Posttonsillectomy hemorrhage: what is it and what should be recorded?

OBJECTIVES: To report on our incidence of posttonsillectomy hemorrhage and to define what constituted posttonsillectomy bleeding. DESIGN: Retrospective study. SETTING: Tertiary care children's hospital and a local satellite facility. PATIENTS: A series of 1438 consecutive patients who had undergone either tonsillectomy or adenotonsillectomy between January 1, 1999, and December 31, 1999. INTERVENTION: During this period, parents were instructed to return with their children for clinical evaluation if any blood was seen in the postoperative period. MAIN OUTCOME MEASURES: Postoperative day of evaluation, age, sex, location of bleeding, management strategy, length of hospital admission, and any bleeding disorders were noted for each patient. RESULTS: A total of 112 patients underwent evaluation 134 times. Of these patients, 96 required only 1 evaluation and 16 required more than 1 evaluation. All patients who had more than 1 evaluation required intervention. The total number of children requiring intervention for posttonsillectomy hemorrhage was 51 (3.5%) of the 1438 patients. Female patients were more likely than male patients to return for evaluation. Patients who were 12 years and older were the most likely and those 3 years and younger were the least likely to have posttonsillectomy hemorrhage. The most common time from surgery to initial evaluation for hemorrhage was 6 days. CONCLUSIONS: By reviewing our own criteria for defining and recording posttonsillectomy hemorrhage, we conclude that posttonsillectomy hemorrhage is defined differently in the literature. This supports the need for a standard definition to allow for direct comparisons.

Hearing loss in children with Down syndrome.

OBJECTIVE: Previous studies report a 38-78% incidence of hearing loss in children with Down syndrome (DS). The purpose of this study was to establish more up to date information about hearing loss in children with DS. METHODS: A 5-year longitudinal study following the otolaryngologic problems seen in children with DS was initiated in February, 1999 at the Children's Hospital Medical Center in Cincinnati, OH. Aggressive, 'state of the art' treatment, both medical and surgical, was provided to a group of children, (n=48), all of whom were entered into the study at an age under 2 years. Specific interventions and treatments were reviewed in regards to following and treating the children's chronic ear disease. Hearing level results at the end of the first year of the study were evaluated in this publication. This includes both pre-treatment and post-treatment audiologic results. RESULTS: After treatment of easily reversible hearing loss from chronic otitis media, either with medical or surgical treatment with PET's, 98% of the children had normal hearing levels. Only two children had residual mild hearing losses after treatment interventions. CONCLUSION: Aggressive, meticulous and compulsive diagnosis and treatment of chronic ear disease in children with DS, started soon after birth, provides significantly improved hearing levels than reported previously.

Laryngotracheoplasty for subglottic stenosis in Down Syndrome children: the Cincinnati experience.

Previous studies from our institution have noted difficulties in the surgical repair of subglottic stenosis (SGS) in children with Down Syndrome. The objectives of this paper were to update our 15 year experience in the Down Syndrome patient population, compare our results with our overall series of laryngotracheoplasty for SGS, and to report on the increased incidence of posterior glottic stenosis (PGS) within this group of patients. Medical records of all children with SGS and Down Syndrome evaluated between 1982 and 1997 were reviewed for history of prior intubation, tracheotomy, gastroesophageal reflux disease (GERD), pre-operative SGS grade, and decannulation. From this review several conclusions have been drawn. First, the risk factors for SGS appear to be the same in the Down Syndrome group as the general population. Second, SGS continues to be more prevalent among children with Down Syndrome than among children in the general population. Third, we have now found a higher rate of PGS within these patients when compared to our overall series. Finally, it now seems that our decannulation rates in Down Syndrome children are approaching our overall series results.

Down syndrome: analysis of airway size and a guide for appropriate intubation.

OBJECTIVES/HYPOTHESIS: The purpose of this study is to prospectively evaluate the airway size of children with Down syndrome (DS). Previous studies have observed an increase in postintubation stridor in children with DS. Anesthetic literature suggests using a smaller endotracheal tube in children with DS, but more specific recommendations are not offered. With this study, recommendations are presented for the appropriate endotracheal tube size to use in children with DS undergoing intubation. STUDY DESIGN: A prospective, nonrandomized study was performed on a cohort of 42 children with DS and 32 control subjects. Sizing of the airway was assessed through measurement of an air leak around the endotracheal tube at intubation. The size of the airway was also evaluated through measurements of the tracheal diameter at the "tracheotomy point" on magnetic resonance imagine (MRI) studies of the head and neck which were performed on a group of children with DS. These were compared with normative values of the tracheal diameter in children. METHODS: The proper size of endotracheal tube in a population of children with DS and in a group of normal controls was determined. The "proper size" of an endotracheal tube was defined as that size of tube which allowed an audible air leak around the tube between 10 and 30 cm of H2O pressure. Anesthetic technique was controlled and identical for all study subjects. Participants had no previous history of airway compromise, stridor, or previous intubation. Weight and age were recorded and evaluated for their influence on the results. A retrospective evaluation was made of MRI studies of the neck that were performed on children with DS. Using measurement techniques described by Reed et al., the tracheal diameters at the "tracheostomy point" were compared with normative values for children. Measurements were both obtained by the author and confirmed by a pediatric radiologist. RESULTS: Using this prescribed method to determine the proper size of endotracheal tube, the control group used endotracheal tubes that were predicted from established anesthesia charts and formulas. However, children with DS required endotracheal tubes at least two sizes smaller. Age was found to be a more reliable factor in predicting the endotracheal tube size. A table of endotracheal tube sizes for intubation in children with DS is presented. Evaluation of the tracheal diameter at the tracheotomy point revealed that children with DS have a smaller trachea when compared with control children. It is not only the subglottis that is smaller; the tracheal diameter as well must be assumed to be of a smaller diameter in children with DS. CONCLUSIONS: Children with DS have smaller airways than other children. This is because of an overall decrease in the diameter of the tracheal lumens. Initial intubation of a child with DS should be performed with an endotracheal tube at least two sizes smaller than would be used in a child of the same age without DS, to avert potential trauma to the airway.

Airway management in Pierre Robin sequence.

There is a great deal of controversy regarding the long-term management of airway obstruction in children with Pierre Robin sequence. All 23 pediatric otolaryngology fellowship programs were surveyed to determine their current practice patterns. Issues that were addressed included methods of evaluation of airway obstruction, including polysomnography, choices for home care in children in whom observation and positioning treatment failed, and complications of the various treatment modalities. The lack of unanimity among the respondents mirrors the controversy found in the literature. Though tracheotomy appears to be favored as the method of long-term management, responses from those surveyed often were based on emotions as much as on scientific data. This report details those findings and offers suggestions to clinicians involved with the management of patients with Pierre Robin sequence with airway compromise.

Blunt laryngotracheal trauma in children.

OBJECTIVES: To demonstrate the diverse causes and manifestations of blunt laryngotracheal trauma in children, and to recommend an appropriate treatment protocol for these patients. DESIGN: A retrospective review of the medical records of patients treated at a tertiary care children's hospital for blunt laryngotracheal trauma during the 12 years before March 1, 1995 was performed. Clinical signs and symptoms, mechanisms of injury, and the results of laryngoscopy were included. PATIENTS: The study included 23 patients ranging from 2 1/2 to 18 1/2 years of age. The medical records of patients who had sustained an injury as a result of penetrating trauma, intubation, or foreign body were excluded. RESULTS: Four patients urgently required tracheotomies; 2 of these patients required subsequent reconstructive airway procedures. One child required a microlaryngoscopy with relocation of the arytenoid cartilage. The remaining 18 patients were treated conservatively with continuous pulse oximetry, cool mist room air, and serial flexible fiberoptic laryngoscopy. The 18 patients were discharged from the hospital after 24 to 48 hours of observation without sequelae. CONCLUSIONS: The signs and symptoms of blunt laryngotracheal trauma in children are not always specific to the extent or type of injury. A prompt diagnosis and treatment plan are needed to prevent potentially catastrophic complications. Patients with obvious airway compromise require immediate intervention. Those without acute airway symptoms often can be treated conservatively, provided that flexible fiberoptic laryngoscopy confirms a safe airway.

Impalement injuries of the palate in children: review of 131 cases.

Impalement injuries of the soft palate and oropharynx are common injuries especially in children. Devastating neurologic sequelae secondary to thrombus propagation in the internal carotid artery are rare but well-documented complications of these innocuous appearing injuries. Neurologic sequelae have been reported anywhere from 3 to 60 hours after the injury. Protocols that include hospitalization up to 72 hours have been advocated. In order to evaluate the effectiveness and practicality of such protocols, all hospital admissions for palate injuries in the past 17 years were reviewed. Of the 131 cases reviewed, no complications were discovered during hospitalization, nor were there any complications in these patients seen in follow up. Based on this review, the majority of soft plate and oropharyngeal impalement injuries can be managed on an outpatient basis. Parental counseling, similar to instructions given in instances of mild head trauma, as well as close follow up in the office are felt to be a more reasonable and as well as a safe treatment plan. A suggested instruction form is presented.

Apnea and the elongated uvula.

Four cases of respiratory distress and apnea associated with an elongated uvula are presented. In all cases, the uvula was found to intermittently fall onto the epiglottis and vocal cords. In all four patients, resection of the uvula led to resolution of all airway symptoms. It is hypothesized that the uvula, touching the vocal cords, caused intermittent laryngospasm and subsequent symptoms of cough, airway obstruction, and cyanosis. The anatomic reasons for such phenomenon are discussed.

Surgical management of sialorrhea.

Sialorrhea is a distressing problem in children with cerebral palsy, in children with other neurologic disorders, and in normal children. The constant need for clothing or bib changes in handicapped patients frequently results in further social isolation and causes normal children to be viewed as "impaired." The surgical treatment of sialorrhea at Children's Hospital Medical Center, Cincinnati, Ohio, has evolved over the past 5 years. Since 1981, 70 surgical procedures have been performed for drooling at this institution; follow-up information is available on 52 patients. The surgical procedures performed included submandibular rerouting alone, submandibular duct rerouting with bilateral tympanic neurectomy with bilateral submandibular gland excision, and bilateral submandibular gland excision with bilateral parotid duct ligation. Our review indicates that bilateral submandibular gland excision with parotid duct ligation is the only procedure in which consistent control of sialorrhea can be expected. Postoperative complications after this procedure were minimal and only one parent complained that the child had a dry mouth after the procedure. Postoperative hospitalization after bilateral submandibular gland excision and bilateral parotid duct ligation was not significantly different from that required after any of the other procedures. In conclusion, this surgical procedure appears to be the most effective surgical treatment for sialorrhea and precludes the need for multiple operative procedures for this problem.

Nasal obstruction in the neonate.

At birth, the neonate is an obligate nasal breather and any compromise of the nasal passages is potentially life threatening. It is important for the otorhinolaryngologist to quickly recognize and manage even subtle constrictions or obstructions of the nasal passages in this age group. Many times the nasal airway is disregarded as the source of airway difficulty if small catheters can be passed. Conversely, the inability to pass nasal catheters is often arbitrarily diagnosed as choanal atresia or stenosis. This limited outlook can delay appropriate therapy. The differential diagnosis of nasal obstruction in the neonate is presented wit emphasis on evaluation of nasal obstruction in anatomically normal appearing noses.

Efficacy of tonsillectomy and adenoidectomy as an outpatient procedure: a preliminary report.

One of the recent trends in medical practice has been the use of ambulatory surgery for a substantial number of surgical procedures. A prospective evaluation of tonsillectomy and tonsillectomy with adenoidectomy as outpatient procedures at the Children's Hospital Medical Center in Cincinnati, OH, is reported. Patients who were felt to be inappropriate candidates for adenotonsillectomies as outpatients included patients under 3 years of age, patients who lived more than one hour from the hospital and patients who demonstrated obstructive sleep apnea or who had other significant medical problems. A review of this 9-month experience indicates that outpatient surgery for adenotonsillectomy is both safe and cost-effective in most circumstances. In an analysis of complications requiring readmission to the hospital (bleeding, dehydration, poor social situation), patients who had their original surgery performed on an ambulatory basis had no more complications than patients who were hospitalized following their surgery. Excluding the professional fees for the surgeon and anesthesiologist, a savings of approximately 50% can be expected from the performance of a tonsillectomy and adenoidectomy on an outpatient basis.

Value of CT scan in the diagnosis of temporal bone diseases in children.

CT scan of the temporal bone has become a frequently ordered test for diagnosis of temporal bone pathology. We retrospectively examined our experience with CT scans of the temporal bones in 124 consecutive children from January 1983 to September 1984 in an attempt to assess its usefulness in diagnosis and treatment of ear disease in children. Patients were divided into six categories according to their pre-scan diagnosis, (trauma, congenital aural atresia, dizziness, facial nerve paralysis, middle ear disease, congenital sensorineural hearing loss) and CT findings were compared to data found by physical examination, by otologic studies such as audiogram and BSER, by other x-ray studies and ultimately compared to findings at surgery when applicable. CT was found to be instrumental in diagnosing middle ear disease; gave necessary preoperative information in children with aural atresia; delineated most temporal bone fractures; ruled out gross inflammatory, neoplastic, or traumatic etiologies in dizzy patients and in facial nerve abnormalities; and provided anatomic information about the inner ear in patients with sensorineural hearing loss. In our group of patients with sensorineural hearing loss, a 6.8% incidence of anatomic malformations was found by CT. However, CT had major limitations in stapes and oval window areas, especially in cases of perilymph fistulas. CT use was also limited in children because of the difficulty in achieving projections that require active patient cooperation.