Antimicrobial therapy for children with adenotonsillar hypertrophy and obstructive sleep apnea: a prospective randomized trial comparing azithromycin vs placebo.

OBJECTIVE: Multiple clinical trials demonstrate the value of administering antibiotics for recurrent tonsillitis. However, there is no consensus as to the role of antibiotics in the management of adenotonsillar hypertrophy and obstructive sleep apnea (OSA). It has been suggested that antibiotics may reduce adenotonsillar size, improve obstructive symptoms, and obviate the need for surgery. The goal of this pilot study was to evaluate the efficacy of a broad-spectrum antibiotic in the management of adenotonsillar hypertrophy and OSA. METHODS: Twenty-two children ages 2 through 12, with evidence of OSA, were enrolled in this double-blinded, prospective clinical trial. Children were randomly assigned into 1 of 2 groups. Group I received azithromycin for a 30-day period (12 mg/kg on days 1-5; the regimen was repeated on days 11-15 and days 21-25). Group II received a placebo administered in the same regimen for a 30-day period. Overnight polysomnography was performed before and within 2 weeks after drug administration. RESULTS: Polysomnographic indices of OSA severity appear to indicate an improvement in the antibiotic as compared to the placebo group, but a comparison of mean +/- standard error for each parameter failed to demonstrate statistical significance using the paired t test. Only 1 of 11 (9%) children had normalization of their polysomnographic parameters. CONCLUSIONS: These results suggest that a course of a broad-spectrum antibiotic may be effective in temporarily improving OSA due to adenotonsillar hypertrophy, but does not appear to obviate the need for surgery.

Functional outcomes following palatal reconstruction with a folded radial forearm free flap.

Defects of the soft palate often occur after extirpative procedures are performed to treat oropharyngeal cancers. These defects usually result in velopharyngeal insufficiency and an alteration in speech and deglutition. Palatal prostheses have been used to circumvent this problem in the past. Recently, however, folded radial forearmfreeflaps have been introduced for reconstruction of the soft palate to eliminate velopharyngeal insufficiency and the need for a prosthesis. We conducted a study to evaluate pharyngeal and palatal functions following reconstruction of soft-palate defects with radial forearm free flaps in 16 patients who had undergone resection of the soft palate for squamous cell carcinoma. Nine patients had partial soft-palate defects and 7 had total defects. All patients had lateral pharyngeal-wall defects. In addition, 14 patients had defects of the base of the tongue. Patients were followed for 3 to 40 months. Outcome measures were determined according to several parameters, including postoperative complications, resumption of diet, intelligibility of speech, and decannulation. All patients were evaluated by a speech pathologist and an otolaryngologist with a bedside swallowing evaluation and flexible nasopharyngoscopy. Twelve patients underwent videofluoroscopic studies. There was no incidence of flap failure. One patient developed a transient salivary fistula, which resolved with conservative management. Four patients without dysphagia resumed oral intake 2 weeks after surgery. The 12 patients with dysphagia underwent swallowing therapy. Ten of them responded and were able to resume oral intake, while the other 2 required a palatal prosthesis. Overall, 10 patients resumed a normal diet and 4 tolerated a soft diet within 6 weeks. The 2 patients who required a palatal prosthesis were able to take purees. All patients were decannulated, and all were able to speak intelligibly. Speech was hypernasal in 2 patients and hyponasal in 3. We conclude that the folded radial forearm free flap procedure is a useful alternative for reconstruction of palatal and pharyngeal defects. It is safe and effective, and it results in excellent functional outcomes.

Three-layer reconstruction for large defects of the anterior skull base.

OBJECTIVES: To evaluate and discuss a three-layer rigid reconstruction technique for large anterior skull base defects. STUDY DESIGN: Prospective, nonrandomized, non-blinded. SETTING: Tertiary teaching medical center. METHODS: Twenty consecutive patients underwent craniofacial resection for a variety of pathology. All patients had large anterior cranial base defects involving the cribriform plate, fovea ethmoidalis, and medial portion of the roof of the orbit at least on one side. A few patients had more extensive defects involving both roof of the orbits, planum sphenoidale, and bones of the upper third of the face. The defects were reconstructed with a three-layer technique. A watertight seal was obtained with a pericranial flap separating the neurocranium from the viscerocranium. Rigid support was provided by bone grafts fixed to a titanium mesh, anchored laterally to the orbital roofs. All patients had a computed tomography scan of the skull on the first or second postoperative day. Patients were observed for immediate and long-term postoperative complications after such reconstruction. RESULTS: Postoperative computed tomography scans showed small pneumocephalus in all patients. It resolved spontaneously and did not produce neurologic deficits in any patient. There was no cerebrospinal fluid leak, hematoma, or infection. On long-term follow-up, exposures of bone graft or mesh, brain herniation, or transmission of brain pulsation to the eyes were not observed in any patient. CONCLUSIONS: Three-layer reconstruction using bone grafts, titanium mesh, and pericranial flap provides an alternative technique for repair of large anterior cranial base defects. It is safe and effective, and provides rigid protection to the brain.