Post-operative pain following coblation or monopolar electrocautery tonsillectomy in children: a prospective, single-blinded, randomised comparison.

OBJECTIVE: To compare post-operative pain following tonsillectomy by either coblation or monopolar electrocautery in children. DESIGN: A parallel-designed, prospective, single-blinded, randomised trial. SETTING: Ambulatory surgical facility. STUDY PARTICIPANTS: Eighty otherwise healthy paediatric patients undergoing coblation or electrocautery tonsillectomy by a fellowship-trained paediatric otolaryngologist. MAIN OUTCOME MEASURES: (i) The number of post-operative days with severe pain based on subjective qualification by the caretaker, (ii) post-operative days with pain rated ≥ 5 on a scale of 1-10, (iii) post-operative days requiring oral paracetamol/acetaminophen with codeine solution and (iv) post-operative days until resumption of a regular diet were assessed and recorded daily using a post-operative pain survey as a form of daily diary that was returned at the 2-week follow-up visit. RESULTS: Patients were consecutively enrolled into two groups of 40 patients. Average ages were 5.2 years for coblation tonsillectomy and 6.0 years for electrocautery tonsillectomy. The average number of post-operative days with severe pain was 4.2 for coblation and 5.9 for electrocautery (P = 0.006), days rating pain ≥ 5 were 3.6 for coblation and 4.8 for electrocautery (P = 0.037), days of codeine use were 2.5 for coblation and 2.9 for electrocautery (P = 0.324), and days until resumption of a regular diet were 5.2 for coblation and 6.2 for electrocautery (0.329). CONCLUSIONS: Coblation tonsillectomy may reduce post-operative pain and the time until resumption of a regular diet compared to electrocautery tonsillectomy.

Dimensions of rabbit subglottis and trachea.

One of the most challenging problems confronting otolaryngologists today remains the management of subglottic stenosis (SGS) in infants and children. It is a problem of decreased airway calibre, usually associated with prolonged intubation. The pathophysiology of an intubated airway becoming stenotic is not fully understood. Although an ideal animal model for studying SGS does not currently exist, several studies have used the rabbit's airway as a wound healing model. In order to establish such a model in the rabbit, sizes of the normal rabbit larynx must be measured in order to compare them to the diseased airway. Measuring the airway diameters of 35 rabbits ranging from 2.3-5.1 kg, the average airway at the level of the cricoid was found to be 5.81 mm (ventral-dorsal) by 5.41 mm (lateral). These dimensions did not vary significantly with animal weight.

Improved airway healing using transforming growth factor beta-3 in a rabbit model.

Laryngeal wound healing is essential following laryngotracheal surgery. Patients with poor wound healing develop poor epithelial closure and increased granulation tissue which cause a stenosis of the repaired airway. Transforming growth factor-beta3 has been shown to enhance wound healing in cutaneous wounds, but has never been used in the airway. This study utilized a rabbit laryngeal wound-healing model that has been shown to be reproducible with limited morbidity. Thirty-four rabbits underwent a cricoid-split operation with collagen sponge insertion. All animals were classified randomly into three groups: local administration of placebo (Group G1, n = 13), 0.18 microg transforming growth factor-beta3 (Group G2, n = 11) and of 1.0 microg transforming growth factor-beta3 (Group G3, n = 10). All animals survived the postoperative period without respiratory distress. The airway was harvested six days after surgery and assessed by light microscopy. Histologic evidence for healing was subjectively graded by two blinded, independent investigators, and the results were statistically analyzed for significance. A significant improvement in the epithelial closure (p < 0.01) and subepithelial connective tissue closure (p < 0.005) was found in the 1.0 microg transforming growth factor-beta3 group (G3) compared with the placebo group (G1). Analysis of the 0.18 microg transforming growth factor-beta3 group (G2) did not reveal any significant differences compared with the placebo group (G1). These results suggest an application for transforming growth factor-beta3 in accelerating wound healing in the larynx.

Neonatal subglottic stenosis--incidence and trends.

OBJECTIVE/HYPOTHESIS: Neonatal subglottic stenosis is a known entity arising from endotracheal tube intubation. In the 1970s and 1980s, estimates of the incidence of subglottic stenosis were in the range of 0.9% to 8.3% of intubated neonates. Because of improved techniques of handling neonates who require ventilatory support, we thought the actual incidence of neonatal subglottic stenosis in the late 1990s was much lower. STUDY DESIGN: We retrospectively reviewed all neonatal intensive-care unit (NICU) admissions from 1997 at our institution, which serves as a level 3 NICU. We also performed a MEDLINE search of the reported incidence of neonatal subglottic stenosis between 1960 and 1999. METHODS: Analysis was performed to identify all children who developed subglottic stenosis at our institution. Data were also collected and analyzed with regard to average gestational age, average birth weight, average duration of intubation, and the number of children requiring tracheostomy. The reports identified in the literature were reviewed as to the incidence of subglottic stenosis. RESULTS: A total of 544 neonates were admitted to the unit. Of these, 281 were intubated for an average of 11 days. No patients developed subglottic stenosis. Three patients required tracheostomies for other reasons. All studies published after 1983 reported an incidence of neonatal subglottic stenosis as less than 4.0%, and all studies published after 1990 reported an incidence of neonatal subglottic stenosis as less than 0.63%. CONCLUSIONS: Although our report applies to only a single institution in a single year, after reviewing the literature we think a downward trend exists in the incidence of neonatal subglottic stenosis in the late 1990s. The current incidence of neonatal subglottic stenosis is likely between 0.0% and 2.0%.

Potential role of growth factors and extracellular matrix in wound healing after laryngotracheal reconstruction.

Laryngotracheal reconstruction (LTR) has been used for more than 20 years to treat infants and children with subglottic stenosis. Results after pediatric LTR have been satisfactory; however, approximately 10% of children have recurrent airway narrowing after LTR. The purpose of our study was to determine whether a correlation existed between specific growth factors and extracellular matrix in patients with adequate wound healing capability as compared with patients with poor wound healing capability. Histologic sections from 27 patients who underwent LTR were cut, and immunohistochemical staining was performed for transforming growth factor-beta, platelet-derived growth factor, fibronectin, tenascin, transforming growth factor-alpha, and vascular endothelial growth factor. Results showed that patients with adequate wound healing capability had a positive correlation with vasculature fibronectin, vasculature tenascin, and stromal fibronectin. Patients with poor wound healing capability had a positive correlation with stromal vascular endothelial growth factor.

Expression of Ki-67, tumor suppressor proteins, growth factor, and growth factor receptor in juvenile respiratory papillomatosis: Ki-67 and p53 as predictors of aggressive disease.

The enhanced proliferation of epithelial cells is a typical feature of respiratory papilloma. The mechanism or mechanisms leading to abnormal epithelial proliferation remain unclear. Overexpression of growth factors and their receptors and inactivation of tumor-suppressor proteins are known to cause cell transformation and proliferation. The objectives of this study were to evaluate the expression of these factors in juvenile respiratory papillomas with correlation to cellular proliferation activity, and to determine whether such expression is associated with the clinical course of the disease. The expression of transforming growth factor-alpha, epidermal growth factor receptor, p53 protein, retinoblastoma proteins and Ki-67 was quantified by immunohistochemistry in paraffin-embedded biopsy specimens taken at the initial surgical excision from children in whom respiratory papillomatosis was diagnosed. Clinical information regarding the number of disease sites, tracheobronchial spread, malignant transformation, and frequency of recurrences was reviewed. Thirty-five specimens were suitable for immunohistochemical evaluation. Ki-67 expression was significantly higher in patients with multiple sites of disease and frequent recurrences. High p53 expression was significantly associated with malignant transformation. We concluded that Ki-67 and p53 expression may be predictive of the clinical course in children with respiratory papillomatosis.

Management of persistent tracheocutaneous fistula in the pediatric age group.

Different surgical methods have been advocated for closure of persistent tracheocutaneous fistula (TCF) in children. The objective of this study was to compare different methods of repair and postoperative care that were used for management of TCF in children. The charts of 98 children with persistent TCF who were surgically managed in our department between January 1990 and April 1997 were reviewed retrospectively. Excision of the fistulous tract and healing by secondary intention was employed in 18 patients. Eighty patients were managed by tract excision followed by primary closure. Sixty-three patients remained intubated for 18 to 24 hours postoperatively, while 17 patients were extubated in the recovery room. One patient had a large tracheal granuloma on follow-up endoscopy. Three patients needed a second procedure. No significant correlation was found between the method of surgical repair or the length of postoperative intubation and outcome. In our experience, TCF repair, either by primary closure or secondary intention, is a relatively safe and effective procedure in the pediatric age group. Preoperative evaluation and possible indications for selecting the method of repair are discussed.

Margins of partial cricotracheal resection in children.

OBJECTIVE: To review the surgical margins of partial cricotracheal resection in our series of patients. This includes specific anatomic detail as to each superior and inferior resection margin. To apply this information and access the utility of partial cricotracheal resection for the treatment of subglottic stenosis. STUDY DESIGN/METHODS: A retrospective review was performed of 38 children with severe subglottic stenosis who underwent partial cricotracheal resection. Information was obtained with regard to the specific anatomic location of the superior and inferior resection margins, the grade of subglottic stenosis preoperatively, the type of stenting material used postoperatively, and other surgical details specific to each procedure. RESULTS: The superior resection margins were generally to the superior aspect of the cricoid cartilage but as high as the undersurface of the true vocal folds in a minority of patients. Inferior resection margins were generally to the second tracheal ring. Length of resection varied, but was as long as 3.0 cm in one patient. Overall surgical success based on decannulation was > 86%. CONCLUSION: Partial cricotracheal resection is a safe and successful procedure for the treatment of subglottic stenosis. The margins and length of resection should be tailored specifically for each patient; and special considerations must be taken when extensive resection to the level of the true vocal folds is required. Safe airway management in the postoperative period is essential.

Correlation between computed tomography and surgical findings in retropharyngeal inflammatory processes in children.

Retropharyngeal abscess (RPA) in children is a potentially life-threatening process which often requires immediate surgical intervention. Contrast enhanced computed tomography (CT) is utilized frequently to determine abscess versus cellulitis/phlegmon and aids in determining cases needing surgical drainage. The purpose of this retrospective study was to determine the accuracy of CT in distinguishing retropharyngeal abscess from cellulitis in children. The medical records of 32 children from 1989 to 1997 suspected of having a retropharyngeal abscess were reviewed. All patients included in the study underwent a CT scan as well as surgical exploration within 48 h of the scan. Two patients required two surgical procedures (n = 34). A comparison between CT results and operative findings was made to determine the accuracy of CT imaging in confirming the presence of RPA versus cellulitis. Suspected diagnosis of abscess or cellulitis/phlegmon on CT was confirmed at surgery in 25 of 34 cases (73.5%). The false positive rate of CT scan was 11.8% (4/34), while the false negative rate was 14.7% (5/34). Based on our results, CT is accurate in differentiating abscess from cellulitis in 73.5% of cases. Clinical findings, as well as radiologic findings, must be considered together prior to surgical drainage of a suspected retropharyngeal abscess in children.

Does the presence of a tracheoesophageal fistula predict the outcome of laryngeal cleft repair?

OBJECTIVE: To determine if the presence of a tracheo-esophageal fistula (TEF) alters outcome following laryngeal cleft repair. DESIGN: A retrospective review of patients diagnosed and treated for laryngeal clefts, with a minimum follow-up period of 1 year. SETTING: An academic tertiary care children's hospital. PATIENTS: Twenty-five pediatric patients diagnosed and surgically treated for laryngeal cleft. MAIN OUTCOME MEASURES: Each chart was reviewed to determine if patients with a laryngeal cleft had been diagnosed with TEF and had undergone a surgical TEF repair procedure. The success of the surgery was evaluated based on the resolution of symptoms and the endoscopic evaluation of the repair site. RESULTS: Twenty-five patients were reviewed for study purposes. Fourteen had a history of TEF repair and 11, no history of TEF. All 25 patients underwent surgical repair of the laryngeal cleft. Twelve of the 14 patients with a history of TEF repair experienced a breakdown of the laryngeal cleft repair. Only 1 of the 11 patients with no history of TEF experienced such a breakdown. In 8 of 9 patients with a laryngotracheoesophageal type I cleft, surgical repair was not successful. CONCLUSIONS: In our series, patients with laryngeal clefts who also had a history of TEF had a much higher incidence of breakdown of cleft repair compared with patients with no history of TEF. This finding is not conclusive and requires further investigation. The failure of cleft repair correlated with the severity of the cleft. The importance of these associations may lead to enhanced surgical planning and realistic preoperative family expectations.

Utility of radiographs in the evaluation of pediatric upper airway obstruction.

The evaluation of children with airway obstruction always involves a history and physical examination. The definitive diagnosis is most often made with microlaryngoscopy and bronchoscopy (MLB), and in cases of extrinsic compression, information is gained from magnetic resonance imaging. Although plain radiographs of the airway are often used as a primary diagnostic modality in children with airway obstruction, the accuracy of plain radiographs in predicting specific airway abnormalities has not previously been evaluated. This study was designed to correlate the findings of plain airway radiographs with the diagnosis made at the time of MLB. Medical records from 1991 to 1996 were reviewed to identify patients that had MLB and airway radiographs within 2 days of one another. One hundred forty-four cases were identified and divided into diagnostic categories. Statistical analysis showed a high sensitivity (>86%) for the accuracy of the radiologic diagnoses of exudative tracheitis, airway foreign body, and innominate artery compression. Laryngomalacia and tracheomalacia had a much lower sensitivity (5% and 62%, respectively). We believe that plain radiographic evaluation of the airway provides important information to the diagnostician. However, plain radiographs can be inaccurate and must be considered along with a history, physical examination, and clinical suspicion. Microlaryngoscopy and bronchoscopy remains the ultimate diagnostic test for airway disorders.

Model for evaluating the effect of growth factors on the larynx.

Growth factors are proteins that help regulate the inflammatory response and wound healing in tissues. After laryngotracheal surgery, proper wound healing is important in maintaining the reconstructed airway. The application of growth factor to the respiratory mucosa of the larynx and its effect on wound healing within the airway have not been studied. This study was designed to establish a model for the evaluation of wound healing after the application of growth factor to composite respiratory mucosa and cartilage surfaces at the time of laryngotracheoplasty. Forty rabbits underwent anterior cricoid cartilage split with or without the use of a cartilage graft. Platelet-derived growth factor or a placebo substance was applied to the wound at the time of surgery. This study offers a model for studying wound healing in the airway that is reproducible with limited morbidity.

Gastroesophageal reflux in patients with subglottic stenosis.

OBJECTIVES: To determine the incidence of gastroesophageal reflux in patients with subglottic stenosis (SGS) and to determine if upper esophageal reflux occurs in addition to lower esophageal reflux in these patients. DESIGN: Esophageal pH probe studies were reviewed in patients diagnosed as having SGS. SETTING: A tertiary care pediatric medical center. PATIENTS: All patients diagnosed as having SGS between January 1990 and July 1996 who had undergone monitoring with an overnight esophageal pH probe. Seventy-four patients qualified for the study. All 74 patients underwent lower probe testing, and 55 of the 74 underwent dual (upper and lower) probe testing. MAIN OUTCOME MEASURES: The percent of time a pH measurement of less than 4.0 was recorded in the upper and lower esophagus. A lower probe pH measurement of less than 4.0 more than 10% of the study time was considered high risk for developing reflux-associated pathologic symptoms. A lower probe pH measurement of less than 4.0 for 5% to 10% of the study time was considered a marginal risk for developing reflux-associated pathologic symptoms. Upper probe criteria for reflux-associated symptoms have not been established. Therefore, patients were grouped as having a pH of less than 4.0 in the upper esophagus for 0%, 0.1% to 0.9%, 1.0% to 1.9%, 2.0% to 3.0%, or more than 3% of the study time. RESULTS: Thirty-seven of the 74 patients who underwent lower probe testing had a pH of less than 4.0 more than 5% of the study time, and 24 had a pH of less than 4.0 more than 10% of the study time. Twelve of the 55 patients who underwent upper probe testing had no measurable reflux; 27 of the 55 had a pH of less than 4.0 more than 1% of the study time; 14 had a pH of less than 4.0 more than 2% of the study time, and 11 had a pH of less than 4.0 more than 3% of the study time. CONCLUSIONS: Gastroesophageal reflux is frequently present in patients with SGS. Gastric contents frequently reach the upper and lower esophagus in these patients. In addition, the high incidence of gastroesophageal reflux in these patients suggests that it may play a role in the development of SGS. The possible effect of gastroesophageal reflux on the surgical repair of SGS requires further study.

The role of second-look nasal endoscopy after pediatric functional endoscopic sinus surgery.

OBJECTIVE: To determine if second-look nasal endoscopy (SLE) improves clinical outcome after pediatric functional endoscopic sinus surgery (FESS). DESIGN: A retrospective review was performed for all patients who had undergone FESS between January 1993 and December 1994. The patients were divided into 2 groups: those who underwent SLE 2 to 3 weeks after FESS (n=94) and those who did not undergo SLE after FESS (n=53). Patients with a history of cystic fibrosis, bone marrow transplantation, or isolated sphenoidal sinus disease were excluded from the study. SETTING: Pediatric tertiary care hospital. PATIENTS: All patients had a diagnosis of chronic rhinosinusitis, had failed medical therapy, and had subsequently undergone FESS. MAIN OUTCOME MEASURES: The need for revision sinus surgery was used as the definition for poor clinical outcome, indicating that sinus disease recurred or was persistent. The number of patients requiring revision sinus surgery in each group was compared. RESULTS: Revision surgery was performed in 20 of the 94 patients who underwent SLE after FESS. Revision surgery was performed in 10 of the 53 patients who did not undergo SLE after FESS. Six patients in the "no-second-look group" underwent follow-up nasal endoscopy at some time after the initial FESS. There was no significant difference in terms of clinical outcome between the 2 groups. CONCLUSIONS: The rate of revision sinus surgery was comparable in those patients who underwent SLE after FESS and those who did not. The usefulness and application of SLE need to be considered carefully.

Partial cricotracheal resection with primary anastomosis in the pediatric age group.

The traditional approach to severe subglottic stenosis (SGS) in the pediatric age group is laryngotracheal reconstruction (LTR). This approach may be complex and multistaged, with variable and unpredictable success rates in the individual patient. Excellent results have been reported in adults who had severe SGS and underwent partial resection of the cricoid and primary thyrotracheal anastomosis. This procedure has not been widely reported in infants and children. We report our experience with this procedure in 16 pediatric patients with grade III or IV SGS. Eleven patients had multiple previous LTR operations. The preoperative evaluation, surgical techniques, postoperative care, complications, and final results are described and discussed. Fourteen patients were decannulated after the procedure, 1 patient needed a second open procedure prior to decannulation, and 1 patient with concomitant bronchopulmonary dysplasia remains cannulated, for an overall 94% decannulation rate. Fourteen patients have no limitation of respiration, and 1 patient has moderate exercise intolerance. The results of this series suggest that partial cricotracheal resection with primary anastomosis is a relatively safe and effective procedure for pediatric patients with severe SGS.

Supraglottic stenosis in infants and children. A preliminary report.

OBJECTIVES: To describe a condition identified in the pediatric population that narrows the supraglottic larynx. This condition has been termed supraglottic stenosis/collapse. To discuss common factors present in these children and to examine potential causes of this specific condition. DESIGN: Retrospective review of patients with supraglottic stenosis/collapse from October 1985 to June 1993. SETTING: Academic tertiary care children's hospital. PATIENTS: Seventeen patients aged 7 months to 14 years underwent laryngoscopy and bronchoscopy for evaluation or follow-up of upper airway obstruction or respiratory failure and were found to have supraglottic stenosis/ collapse. MAIN OUTCOME MEASURES: Each patient's records were reviewed for the average age at the time of diagnosis, history of prematurity, evidence of gastroesophageal reflux, history of long-term intubation, and any associated medical problems. In addition, patients were compared based on previous airway surgery (tracheostomy, laryngotracheal reconstruction, or anterior cricoid split). RESULTS: Chronic upper airway obstruction was identified in 17 patients caused by supraglottic stenosis/ collapse. All patients (100%) had undergone tracheostomy prior to the recognition of supraglottic stenosis/ collapse. Fifty-nine percent of the patients had undergone laryngotracheal reconstruction, and 53% had a history of gastroesophageal reflux. CONCLUSION: Supraglottic stenosis/collapse is a distinct entity that may be related to prior laryngeal or tracheal surgery. This diagnosis should be considered when evaluating and treating patients with chronic upper airway obstruction following laryngeal and/or tracheal surgery.

Tongue hypoplasia in a newborn.

Congenital anomalies of the tongue are uncommon. Since de Jussieu first described lingual hypoplasia in 1719, fewer than 50 cases have been described. These are usually in association with the hypoglossia-hypodactylia syndrome. We present a case of a newborn with absent anterior tongue, a rudimentary posterior remnant and associated micrognathia. Embryology and theories of pathogenesis are discussed.