The safety of conscious sedation in peritonsillar abscess drainage.

OBJECTIVE: To demonstrate the safety of conscious sedation in draining peritonsillar abscesses (PTAs). DESIGN: Children diagnosed as having a PTA in the pediatric emergency department were identified, and their medical records were retrospectively reviewed. Results of the present study were compared with those of a previous report. SETTING: A tertiary referral children's hospital pediatric emergency department. PARTICIPANTS: Ninety-one consecutive children initially evaluated in the emergency department and managed for a PTA. INTERVENTIONS: Peritonsillar abscess incision and drainage with or without sedation. A team of physicians whose activities were documented on a formal conscious-sedation record was present. Patients were monitored for major and minor complications. OUTCOME MEASURES: The primary outcome measures were major and minor complications. Secondary outcome measures were recurrence of PTA and the need for admission. RESULTS: There were 62 episodes of conscious sedation for drainage of a PTA. Among the 91 patients, 3 had a recurrence and 24 were admitted after the procedure. A previous study evaluated 30 episodes of conscious sedation for drainage of a PTA. No major complications occurred in either series. Combining the previous data with the present data produced 92 episodes of conscious sedation for drainage of a PTA. The 1-sided upper 95% confidence limit for the rate of major complications is 3.2%. CONCLUSION: Our series, when combined with previously published data, demonstrates that conscious sedation can be safely used when draining a PTA in pediatric patients.

Parathyroid hyperplasia: an unusual cause of neonatal hypercalcemia.

Primary hyperparathyroidism (PHPT) in infants is caused by parathyroid chief cell hyperplasia. Patients present with symptoms of chronic hypercalcemia, such as failure to thrive, irritability, abdominal pain, and anorexia. Medical therapy is inadequate, often resulting in chronic hypercalcemia or death. Partial or total surgical removal of the parathyroid gland is the preferred treatment. We describe a case of a 7-month-old infant with PHPT secondary to hyperplasia successfully treated with a subtotal parathyroidectomy.

Gastroesophageal reflux and pediatric otolaryngologic disease: the role of antireflux surgery.

OBJECTIVE: To determine the role of antireflux surgery in the treatment of gastroesophageal reflux-induced otolaryngologic disease (GEROD). DESIGN: A retrospective medical record analysis was performed. Patient demographics, otolaryngologic disease secondary to gastroesophageal reflux (GER), method of GER diagnosis, medical treatment used before antireflux surgery, and response to surgical intervention were considered. SETTING: Tertiary care children's hospital. PATIENTS: Among patients undergoing antireflux surgery between January 1, 1996, and December 31, 1999, children with GEROD were included in the study. INTERVENTIONS: Children with GEROD who failed medical therapy underwent antireflux surgery. MAIN OUTCOME MEASURES: The demographics of patients requiring antireflux surgery for treatment of their otolaryngologic disease and their clinical response to surgery were reviewed. RESULTS: Fourteen (17%) of 82 children, ranging in age from 48 days to 3 years (mean age, 9.7 months), who underwent antireflux surgery for GER at our institution between 1996 and 1999 were diagnosed as having GEROD. Twelve (86%) of the 14 patients were found to have upper airway abnormalities, including subglottic edema, fixed subglottic stenosis, reflex apnea, and recurrent croup. Two patients (14%) had severe chronic sinusitis and otitis media. Nine (64%) of the 14 had normal neurologic function for their age vs 5 (36%) who had neurologic impairment. After antireflux surgery, all 14 patients with GEROD had complete resolution of clinical symptoms. CONCLUSIONS: Gastroesophageal reflux has an important role in the cause of numerous otolaryngologic disorders. Although medical management should remain the mainstay of GER therapy, antireflux surgery provided definitive and successful treatment of potentially life-threatening manifestations of GEROD.

Autosomal dominant familial frontonasal dermoid cysts: a mother and her identical twin daughters.

A dermoid cyst is an ectodermal cyst that contains an epithelial lining as well as adnexal structures, and may occur in numerous areas of the body. The nasal dermoid accounts for 1% of all dermoid cysts and 3-12% of head and neck dermoid cysts. While there have been familial cases reported, a genetic inheritance for nasal dermoids has not been suggested. We present the first reported case of a mother and her identical twin daughters who were all found to have evidence of frontonasal dermoid cysts. Our case and a review of literature seem to implicate an autosomal dominant inheritance in certain instances of nasal dermoids.

Doxycycline sclerotherapy of benign lymphoepithelial cysts of the parotid: a minimally invasive treatment.

Benign lymphoepithelial cysts (BLCs) of the parotid gland are associated with human immunodeficiency virus infections in both children and adults. These cysts may become painful and unsightly, often initiating a request for therapeutic intervention. There are several treatment options described in the literature. We report the use of doxycycline sclerotherapy in the treatment of a child with BLCs of the parotid.

Maturation of the pediatric tracheostomy stoma: effect on complications.

The pediatric tracheostomy stoma can be matured via a technique that places 4-quadrant sutures from the tracheal cartilage to the dermis. This has the potential of decreasing the risk of accidental decannulation and the formation of granulation tissue. A retrospective analysis of 149 tracheostomies performed between January 1989 and December 1996 was done for the following factors: age, underlying diagnosis, indication for tracheostomy, type of tracheal incision, maturation of stoma, duration of tracheostomy, and early and late (>7 days) complications. Maturation of the stoma was performed in 88 (59.1%) of the 149 tracheostomies. There was an overall complication rate of 21.5% (32/149, not including granulation tissue formation). There were 9 (6.0%) early complications and 23 (15.4%) late complications. The overall incidence of tracheocutaneous fistulas occurred in 11 (11.2%) of the 98 decannulated patients: 6 (10.2%) of the 59 matured stomas and 5 (12.8%) of the 39 nonmatured stomas. Granulation tissue was found on subsequent laryngoscopy in 24 (27.3%) of the 88 matured stomas versus 23 (37.7%) of the 61 nonmatured stomas. There were no tracheostomy-related mortalities. Maturing the tracheostomy stoma resulted in a decreased morbidity from accidental decannulations and did not increase the incidence of tracheocutaneous fistulas or granulation tissue formation.

Conscious sedation: a new approach for peritonsillar abscess drainage in the pediatric population.

OBJECTIVE: To assess the safety and efficacy of conscious sedation (CS) in children undergoing emergency department incision and drainage (I&D) of peritonsillar abscesses (PTAs). DESIGN: A 33-month retrospective chart review of all children presenting to the emergency department with the diagnosis of a PTA or peritonsillar cellulitis. Children who underwent CS prior to I&D were compared with children without CS for complications and efficacy. SETTING: St Louis Children's Hospital, an academic tertiary care pediatric hospital. PATIENTS: Fifty-two children were enrolled; 30 PTAs were drained with CS in 27 children (3 underwent I&D twice), and 25 PTAs were drained in 25 children without CS. INTERVENTIONS: The CS team included an otolaryngologist, a pediatric emergency department physician, and a registered nurse. A standardized CS protocol assessing vital signs and level of consciousness was employed during each procedure. A combination of midazolam, ketamine hydrochloride, and glycopyrrolate was used in appropriately weighted calculated doses. Patients were assessed for major and minor airway complications. MAIN OUTCOME MEASURES: Airway complications related to CS were reviewed. Patients who underwent I&D with and without CS were compared with regard to purulent drainage. RESULTS: There were no major airway complications in patients undergoing I&D with CS. There was 1 minor complication in this group, oxygen desaturation to 88%, which resolved with stimulation. Of the 55 procedures, 45 (82%) yielded purulence: 29 (97%) of 30 in the CS group and 16 (64%) of 25 in the non-CS group (chi2 = 9.8; P = .002). Of those children undergoing CS, 3 (10%) of 30 were admitted to the hospital from the emergency department as compared with 6 (24%) of 25 without CS (chi2 = 1.95; P = .16). In the CS group, PTAs had a low recurrence rate of 1 (3.3%) of 30 compared with 2 (8%) of 25 in the non-CS group (chi2 = 0.57; P = .45). No one in the CS group required a secondary procedure under general anesthesia. CONCLUSIONS: This preliminary study demonstrates CS to be a potentially safe and efficacious approach to drainage of PTAs in children. Given its efficacy and its associated lower levels of anxiety and pain for the patient, CS seems to be a promising new approach to caring for children with PTAs.

Nontuberculous mycobacterial cervical adenitis.

Granulomatous inflammation is a common finding in pathologic evaluation of surgically excised chronic lymphadenopathy in children. Confusion exists regarding diagnosis and management of these lesions. Over a 10-year period at The Children's Hospital of Philadelphia, a total of 81 children were identified with biopsy-confirmed granulomatous lesions of the head and neck, with nontuberculous mycobacteria (NTM) accounting for 67 of the cases. The typical presentation was that of a nontender mass in the cervicofacial area present for weeks to months, unresponsive to antimicrobials. All underwent surgical excision, which was curative in 54 patients; 13 children required additional procedures. This paper reviews NTM, its typical clinical presentation, difficulty in diagnosis, and the methods of treatment.

Management of the carotid artery following penetrating injuries of the soft palate.

Penetrating injuries of the soft palate are not uncommon in the pediatric population. The majority are minor, requiring only conservative treatment. Despite the close proximity of the carotid artery to lateral soft palate and tonsillar fossa, the incidence of carotid injury is low. When carotid injury does occur, it is usually secondary to blunt trauma to the carotid with a resultant thrombosis. A concomitant neurologic deterioration often follows occurring from 3 h to 3 days after the initial injury (Hengerer et al. (1984). Laryngoscope 94, 1571-1575). The potential neurologic sequelae of such an injury make these seemingly innocuous wounds a diagnostic and management dilemma for the clinician. We present an unusual case of an internal carotid artery pseudoaneurysm in a neurologically intact child following soft palate impalement. We review the diagnostic evaluation including angiography and magnetic resonance angiography, the surgical approach, and postoperative issues including anticoagulation. The literature is reviewed and a discussion regarding the approach to penetrating injuries of the soft palate is presented.

Subdural hematoma associated with metastatic neoplasms.

Two cases of subdural hematoma, one acute and the other chronic, associated with cancer metastatic to the dura are reported. Various mechanisms of the association of hematomas with cancer are reviewed.