Bilateral cleft nasal repair.

In spite of recent advances and innovations in the management of the bilateral cleft lip nasal deformity, no single surgical technique has gained widespread acceptance. Criteria for an ideal approach should include the following: aesthetic and physiologic factors, low complications and technical demands, minimal scarring, unimpaired future growth, and a reasonable burden on patients and caregivers. This article reviews several procedures for bilateral cleft lip nasal correction emphasizing the advantages and disadvantages of each. Particular attention will be given to the forked flap technique of Millard and newer methods utilizing tissue in the nasal tip with or without prosthetic treatment.

Mortality following adenotonsillectomy in a patient with Williams-Campbell syndrome.

Adenotonsillectomy is a commonly performed procedure that can greatly change airway pressure in patients with obstructive sleep patterns related to enlarged tonsils and adenoids. A case is presented in which a patient with a rare subclinical form of Williams-Campbell syndrome died after outpatient adenotonsillectomy. This case report illustrates how patients with structural abnormalities of the tracheobronchial tree can be at increased risk for complications when undergoing surgical procedures that impact airway dynamics.

Invasive fungal sinusitis in the immunocompromised pediatric patient.

Invasive fungal sinusitis in the pediatric population appears to be a relatively rare entity. An increasing incidence has been noted in accordance with the widespread use of antibiotics, steroids, antineoplastic drugs and radiation therapy. Three illustrative cases are described which outline the initial presenting symptoms, findings on physical examination, computed tomography (CT), intraoperative findings, and histopathologic findings. A review of the literature is presented and a treatment protocol is proposed once a diagnosis is made. Early suspicion and diagnosis are the most important prerequisites for successful treatment which consists of control of the underlying disease, surgical debridement, and systemic antifungal therapy. Cooperation between the otolaryngologist, pediatric specialists, and pathologists are key to the survival of children with invasive fungal sinusitis. Survival in this series was dependent upon return of an immune competent state.

Congenital nasolacrimal duct mucocele: a cause of respiratory distress.

Congenital nasolacrimal duct mucocele is an uncommon condition in the newborn. Prolapse or expansion of the mucocele into the nose may lead to respiratory distress and difficulty in feeding, as newborns are preferential nose breathers. Infants with congenital lacrimal sac distension should be examined for signs of respiratory distress and nasal pathology. In the presence of respiratory distress, nasal examination and imaging studies should be done to ensure the diagnosis of nasolacrimal duct mucocele. If significant respiratory distress exists, endoscopic marsupialization of the nasolacrimal duct mucocele in conjunction with nasolacrimal duct probing by the ophthalmologist and possible insertion of lacrimal drainage tubes should be considered. At our institution the nasolacrimal duct mucocele was expectantly managed in two of three cases. Only one of the three patients manifested a significant degree of respiratory distress and required intervention. Endoscopic marsupialization of the nasolacrimal duct mucocele resulted in complete resolution of the mucocele and improvement in symptoms.

CT and ultrasound imaging of retropharyngeal abscesses in children.

PURPOSE: To show the role of ultrasound (US) in distinguishing retropharyngeal abscess from adenitis in children. METHODS: Eleven infants and children had clinical symptoms suggestive of retropharyngeal infection. Radiographic evaluation included, lateral neck radiography (11/11), contrast-enhanced neck CT (10/11), contrast-enhanced neck MR (1/11), and real time US (11/11) patients. US was used to characterize masses as solid (adenitis) or complex (abscess) and for guiding intraoperative aspiration and drainage. RESULTS: Contrast CT and MR showed findings suspicious for abscess in all 11 cases. Only three children had surgically drainable abscesses. CT numbers within inflammatory masses did not distinguish adenitis from abscess. US was able to correctly diagnose abscess or adenitis in each case. CONCLUSION: Lateral neck radiography and contrast CT identify and localize retropharyngeal inflammatory masses in children. US, but not CT, distinguishes between adenitis and abscess and aids in intraoperative aspiration and drainage.

High resolution ultrasonography of the parotid gland in children. Part II.

The authors previously have reported a technique for visualizing the parotid gland with high resolution ultrasonography. The fine morphology of the parotid gland as well as normal anatomical landmarks were well visualized with ultrasonography. This study has continued for the past two years, and an additional twenty patients with suspected parotid pathology are presented. Ultrasound was helpful in (1) making a specific diagnosis in sialectasis, (2) determining whether parotid swelling was secondary to enlargement of adjacent tissues or indeed secondary to an intraparotid mass, (3) demonstrating whether enlargement of adjacent tissues was vascular by using duplex Doppler scanning, and (4) follow-up of enlarged nodes within the parotid and adjacent to the parotid for development of abscess formation.

Infarction of the orbit and paranasal sinuses in sickle cell disease.

We have reported the case of a 19-year-old black man with sickle cell disease who had swelling over the right frontal and periorbital areas. Plain roentgenograms and CT scans were consistent with frontal sinus disease. At trephination, however, sterile liquescent blood clot was found in the frontal sinus. Awareness of the orbital apex syndrome and infarction of the orbit and sinuses in patients with sickle cell disease is necessary to prevent misdiagnosis of these conditions as suppurative sinusitis.

High resolution ultrasound characterization of soft tissue masses in children.

Forty-two soft tissue masses in infants and children were examined with high resolution ultrasonography. Sonography was diagnostically specific in 17/42 (40%), useful but not diagnostic in 24/42 (58%), and misleading in 1/42 (2%) of soft tissue masses. Lesions with diagnostic sonographic features included cystic hygroma, fibromatosis colli, lymphadenopathy with abscess formation, and one case of osteomyelitis.

Umbilical artery clot in the neonate: spontaneous resolution.

Ultrasound has proved to be an effective means of monitoring umbilical artery catheters in the neonate for clot formation. Once a large clot has formed, it usually takes several weeks to months before it completely disappears. This is a report of a large clot that spontaneously resolved in ten days.

The distended gasless abdomen: a fertile field for ultrasound.

Ultrasonography has proven to be a helpful imaging modality in evaluating the child with a distended gasless abdomen. The presence of an unsuspected mass can easily be detected as well as the presence of ascites and/or abnormally dilated loops of small bowel. Thickened loops of bowel can also be easily detected in the abdomen with very little gas. Closed loop obstruction and intussusception, as well as meconium ileus equivalent (distal intestinal obstruction syndrome), are described.

The opaque chest: when to suspect a bronchial foreign body.

A bronchial foreign body should be strongly suspected in a child with an opaque chest without a previous history of airways disease when there is: any sign of volume loss or atelectasis in the lung density and bronchiectasis within the lung density. Ultrasound may be helpful to rule out the presence of pleural fluid and may even demonstrate the bronchiectasis when the bronchi are fluid-filled.

Acquired bone dysplasia secondary to catheter-related complications in the neonate.

Four neonates presented with leg-length discrepancy in the first and second year of life, secondary to physeal growth arrest. All four had stormy postnatal periods, requiring indwelling arterial and/or hyperalimentation catheters. One had documented osteomyelitis. In the last three cases, the growth disturbance may have been secondary to aseptic emboli to the bones from the indwelling catheters. In two cases, there was evidence of other nonseptic embolic phenomena.

High resolution ultrasonography of the parotid gland in children.

High resolution ultrasonography has revolutionized imaging of the superficial parotid gland. The fine morphology of the parotid gland can be exquisitely visulized. Anatomical landmarks such as the mastoid tip, the sternocleidomastoid muscle, the styloid process, the posterior facial vein, the internal jugular vein, and the external carotid artery can easily be identified in relationship to the parotid. The course of the facial nerve can be inferred by visualization of these landmarks. Common masses within the parotid in children such as hemangiomas, mixed parotid tumors, and lymphadenopathy can be demonstrated. Parotid masses are uncommon in children but can be easily evaluated by high resolution ultrasonography.

The three wheeler--a menace to the preadolescent child.

Children riding three-wheeled motorcycles have recently become victims of serious or fatal accidents. Twelve children (aged 3 to 12 years, mean, 8.7 years) all white, sustained serious or fatal injuries as a result of striking objects or overturning while riding these vehicles. The injured children were preadolescent, white, rural, male, and from relatively affluent families. Most injuries were to the head and upper torso causing severe cosmetic and functional deficits. Our experience suggests the need for better regulations for these vehicles when being ridden by children.

Nasopharyngeal brain heterotopia--a cause of upper airway obstruction in infancy.

The finding of mature neuroglial tissue in a mass from the head and neck region of a child raises four differential diagnostic possibilities: teratoma, encephalocele, glioma, and heterotopic brain tissue. We present a review of the literature and discuss the clinical, radiographical, and pathological features of a rare nasopharyngeal brain heterotopia in an infant causing upper airway obstruction.

Infantile methemoglobinemia induced by a topical anesthetic, Cetacaine.

A 2-month-old infant developed severe methemoglobinemia following topical pharyngeal application of a common benzocaine containing agent ( Cetacaine ). Although a number of reports of this complication have appeared in recent years, this is apparently the first case reported in the Otolaryngology literature. The pathophysiology, pharmacology, and treatment of this condition are reviewed.

Lip adhesion in bilateral cleft lip.

Surgical correction of bilateral cleft lip deformities remains one of the most challenging areas in facial plastic surgery. This is particularly true with asymmetrical, incomplete-complete clefts; and with symmetrical, complete clefts with marked protrusion of the premaxilla. Although the lip adhesion procedure has been used with success in certain unilateral clefts, its possible role in the bilateral deformity is less well defined and accepted. The purpose of this report is to propose that lip adhesion has advantages in certain bilateral deformities and to describe a technique for one-stage bilateral adhesions.

Recurrent laryngeal nerve damage following formalin infiltration of ductus arteriosus.

Formalin infiltration of the ductus arteriosus, a recent palliative procedure in neonates with certain congenital cardiac defects, has been shown to result in delayed left recurrent laryngeal nerve paralysis. Implication for the airway and later management are discussed.