowel disease, two with colorectal carcinoma, and one with diverticular perforation, underwent laparostomy during a six-year period for postoperative, severe, intra-abdominal infection. RESULTS: The median age was 42 years, the mean Acute Physiology and Chronic Health Evaluation II score was 22.7, and the observed mortality was 28.6 percent (2/7 patients). In one patient the laparostomy was closed at 11 days; in all the others the wound was left to heal by granulation and contraction, and two of these later required reconstructive surgery. The median follow-up was three years and seven months. CONCLUSION: Laparostomy is an effective and practical method of managing patients with severe intra-abdominal infection as a result of colorectal disease.

Management and outcome of choanal atresia correction.

OBJECTIVES: Outcome analyses of factors that may either maximize success or predict a better outcome following choanal atresia correction. METHODS: A retrospective review of children undergoing choanal atresia correction at Great Ormond Street Hospital for Children, London between January 1990 and April 1998. Children with unilateral or bilateral choanal atresia were studied. In all cases, correction was by a transnasal approach under endoscopic control. A 120 degrees Hopkins rod telescope was used to visualize the atretic plate from the nasopharynx. Straight urethral sounds were used to perforate the plate followed by use of an air drill to remove the bony component. Portex endotracheal tubes were subsequently inserted as nasal stents. RESULTS: Sixty-five children (19 M, 46 F: age range 1 day to 17 years) presented with choanal atresia and the outcomes for 46 were included in the study. Twenty-six patients (40%) had other major anomalies. In children with unilateral atresia neither duration of stenting nor presence of facial anomalies had an impact on outcome. Of those children with bilateral choanal atresia and associated facial anomalies (n=9), 56% were asymptomatic following correction. In children with isolated bilateral choanal atresia (n=19), 74% were asymptomatic following correction; 29% (n2.3 kg (n3. 5 mm (n=6) had an 83% chance of a good outcome. Those patients stented with a tube