Are water precautions necessary after tympanostomy tube placement? A cadaver study.

OBJECTIVES: To determine whether Armstrong pressure equalization tubes allow passage of water into the middle ear with complete submersion in water up to 76 cm for 2 min. METHODS: 10 adult cadaver heads were first assessed for the presence of fluid in both middle ears with zero-degree rigid endoscopes, after being submerged for 2 min in a plastic receptacle filled with 76 cm of water. A 25% perforation was then made in the tympanic membrane of one ear. A myringotomy was then made in the tympanic membrane of the contralateral ear, with the placement of a beveled Armstrong pressure equalization tube. The head was then submerged again for 2 min. Both ears were then examined for the presence of fluid in the middle ear using a rigid endoscope and with suction. RESULTS: Eight out of ten (80%) of the heads showed the presence of fluid in the middle ear on the perforation side after submersion, whereas none of the heads showed fluid in the middle ear on the side with the pressure equalization tube. CONCLUSIONS: At depths of 76 cm, total submersion in water for 2 min does not facilitate the passage of water into the middle ear via an Armstrong pressure equalization tube.

Ex utero intrapartum treatment to extracorporeal membrane oxygenation: lifesaving management of a giant cervical teratoma.

BACKGROUND: Ex utero intrapartum treatment ('EXIT' procedure) is a well described method for maintaining maternal-fetal circulation in the setting of airway obstruction from compressive neck masses. When ex utero intrapartum treatment to airway is not feasible, ex utero intrapartum treatment to extracorporeal membrane oxygenation ('ECMO') has been described in fetal cardiopulmonary abnormalities. OBJECTIVE: This paper presents the case of a massively compressive midline neck teratoma managed with ex utero intrapartum treatment to extracorporeal membrane oxygenation, allowing for neonatal survival, with controlled airway management and subsequent resection. CASE REPORT: A 34-year-old-female presented with a fetal magnetic resonance imaging scan demonstrating a 15 cm compressive midline neck teratoma. Concern for failure of ex utero intrapartum treatment to airway was high. The addition of the ex utero intrapartum treatment to extracorporeal membrane oxygenation procedure provided time for the planned subsequent resection of the mass and tracheostomy. CONCLUSION: Ex utero intrapartum treatment procedures allow for securement of the difficult neonatal airway, while maintaining a supply of oxygenated blood to the newborn. Ex utero intrapartum treatment circulation lasts on average less than 30 minutes. The arrival of extracorporeal membrane oxygenation has enabled the survival of neonates with disease processes previously incompatible with life.

A novel technique for unilateral supraglottoplasty.

OBJECTIVES: Traditional supraglottoplasty for pediatric laryngomalacia is most commonly conducted with either CO2 laser or cold steel instruments. While the procedure enjoys high success rates, serious complications such as excessive bleeding, supraglottic stenosis and aspiration can occur. Unilateral coblation supraglottoplasty may reduce this risk, but data on respiratory and swallowing outcomes are lacking. This study reports our experiences with unilateral coblation supraglottoplasty. METHODS: Pediatric patients with severe congenital laryngomalacia who underwent unilateral supraglottoplasty at a single institution from 2013 to 2016 were retrospectively reviewed. Bipolar radiofrequency ablation (Coblation) was utilized with partial arytenoidectomy, aryepiglottoplasty, and advancement of mucosal flaps. Outcome measures included apnea-hypopnea index (AHI), weight-by-age percentile, and decannulation rate. RESULTS: Twelve patients were included with an average age of 13.1 months (range 2-28 months). In patients without tracheostomy, 88% had complete resolution of respiratory symptoms, while the remainder had significant improvement. In patients without gastrostomy tubes, there was an average increase in weight-age percentile of 6.1, 7.8, and 15.3 points at 1, 3, and 6 months postoperatively, respectively. Three patients had complete polysomnography data with a mean preoperative AHI of 19.3 and postoperative AHI of 4.0. Three of four patients with tracheostomy have been decannulated at a mean follow-up of 1.5 years. There were no early or late postoperative complications and no revision supraglottoplasty. CONCLUSION: Unilateral supraglottoplasty with bipolar radiofrequency ablation can improve respiratory symptoms and decrease OSA severity in severe congenital laryngomalacia. This technique is safe and can lead to substantial improvement in AHI in patients with OSA.

Evaluation of unilateral referrals on neonatal hearing screening.

OBJECTIVE: Examination of neonatal hearing screening practices around the world suggests that more attention is placed on infants who fail bilaterally on their hearing screen than infants who refer (fail) in one ear. Some programmes only report bilateral failures as positive hearing screens. This study investigates how limitations of the screening techniques demand continued audiologic evaluations in unilateral referrals. SETTING: The study sample consisted of all infants born at a single academic paediatric hospital between February 1998 and February 2002. METHODS: There were 16,007 infants screened using ALGO automated auditory brainstem response. Eighteen of the infants who failed the screen in one ear but passed in the other ear were found to have permanent hearing loss, and had their subsequent clinical course and audiologic management analysed. The final audiologic outcome after four years in both the pass and fail ear were examined. RESULTS: One group of unilateral referrals (n = 6) had obvious anatomic reasons for the ear failing the screen (canal atresia/stenosis). There were five patients in which the ear that passed the screen was later found on more extensive audiologic evaluation to have significant hearing loss. Review of recent literature was also completed to examine the methods by which unilateral screening referrals are commonly reported and whether or not this affected follow-up diagnostic evaluation. CONCLUSION: Infants who pass one ear and refer one ear on neonatal hearing screening still need to have thorough and prompt evaluations. In many cases, the ear that passed can be found to have significant hearing loss.

Subglottic hemangioma.

Subglottic hemangioma is a rare condition that can be potentially life threatening because of airway obstruction. It is common for subglottic hemangioma to be misdiagnosed as croup initially. Infants with a subglottic hemangioma and cutaneous facial hemangiomas in a "beard" distribution should be evaluated for PHACE syndrome. Endoscopic laser resection is effective for subglottic hemangioma but carries a chance of subglottic stenosis, up to 25%. Open excision of subglottic hemangioma is an excellent option, particularly in patients with bilateral or circumferential subglottic hemangioma. It is a more extensive surgery when compared with endoscopic laser resection. Surgeons who do not have access to a pediatric intensive care unit staffed by experienced pediatric intensivists should not use this procedure.

Open excision of subglottic hemangioma with microscopic dissection.

OBJECTIVE: To evaluate the efficacy of open excision of subglottic hemangioma utilizing microscopic dissection techniques. DESIGN: Retrospective review of case series. SETTING: Tertiary care teaching children's hospital. PATIENTS: The study included 8 patients ages 7 weeks to 8 months. All patients underwent open microscopic excision of subglottic hemangioma between 2000 and 2006. INTERVENTION: All patients underwent full pre-operative evaluation including micro-direct laryngoscopy and bronchoscopy. All resections were carried out with an anterior cricoid split and partial laryngofissure. Intra-laryngeal dissections were carried out under a cross-table binocular dissecting microscope. Mucosal preservation was practiced whenever possible. Thyroid ala cartilage graft was used to augment subglottic laryngeal framework. Patients were intubated for 3-7 days prior to reassessment and extubation. RESULTS: Eight patients were treated with microscopic open excision of subglottic hemangioma. All patients were successfully extubated. During the follow-up period, 2/8 patients developed early subglottic stenosis that required endoscopic laser treatment. Median follow-up time was 37 months (range 3-84 months). No recurrences have been observed. CONCLUSION: Microscopic dissection adds precision to open excision of subglottic hemangioma. Such precision enables complete excision while accomplishing maximal mucosal preservation, thus limiting the risk of recurrence and subglottic stenosis.

Oropharyngeal atresia in a preterm infant: a case report and review of the literature.

Oropharyngeal atresia is a rare and often fatal condition that presents soon after birth with severe respiratory distress. We present a case of a premature infant who initially was suspected to have tracheo-esophageal atresia due to prenatal ultrasound findings of polyhydramnios and absent stomach bubble, but was found instead to have oropharyngeal atresia and a complete persistent buccopharyngeal membrane. This case is the first described in which the patient was successfully intubated through a small slit in the persistent membrane.

Rofecoxib versus hydrocodone/acetaminophen for postoperative analgesia in functional endoscopic sinus surgery.

OBJECTIVES/HYPOTHESIS: Functional endoscopic sinus surgery (FESS) is less invasive and more tissue sparing than extirpative techniques, with an assumed benefit of diminished postoperative pain. Oral opioids are commonly prescribed after sinus surgery but are associated with adverse effects, including gastrointestinal and neurologic symptoms. Nonopioid analgesics have been suggested to offer similar pain control efficacy with fewer adverse effects. STUDY DESIGN: To investigate postoperative analgesia in FESS, a prospective randomized, double-blinded comparison of hydrocodone/acetaminophen 7.5/750 mg (an opioidderivative) with rofecoxib 50 mg (a cyclooxygenase-2 inhibitor) was performed. METHODS: Forty subjects were enrolled, of which 28 successfully completed the study. Subjects recorded peak pain levels and requirement for rescue analgesia on the day of surgery and for 4 days thereafter. On postoperative day 5, subjects completed an exit survey in which adverse effects and overall satisfaction with pain control were recorded. RESULTS: In this study, there were no statistical differences in peak pain levels between the groups at any point in the postoperative period, regardless of extent of surgery. Adverse effect profiles were also similar for the two groups. CONCLUSIONS: The use of nonopioid analgesics after FESS may provide similar pain control to oral opioids.

Electrocautery versus cold knife technique adenotonsillectomy: a cost analysis.

OBJECTIVE: Much has been written about the merits of various techniques of adenotonsillectomy. Proponents of each technique tout many virtues over one another. However, cost remains one variable that has not been thoroughly addressed. In this study, we compared the surgery time, anesthesia time, bleeding, and cost between 2 well-established techniques. Electrocautery tonsillectomy/adenoid ablation was compared against traditional cold knife dissection with adenoid curette. STUDY DESIGN AND SETTING: A retrospective chart review of 275 patients in a large tertiary teaching hospital. RESULTS: The electrocautery group had overall savings of 8, 8, and 9 minutes in surgery, anesthesia, and operating room times, respectively. In terms of cost, the variable cost of the electrocautery group was 19% less than the cold knife dissection group. CONCLUSION/SIGNIFICANCE: This study demonstrated that cautery ablation of adenoids, when employed as part of adenotonsillectomy, enables the surgical team to save significant amount of time, and substantial cost for patients. EBM RATING: B-3.

Auricular malignant melanoma of early childhood: the role of sentinel node biopsy.

Pediatric melanoma is a rare but lethal disease. These tumors tend to present at more advanced stages when compared to adult cases. Additionally, the inability to obtain accurate diagnosis often further delays the onset of treatment. Here, we present two cases of auricular melanoma in 3-year-old patients that were biopsied by the shave method prior to referral to an otolaryngologist. With the staging of the disease in question, sentinel lymph node biopsy were completed. Case 1 demonstrated positive sentinel nodes and underwent subsequent modified neck dissection. The second patient with negative sentinel nodes required no further surgery. Both patients remain disease free currently, at 16 and 22 months after the sentinel node biopsy. By discussing our experience and reviewing the current literature, we hope to shed some light in the diagnosis, staging and treatment of pediatric melanoma of the head and neck.

Central autonomic activation by intracisternal TRH analogue excites gastric splanchnic afferent neurons.

Intracisternal (ic) injection of thyrotropin-releasing hormone (TRH) or its stable analogue RX 77368 influences gastric function via stimulation of vagal muscarinic pathways. In rats, the increase in gastric mucosal blood flow evoked by a low ic dose of RX 77368 occurs via release of calcitonin gene-related peptide from capsaicin-sensitive afferent neurons, most probably of spinal origin. In this study, the effect of low ic doses of RX 77368 on afferent impulse activity in splanchnic single fibers was investigated. The cisterna magna of overnight-fasted, urethan-anesthetized Sprague-Dawley rats was acutely cannulated, and fine splanchnic nerve twigs containing at least one fiber responsive to mechanical probing of the stomach were isolated at a site immediately distal to the left suprarenal ganglion. Unit mechanoreceptive fields were encountered in all portions of the stomach, both superficially and in deeper layers. Splanchnic afferent unit impulse activity was recorded continuously during basal conditions and in response to consecutive ic injections of saline and RX 77368 (15-30 min later; 1.5 or 3 ng). Basal discharge rates ranged from 0 to 154 impulses/min (median = 10.2 impulses/min). A majority of splanchnic single units with ongoing activity increased their mean discharge rate by >/=20% after ic injection of RX 77368 at either 1.5 ng (6/10 units; median increase 63%) or 3 ng (19/24 units; median increase 175%). Five units lacking impulse activity in the 5-min before ic RX 77368 (3 ng) were also excited, with the onset of discharge occurring within 1.0-5.0 min postinjection. In units excited by ic RX 77368, peak discharge occurred 15.6 +/- 1.3 min after injection and was followed by a decline to stable activity levels

Intracisternal TRH and RX 77368 potently activate gastric vagal efferent discharge in rats.

The influence of intracisternal (ic) TRH and the stable TRH analog, RX 77368, on gastric vagal efferent discharge (GVED) was investigated in urethane-anesthetized rats. Consecutive IC injections of TRH (3, 30, and 300 ng) at 60 min intervals stimulated dose dependently multi-unit GVED with a peak increase of 90 +/- 21%, 127 +/- 18% and 145 +/- 16% respectively. In two separate studies, IC injection of RX 77368 at 1.5 or 15 ng stimulated multi-unit GVED by 142 +/- 24% and 244 +/- 95% respectively. Saline injection IC had no effect on GVED. RX 77368 (1.5 ng, ic) action was long lasting (84 +/- 13 min) compared with TRH (3 ng: 44 +/- 7 min). Single-unit analysis also showed that 13 of 13 units responded to ic RX 77368 (1.5 ng) by an increase in activity. These data indicate that low doses of TRH injected ic stimulate vagal efferent outflow to the rat stomach and that RX 77368 action is more potent than TRH.

Peripheral bombesin induces gastric vagal afferent activation in rats.

Bombesin's influence on gastric vagal afferent discharge (GVAD) was studied in urethan-anesthetized rats. Vehicle and peptides were injected intravenously at 30-min intervals. Cholecystokinin (CCK; 300 pmol) and bombesin (300 pmol) increased ongoing multiunit GVAD by 153 +/- 59 and 162 +/- 37%, respectively; similar increases were induced by a second injection of bombesin and CCK. The bombesin antagonist, ICI-216140, prevented bombesin-induced increase in GVAD, whereas the CCK response was not influenced. The CCK-A receptor antagonist devazepide reduced the activation of GVAD induced by bombesin from 107 +/- 11 to 63 +/- 6%, while abolishing the CCK response. Devazepide given alone or in combination with ICI-216140 did not modify gastric distension (3 ml)-induced increase in GVAD. Of 22 single units that were activated by gastric load (4 ml), 17 and 20 units responded also to bombesin (620 pmol) and CCK (870 pmol), respectively. Of the nine units that did not respond to gastric load, eight had an increase in GVAD induced by both bombesin and CCK. There was no specific binding of 125I-labeled [Tyr4]bombesin on cervical vagus, either intact or 24 h after ligation. These data suggest that intravenous bombesin-induced stimulation of GVAD is indirect and initially mediated through specific receptor activation influencing gastric smooth muscle and the release of CCK.