Primary Posterior Tracheopexy in Esophageal Atresia Decreases Respiratory Tract Infections.

Background: Esophageal atresia (EA) is often accompanied by tracheomalacia (TM). TM can lead to severe respiratory complaints requiring invasive treatment. This study aims to evaluate if thoracoscopic primary posterior tracheopexy (PPT) can prevent the potential sequelae of TM in patients with EA. Methods: A cohort study including all consecutive EA patients treated between 2014 and July 2019 at the Wilhelmina Children's Hospital was conducted. Two groups were distinguished: (group 1) all EA patients born between January 2014 and December 2016 and (group 2) all EA patients born between January 2017 and July 2019, after introduction of PPT. In the latter group, PPT was performed in EA patients with moderate (33-66%) or severe (67-100%) tracheomalacia, seen during preoperative bronchoscopy. Group differences were assessed using the Fisher's exact test for bivariate variables and the Mann-Whitney U-test for continuous variables. Results: A total of 64 patients were included in this study (28 patients in group 1; 36 patients in group 2). In group 2, PPT was performed in 14 patients. Respiratory tract infections (RTIs) requiring antibiotics within the first year of life occurred significantly less in group 2 (61 vs. 25%, p = 0.004). Brief resolved unexplained events (BRUEs) seemed to diminish in group 2 compared to group 1 (39 vs. 19%, p = 0.09). Conclusion: Thoracoscopic primary posterior tracheopexy decreases the number of respiratory tract infections in EA patients. The clinical impact of reducing RTIs combined with the minimal additional operating time and safety of PPT outweighs the risk of overtreatment.

Auditory brainstem response morphology and analysis in very preterm neonatal intensive care unit infants.

OBJECTIVES/HYPOTHESIS: Analysis of auditory brainstem response (ABR) in very preterm infants can be difficult owing to the poor detectability of the various components of the ABR. We evaluated the ABR morphology and tried to extend the current assessment system. STUDY DESIGN: Prospective cohort study. METHODS: We included 28 preterm very low birth weight infants admitted to the neonatal intensive care unit of Sophia Children's Hospital. ABRs were measured between 26 and 34 weeks postconceptional age. The presence of the following ABR parameters was recorded: the ipsilateral peaks I, III and V, the contralateral peaks III and V, and the response threshold. RESULTS: In 82% of our population, a typical "bow tie" response pattern was present as a sign of early auditory development. This bow tie pattern is the narrowest part of the response wave and is predominantly characterized by the ipsilateral negative peak III. This effect may be emphasized by the contralateral peak III. The bow tie pattern is seen approximately 0.1 milliseconds before the ipsilateral peak III. From 30 weeks postconceptional age onward, a more extensive morphologic pattern is recorded in 90% of the infants. A flow chart was designed to analyze the ABR morphology of preterm infants in an unambiguous stepwise fashion. CONCLUSIONS: A typical bow tie pattern preceding peak III seems to be the earliest characteristic of the developing ABR morphology in preterm infants. As ABR characteristics will improve with increasing age, neonatal hearing screening should be postponed until after 34 weeks.

Risk factors for auditory neuropathy spectrum disorder in NICU infants compared to normal-hearing NICU controls.

OBJECTIVES: To evaluate independent etiologic factors associated with auditory neuropathy spectrum disorder (ANSD) in infants who have been admitted to the neonatal intensive care unit (NICU) compared to normal-hearing controls. STUDY DESIGN: Case-control study. METHODS: We included all infants (n = 9) with the ANSD profile admitted to the NICU of Sophia Children's Hospital between 2004 and 2009. Each patient was matched with four normal-hearing controls of the same gender and postconceptional age. The following possible risk factors were studied: birth weight, dysmorphic features, APGAR scores (at 1, 5, and 10 minutes), respiratory distress (IRDS), cytomegalovirus (CMV) infection, sepsis, meningitis, cerebral bleeding, hyperbilirubinemia requiring phototherapy, peak total bilirubin level, furosemide, dexamethason, vancomycin, gentamycin, and tobramycin administration. RESULTS: Nine infants met the ANSD criteria in one or both ears. IRDS (P = .02), meningitis (P = .04), and vancomycin administration (P = .009) were significantly increased in infants with ANSD compared to controls. CONCLUSIONS: In high-risk NICU infants IRDS, meningitis and vancomycin administration are associated with auditory neuropathy spectrum disorder.

Surgical or medical management of subperiosteal orbital abscess in children: a critical appraisal of the literature.

OBJECTIVE: Subperiosteal orbital abscesses (SPOA) are a complication of sinusitis. Traditional treatment of SPOA is surgical. Recently, a number of studies report successful medical treatment. To our knowledge, it is unclear which patients can benefit from medical management alone. Therefore, we questioned (1) what is the outcome of medical versus surgical treatment? (2) which patients can be cured with antibiotics alone? (3) what are the absolute criteria for surgical treatment? METHODS: A structured search was conducted in PubMed, EMBASE and the Cochrane Library for relevant papers which were critically appraised. RESULTS: Five studies addressing our clinical questions were included, one prospective case series and four retrospective studies. Evidence levels varied from 2b to 3. Overall, a high cure rate was achieved with combined modality treatment (95.3-100%). The cure rate of medical treatment alone varied between 26% and 93%. The outcome of medical treatment improved after prior selection of surgical cases. In general, responders to medical treatment had a medial abscess associated with ethmoid sinusitis. Criteria for initial surgical or medical management differed among authors. Most authors agreed upon initial surgical treatment for patients with non-medial abscesses, decreased visual acuity and signs of systemic involvement. Surgery was also indicated when lack of improvement or worsening of symptoms and signs after 48-72 hours of medical treatment were observed. CONCLUSIONS: The outcome of surgical versus medical management of SPOA within and between studies could not be compared. Higher cure rates were observed when both modalities were combined. There is some evidence that medical treatment can cure medially located SPOA. Loss of visual acuity, non-medial abscess, clinical detoriation and failure to improve within 48 hours of antibiotic treatment can be considered as criteria for surgical treatment. In the absence of these criteria a trial of antibiotic treatment can be considered with close monitoring of the patient.