Extracranial repair of pediatric traumatic cerebrospinal fluid rhinorrhea.

OBJECTIVE: To examine the methods of extracranial repair of traumatic defects in the cribriform plate and ethmoid roof resulting in persistent cerebrospinal fluid (CSF) rhinorrhea in pediatric patients. DESIGN: Retrospective case series. SETTING: A single-institution, tertiary care, pediatric hospital. PATIENTS: Four children, ranging in age from 3 1/2 to 9 years, who sustained fractures in the cribriform plate or ethmoid roof. INTERVENTION: Transnasal endoscopic repair in 4 patients, with 2 patients also undergoing external ethmoidectomy because of the large bony defect and the need for further exposure for repair. MAIN OUTCOME MEASURES: Time free from CSF leaks or recurrence, meningitis, and other postoperative complications. RESULTS: All patients except 1 have been free of recurrent CSF leaks, meningitis, and other postoperative complications. The 3 patients who solely underwent the extracranial approach did not experience the complications of the traditional intracranial approach. CONCLUSIONS: In a select group of pediatric patients, the extracranial approach for the repair of CSF leaks is appropriate. Successful use of an extracranial approach in 3 of 4 patients supports this method.

Esthesioneuroblastoma in the pediatric age-group: the role of chemotherapy and autologous bone marrow transplantation.

Esthesioneuroblastoma, a malignant neoplasm arising from olfactory epithelium, is unusual in the pediatric age-group. Management has traditionally involved surgery and radiotherapy, alone or in combination, with chemotherapy reserved for recurrent or high grade disease. We report a single institution experience utilizing chemotherapy and radiotherapy as the initial treatment and successful control of the primary tumor in two patients. In one patient, neck dissection and high dose chemotherapy combined with autologous bone marrow transplantation were used as successful salvage therapy of neck metastasis. Both patients are alive and disease free with a mean follow-up of 56 months. These results support the role of chemotherapy in the treatment of esthesioneuroblastoma and suggest that chemotherapy be used as part of the initial combined modality treatment plan.

Airway obstruction secondary to rhinoscleroma during pregnancy.

Dyspnea is a fairly common complaint during pregnancy. However, if one excludes allergic nasal congestion of pregnancy, upper airway obstruction is a distinctly uncommon cause of dyspnea in the pregnant patient. Three cases of laryngeal rhinoscleroma in pregnant women requiring tracheostomy for airway management are reported. All three delivered healthy infants vaginally. Postpartum, two of the three were successfully decannulated, while the third became pregnant again before decannulation was accomplished. Treatment options and a review of the literature are presented.

Preoperative thyroid scanning in presumed thyroglossal duct cysts.

The purpose of this study was to determine if preoperative thyroid scans are essential in the workup of presumed thyroglossal duct cysts. Questionnaires were sent to pediatric otolaryngologists and pediatric general surgeons with a 65% response rate. Fifty-seven percent of the physicians have encountered ectopic thyroid. In 58% of these, this was the only functioning thyroid tissue. Twenty eight percent of pediatric surgeons vs 65% of pediatric otolaryngologists routinely order scans. Two of the physicians encountering ectopic thyroid volunteered that they had successful litigation directed against them for removing the sole functioning thyroid and creating permanent hypothyroidism. There is a likelihood of encountering ectopic thyroid during the course of one's practice. A case of ectopic thyroid is presented, and management strategies are discussed.

Otolaryngologic manifestations of the mucopolysaccharidoses.

A retrospective review of 45 children with mucopolysaccharidoses was performed to determine the frequency of complications related to the head and neck. In this series, every patient had at least one complication involving the head and neck region, and in over half, operative intervention by the otolaryngologist was required. Upper airway obstruction occurred in 17 (38%) and necessitated a tracheostomy in 7 (16%). Cervical spine instability occurred in 8 (18%), making airway management difficult. Recurrent respiratory infections occurred in 17 (38%), and chronic recurrent middle ear effusions were noted in 33 (73%). This review demonstrates that children afflicted with the mucopolysaccharidoses frequently have otolaryngologic-related complications that are common throughout their life span and often the primary management issue in their continuing care. The otolaryngologic management of these patients is outlined based on the results of this study and review of the relevant literature.

Pleomorphic adenoma of the palate in a child.

Pleomorphic adenoma of the palate is a rare entity in childhood. Only 4 cases of this lesion are documented in detail in the literature. We present a patient with this lesion and discuss the usefulness of magnetic resonance imaging (MRI) in the preoperative evaluation. A review of the previously reported cases is provided along with a discussion of the treatment of this lesion.

Management of complicated fractures involving the orbits and nasoethmoid complex in young children.

This article presents some ideas and techniques for surgical reduction of complicated orbit and nasoethmoid complex fractures in young children. Operative techniques for surgical exposure and fracture reduction and fixation have evolved from standard facial incisions and wire fixation to complete exposure of the cranium and orbits via a bicoronal scalp flap, application of rigid plating techniques, and use of cranial bone grafts when necessary. This evolution of surgical techniques has been accompanied by an overall improvement in cosmetic and functional results.

Evaluation of epiglottoplasty as treatment for severe laryngomalacia.

Six patients with severe laryngomalacia underwent epiglottoplasty. Four of these patients had life-threatening episodes of airway obstruction before surgery; of these, two had required tracheal intubation and one had required cardiopulmonary resuscitation. Two patients had failure to thrive and two had cor pulmonale. Patients had required a mean of two hospitalizations related to upper airway obstruction. We performed polysomnography during a daytime nap, both before and after epiglottoplasty, in all patients. Respiratory effort, arterial oxygen saturation, and end-tidal carbon dioxide pressure were monitored with continuous electrocardiograms and electrooculograms. All patients had abnormal polysomnograms preoperatively. Six patients had obstructive apnea, four had hypoxemia (arterial oxygen saturation less than 90% while breathing room air), and four had hypoventilation (end-tidal carbon dioxide pressure greater than 45 mm Hg) before epiglottoplasty. Mean age (+/- SEM) at epiglottoplasty was 10.3 +/- 5.3 months. No patients had surgical complications. An endotracheal tube was in place for 25 +/- 7 hours postoperatively, and patients were discharged 4 +/- 1 days postoperatively. Polysomnography performed 2.8 +/- 1.0 months after surgery showed that all patients had improved. Two patients had residual, mild episodes of obstructive apnea, and one patient had mild hypoventilation and desaturation. No patient had further life-threatening events or required further hospitalizations after epiglottoplasty. We conclude that epiglottoplasty is an effective and safe treatment for a selected group of patients with severe laryngomalacia.

Management of a large frontoethmoid osteoma with sinus cranialization and cranial bone graft reconstruction.

Osteoma represents the most common benign neoplasm of the nose and paranasal sinuses. The etiology of osteomas is uncertain and the majority occur in the frontal. ethmoid, and maxillary sinuses in that order. We present a 14-year-old male with a large frontoethmoid osteoma that required frontal sinus cranialization and pericranial bone graft reconstruction following removal. The osteoma recurred 6 months postoperatively and was excised. Treatment alternatives and a review of the literature are presented.

Laryngeal laser surgery.

The application of laser systems for the surgical management of many congenital and acquired, as well as benign and malignant, diseases of the larynx has been established. Ideas regarding wavelength selection and the rationale for use of the laser in the larynx, including potential pitfalls and problems with wound healing, as well as new instrumentation and safety concerns are discussed. Recent contributions to the literature regarding laser treatment of benign laryngeal disease and malignant neoplasms, and the use of the laser to manage laryngeal airway obstruction and improve voice quality are presented.

Maxillofacial trauma.

Although the general principles for evaluation and management of facial fractures in children are the same as for adults, some modification in assessment, timing, and technique must be considered. This article has a double purpose: to re-emphasize acute assessment and medical management so that the pediatrician can function as the coordinator of the maxillofacial trauma team, and to present both established and new techniques for the reduction of simple and complex fractures in children.

Lasers in pediatric otolaryngology.

Extensive clinical experience and anecdotal evidence indicate that application of laser technology has improved the management of many congenital and acquired diseases of the head and neck in pediatric patients. The general principles of laser surgery, with respect to laser-tissue interaction, must be adhered to at all times to achieve the best surgical effect. Improperly used, the laser can damage normal tissue in the infant's or child's larynx, with devastating consequences.

Hamartoma of the larynx: report of two cases and review of the literature.

Hamartomas of the larynx are rare. Signs and symptoms vary but there is generally some degree of voice change and upper airway obstruction. The pathology may be misleading and can often be confused with other benign tumors of the larynx. Management should consist of conservative excision. Partial or total laryngectomy should be reserved for lesions involving too much of the laryngeal framework. Two cases of hamartomas of the larynx are reported requiring partial laryngectomy.

Granulocytic sarcomas of the head and neck.

Granulocytic sarcomas (chloromas) are rare tumors with a predilection for head and neck sites. In a review of six cases from two teaching institutions, chloromas were associated with the development of acute myelogenous leukemia or a relapse in five cases. Treatment modalities included chemotherapy and radiation therapy for problematic lesions. Our only survivor received combination therapy despite a negative bone marrow examination. Work-up should include a computed tomographic scan or magnetic resonance imaging to evaluate the extent of the tumor. Bone marrow examination and biopsy should be performed and specimens prepared for immunohistochemical studies or electron microscopy. Recommended treatment includes both aggressive chemotherapy and 2000 to 3000 cGy of external-beam radiotherapy to the tumor when possible.

Plunging ranula in an infant.

This unusual case extends the age range of persons with plunging ranula to include those with congenital neonatal submandibular masses. The congenital nature of plunging ranula has not been widely discussed. Clinical diagnosis can be reinforced by diagnostic imaging (CT, MRI) if the mass extends into or abuts the sublingual space. Definitive treatment (generally excision) leads to resolution of the mass and prevention of recurrence.

Hypoxia and hypercapnia in infants with mild laryngomalacia.

We evaluated 15 infants with laryngomalacia and 12 healthy infants to determine their risk of hypoxia and hypercapnia as complications of partial upper airway obstruction. Transcutaneous carbon dioxide pressure and oxygen pressure were recorded continuously overnight with episodes of hypercapnia and/or hypoxia scored for frequency, duration, and relationship to activity. Episodes occurred in 12 infants with laryngomalacia and eight control infants. Infants with laryngomalacia had significantly more episodes. The greatest decrease in transcutaneous oxygen pressure was 29 mm Hg and increase in transcutaneous carbon dioxide pressure was 31 mm Hg, both occurring in infants with laryngomalacia. Three infants had prolonged episodes of hypoxia and hypercapnia. History or physical examination did not distinguish those infants with laryngomalacia who had hypercapnia and/or hypoxia from those without episodes. Two- to 15-month follow-ups in 13 infants with laryngomalacia revealed that symptoms were unchanged or improved. Twelve of these 13 infants had normal growth without developmental delay or other complications. These results demonstrate that episodes of hypoxia and hypercapnia occur more frequently in infants with laryngomalacia than in control infants; however, their apparent risk for complications is low.

Experience with surgical management of velopharyngeal incompetence.

Accurate mapping of the defect of velopharyngeal closure in patients with velopharyngeal incompetence is paramount to the planning of an operative procedure that will have a successful outcome. Nasoendoscopy and videonasoendoscopy are valuable tools for examination of the abnormal pattern of velopharyngeal movement in patients with velopharyngeal incompetence. On the basis of the knowledge of the observed defect in velopharyngeal closure for the particular patient, a pharyngeal flap operation is planned. The flap width, level of placement of the flap base, and control of the lateral port size vary to suit each individual velopharyngeal closure defect. Postoperative speech results in 86 patients are reported.

Airway management of acute supraglottitis at the Children's Hospital, Boston: 1980-1985.

A controversy has existed in recent years regarding the ideal method of establishing and maintaining an airway in the pediatric patient with acute supraglottitis. Nasotracheal intubation has been used as the sole method of airway management of acute supraglottitis at The Children's Hospital, Boston, since 1970. This paper reviews our experience with 80 children with acute supraglottitis presenting at our institution during the years 1980 to 1985.