Tuberculous lymphadenopathy masquerading as a bronchial foreign body.

A case of recent onset of wheezing with clinical and radiologic findings suggestive of foreign body aspiration is presented. Rigid bronchoscopy revealed an extraluminal compression of the airway. Histopathologic and microbiologic examination revealed tuberculous lymphadenopathy.

Pediatric functional endoscopic sinus surgery: is a second look necessary?

Functional endoscopic sinus surgery (FESS) has become the surgical procedure of choice for the treatment of chronic sinusitis that is refractory to medical treatment. It has become routine to perform endoscopy in children under general anesthesia 2 to 3 weeks after FESS to facilitate examination and cleaning of the operative site. We compared the clinical outcome of 50 children who underwent FESS without a second-look endoscopy with 50 children who underwent a routine second look. Patients with systemic disease (cystic fibrosis, immotile ciliary syndrome, immunoglobulin deficiency) or undergoing a revision procedure were excluded from the study. The results show that the postoperative improvement in nasal obstruction, nasal drainage, and chronic cough was the same for both groups. We conclude that in the vast majority of children without systemic disease and not undergoing a revision procedure, a second endoscopic procedure may not offer any apparent advantage.

Pseudoaneurysm of the right lingual artery: an unusual cause of severe hemorrhage during tonsillectomy.

Profuse intraoperative hemorrhage is an uncommon complication of tonsillectomy. We present a three-year-old girl who underwent a routine adenotonsillectomy during which massive bleeding occurred from a large vessel in the right tonsillar fossae. Angiography revealed an aberrant right lingual artery with a pseudoaneurysm. The right lingual artery was embolized with multiple coils and the bleeding was halted. The causes and treatment of extracranial carotid artery pseudoaneurysms are discussed.

Outpatient adenotonsillectomy. Is it safe in children younger than 3 years?

OBJECTIVE: To evaluate the safety of ambulatory adenotonsillectomy in children younger than 3 years. MATERIALS AND METHODS: The records of 102 children younger than 3 years who underwent adenotonsillectomy as an outpatient procedure were reviewed during a 3-year period. RESULTS: Ten patients (10%) required overnight hospital admission for an average of 1.4 days. Nine patients were admitted directly from the day-stay unit and 1 patient was admitted 48 hours after surgery. The reason for hospital admission was poor oral intake. None of the patients had postoperative bleeding or respiratory problems or required intensive care unit admission. CONCLUSION: The safety of ambulatory adenotonsillectomy depends on judicious selection criteria and can be performed in children younger than 3 years.

Subglottic stenosis complicating cardiac surgery in children.

OBJECTIVE: To highlight the incidence of subglottic stenosis (SGS) as a complication of surgery for congenital heart disease and the role of single-stage laryngotracheoplasty in treating this complication. DESIGN: Retrospective case series. SETTING: University-based referral center specializing in surgery for congenital heart disease and complex airway problem management. INTERVENTION: Laryngotracheal reconstruction (LTR). MAIN OUTCOME MEASURE: Successful airway expansion. RESULTS: At last follow-up, 87.5% (7 of 8) of patients remain free of obstructive airway symptoms. CONCLUSION: SGS can complicate surgery for congenital heart disease in children. Single-stage LTR is an effective treatment modality for this problem.

Peritonsillar abscess in early childhood. Presentation and management.

OBJECTIVE: To highlight the modes of presentation and management of a peritonsillar abscess in children younger than 5 years. DESIGN: Retrospective case series. SETTING: Tertiary referral pediatric otolaryngology practice. PATIENTS: Seven children younger than 5 years. RESULTS: The mean age of the children studied was 27 months (age range, 7-41 months). Five (71%) of the 7 patients underwent computed tomographic scanning to confirm the diagnosis. Pus was cultured at surgery in every case. The most common organism detected was Streptococcus viridans. The average hospital stay was 72 hours (range, 22 hours to 12 days). After diagnosis of an abscess, all patients underwent an electrocautery tonsillectomy and had an uneventful recovery. CONCLUSIONS: Children younger than 5 years who present with poor oral intake, high fever, drooling, and trismus should be suspected of having a peritonsillar abscess. A computed tomographic scan of the neck is usually required to confirm a suspected diagnosis. Prompt diagnosis and treatment will lead to a considerable decrease in morbidity. Immediate tonsillectomy is a safe and effective means of abscess drainage.

Laryngotracheal reconstruction without stenting.

Many surgical procedures, including laryngotracheal expansion with or without grafting, have been suggested for repairing laryngotracheal stenosis in children, and although a variety of stents have been described, the practice of prolonged stenting continues to diminish. We describe 21 pediatric patients with moderate-to-severe subglottic or tracheal stenosis who had laryngotracheal reconstructions with anterior rib cartilage grafts without stenting or intubation. The patients were between 6 months and 7 years of age at the time of surgery. All patients were extubated in the operating room after the procedure was terminated. One patient required reintubation in the intensive care unit for 48 hours after surgery, and another patient required a tracheotomy. Wound infection occurred in one patient. Most patients were discharged to their homes 3 to 5 days after surgery. We report the indications, technique, results, and complications of laryngotracheal reconstruction using a rib graft without stenting.

Fat graft myringoplasty in children--a safe and successful day-stay procedure.

The surgical closure of dry tympanic membrane perforations in children remains a controversial issue due to conflicting opinions on the appropriate technique, graft material and success rate. We present a review of 342 children who underwent fat graft myringoplasty as a day-stay procedure over a six-year period. Successful closure of the tympanic membrane perforation was achieved in 92 per cent of ears. Subsequent recurrent otitis media with effusion required insertion of ventilation tubes in 12 per cent. No relationship was observed between the age of the child and a successful outcome. We conclude that day-stay fat graft myringoplasty is a safe and successful procedure which results in a dry and safe ear in the majority of children.

Management of medial subperiosteal abscess of the orbit in children--a 5 year experience.

A medial subperiosteal abscess (SPA) of the orbit is the most common serious complication of sinusitis in children. The distinction between SPA and the more benign pre-septal disease is difficult to make especially in a young child in whom an ophthalmological evaluation is often difficult. Computerised tomography (CT) is the investigation of choice in making this distinction. Subperiosteal inflammatory disease of the orbit is initially treated with intravenous antibiotic therapy with surgery reserved for those patients who do not respond to medical treatment and in whom a medial SPA is confirmed by CT. Conventionally, the abscess is drained via an external incision and an ethmoidectomy is performed at the same time. More recently, successful drainage of SPA's has been accomplished endoscopically via a intranasal approach with less morbidity and superior cosmesis. We present a 5 year experience of 24 patients with CT scans suggestive of medial SPA who underwent endoscopic exploration of the medial subperiosteal orbital space. We discuss the current management of medial subperiosteal disease of the orbit in children and include a review of the literature. Also included is a clinical staging system which aids the management of orbital complications of sinusitis.

The management of asymptomatic firearm injuries in children.

Paediatric firearm injuries in the UK are uncommon. We present two children with BB-gun pellets in the parapharyngeal space who were managed conservatively and remained asymptomatic 6 months after the gunshot injury. The management of asymptomatic firearm injuries in children is discussed and a literature review included.

Campomelic syndrome--laryngotracheomalacia treated with single-stage laryngotracheal reconstruction.

The campomelic syndrome is a rare osteochondrodysplasia which frequently leads to early death from pulmonary insufficiency. We describe a patient with anatomic compromise of the upper airway due to diffuse laryngotracheomalacia and a moderate subglottic stenosis, treated successfully with single-stage laryngotracheal reconstruction using a rib graft. To our knowledge this has not been previously described. A review of the current literature is included.

Bilateral fat graft myringoplasty in children.

The results after simultaneous bilateral fat graft myringoplasties in children have not been previously reported in the literature. We report on 28 children who underwent bilateral fat graft myringoplasties as outpatient procedures under general anesthesia. The success rate was 91% at final follow-up, with only 16% of children requiring insertion of pressure-equalizing (PE) tubes following surgery. No complications were documented. We concluded that bilateral fat graft myringoplasties are safe to perform, with an excellent success rate, and are suitable as outpatient procedures.

Criteria for success in pediatric functional endonasal sinus surgery.

Functional endonasal sinus surgery (FESS) is widely used in the treatment of chronic sinusitis in adults and children. Although success rates of 80% to 93% have been reported, no criteria for success or improvement have been suggested. Standardized measures are needed to assess the outcome of FESS and to compare the results obtained by different surgical teams and for various patient groups. After reviewing the charts of 500 pediatric patients who underwent FESS between July 1987 and June 1992, the authors of this study formalized criteria for assessing the outcome of surgery.

Evaluation and management of hemoptysis in infants and children. A report of nine cases.

Hemoptysis is an occasional complication of adult pulmonary disease and is rare in children. The most common causes in adults are infection, bronchiectasis, pulmonary neoplasm, cystic fibrosis, pulmonary infarct, and trauma; in children the most common causes are infection and congenital abnormalities of the cardiopulmonary vasculature. Nine cases of hemoptysis in seven infants and two children will be presented. Two cases were fatal, thus illustrating the importance of rapid and definitive therapy early in the course. One of the fatal cases is the first case report in the otolaryngological literature of fatal hemoptysis in the newborn as a result of vascular anomalies associated with an absent left pulmonary artery. Eight cases of various causes, including small vessel vascular abnormality, trauma, recurrent pulmonary infection, and laryngotracheal papilloma, are discussed. The literature is reviewed, embryology is discussed, and a mechanism of death is theorized for the patient with the congenital vessel anomaly. Management considerations for hemoptysis in infants and children are discussed.

Delayed toxic shock syndrome after functional endonasal sinus surgery.

Toxic shock syndrome (TSS) is an uncommon, severe, multisystem illness that may follow any surgical procedure. It usually occurs in the immediate postoperative period and is manifested by the sudden onset of a high fever and a variety of other signs and symptoms. The reported incidence of TSS after nasal surgery is 16 cases per 100,000 patients. We report five unusual cases of delayed TSS that occurred after functional endonasal sinus surgery in which no packing was used. Toxic shock syndrome developed in three children and two adults 5 days to 5 weeks postoperatively. All patients were treated successfully with no sequelae. The pathophysiologic features, clinical manifestations, and treatment of TSS are described in detail.

Transnasal repair of choanal atresia using telescopes.

OBJECTIVE: Choanal atresia, consisting of a unilateral or bilateral bony or membranous septum between the nose and the pharynx, occurs in approximately one of 7000 live births. Conventional treatment has consisted of watchful observation and elective surgical repair or immediate intervention using a variety of surgical techniques. We attempted transnasal repair using a telescope to remedy the obstruction. PATIENTS: Over an 18-month period, six female and four male patients, who were between 3 weeks and 14 years of age at the time of surgery, underwent transnasal repair of unilateral or bilateral choanal atresia with the aid of a rod-lens telescope. All 10 patients had nasal stents made from endotracheal tubes that were fixed with sublabial and transseptal sutures. RESULTS: Seven patients remain free of symptoms 18 to 24 months after surgery. Three patients required revision surgery. Two of the revision cases recovered completely, with no restenosis 12 months after the second surgery. There were no postoperative complications. CONCLUSION: Transnasal repair of choanal atresia using a rod-lens telescope appears to be an effective procedure with low morbidity.

Cavernous sinus thrombosis: successful treatment using functional endonasal sinus surgery.

OBJECTIVE: Infections of the paranasal sinuses can be complicated by septic thrombosis of the cavernous venous sinuses. After standard antibiotic treatment, fewer than 50% of the patients recover completely, and the mortality rate is approximately 30%. We chose to treat this potentially catastrophic complication with functional endonasal sinus surgery in addition to standard antibiotic therapy. DESIGN: Case study. PATIENT: A 15-year-old boy presented to the emergency room of LeBonheur Children's Medical Center, Memphis, Tenn, with right proptosis, chemosis, ptosis, ophthalmoplegia, cranial nerve palsies, and paresthesia. The physical examination and computed tomographic scans of the sinuses and orbits revealed edema of the right orbit and pansinusitis, with secondary right cavernous sinus thrombosis and right superior ophthalmic vein thrombosis. INTERVENTION: The patient was started on a regimen of cefuroxime and nafcillin sodium and was scheduled for emergency functional endonasal sinus surgery to drain the primary sites of infection. After surgery, the patient was placed on a 3-week regimen of cefotaxime sodium, metronidazole hydrochloride, vancomycin hydrochloride, and heparin sodium. RESULTS: During surgery, the frontal recess and ethmoid, sphenoid, and maxillary sinuses were found to be filled with polypoid tissue and purulent material. Functional endonasal sinus surgery restored the sinuses to their normal physiologic state. The sinuses demonstrated the progress observed clinically. CONCLUSIONS: The improvement in outcome effected by standard antibiotic therapy can be significantly augmented by using functional endonasal sinus surgery in the treatment of cavernous sinus thrombosis.

Functional endonasal sinus surgery in adults and children.

Functional endonasal sinus surgery (FESS) is becoming the procedure of choice for the surgical treatment of chronic and recurrent sinusitis in adults and children. Retrospective analysis of the charts of 513 adult and 260 pediatric patients who underwent FESS after failing to respond to optimal medical treatment revealed an improvement rate of approximately 80% for both age groups. Although high response rates and low complication rates were found for both groups, there were significant differences in indications, preoperative evaluation, operative technique, and methods of postoperative follow-up for children.