Observations on the early results of treatment of recurrent respiratory papillomatosis using cidofovir.

OBJECTIVE: To document the response of two patients with severe recurrent laryngeal papillomatosis following treatment with intralesional cidofovir in conjunction with carbon-dioxide laser evaporation. SETTING: Tertiary referral centre. METHODS: Retrospective review of treatment of two patients followed up over a 12-month period. INTERVENTION: Microlaryngoscopy and carbon-dioxide laser evaporation of lesions followed by intralesional injection of cidofovir. OUTCOME MEASURES: Photodocumentation and descriptive statistical representation of intervals between endoscopic treatment. The disease was staged according to severity on endoscopy. RESULTS: Initially, both patients showed a marked improvement of disease. However, the disease relapsed to a significant extent. Overall, there was no demonstrable change in the frequency of required endoscopies despite subjective improvement of the airway. CONCLUSION: Cidofovir may be of some benefit in the management of recurrent respiratory papillomatosis, but further studies are still required.

A study of anthropometric measures before and after external septoplasty in children: a preliminary study.

OBJECTIVE: To test the hypothesis that surgery on the growing nasal septum does not adversely affect nasal and midfacial dimensions. DESIGN: Paired study. SETTING: Tertiary care center. PARTICIPANTS: Children treated consecutively during a 4-year period; all had significant nasal obstruction and cosmetic disfigurement secondary to skeletal septal deformities. INTERVENTION: Nasal septal surgery (using an external approach), in which the quadrilateral cartilage was removed, remodeled, and reinserted as a free graft. OUTCOME MEASURES: Anthropometric linear measurements and indexes of the face and nose preoperatively and postoperatively; nasal dorsum length, nasal height, nasal dorsum index, nasal tip protrusion, columellar length, facial height, face width, upper face height, facial index, nose-upper face height index, and columellar length-nasal tip protrusion index. Continuous measurements were transformed into ordered categories with reference to normative data. Data were analyzed using Wilcoxon signed rank sum test (alpha level of.05) and by applying the Bonferroni adjustment for multiple testing. RESULTS: Twenty-six children were studied (12 females and 14 males); age at surgery ranged from 4.5 to 15.5 years (mean age, 9.5 years); average age at postoperative measurement, 12.5 years; mean follow-up, 3.1 years. Only nasal dorsum length (P =.007) and nasal tip protrusion (P =.04) were decreased by a statistically significant level before the Bonferroni adjustment. The change was not considered clinically significant. Thus, relative to age-appropriate norms, the dimensions of the nose and midface and their proportionality did not change after surgery. CONCLUSIONS: Appropriate nasal septal surgery involving excision and subsequent reinsertion of a remodeled segment of the quadrilateral cartilage has no deleterious effects on development of the nose and midface. We question the absolute dogma that nasal surgery in children must always be avoided.

Management of drooling in individuals with neurodisability: a surgical experience.

From 1975 to 1 January 1999, 1103 neurologically involved patients (mean age 13.2 years; 686 males, 417 females) referred with problematic drooling, or sialorrhea, were assessed at a pediatric rehabilitation center by a team consisting of an otolaryngologist, speech pathologist, and a dentist. The initial standard treatment for persistent sialorrhea (in the compliant or aware patient) is oral-motor training. A group of 522 patients with persistent significant drooling after a minimum of 6 months of oral-motor training, or profuse drooling in the presence of a low cognitive level, underwent surgery, usually when over 6 years of age. From 1978 to 1 January 1998, the operation of first choice was submandibular duct relocation (SDR), and was completed in a total of 226 patients. Midway through 1988, sublingual gland excision was also completed at the time of submandibular duct relocation (SDRSGE); 249 of these procedures have been completed to January 1st 1999. Those patients who had SDRSGE had significantly fewer complications that required additional surgery than those that had SDR only. However, the impact of surgery on the drooling as evaluated in subsets of both groups (SDR n=115, SDRSGE n=106) was statistically similar. The study of 11 children with salivary gland radionuclitide scans to determine the effect of submandibular duct surgery on gland function was inconclusive. The pattern of oral-motor function in 26 children studied after SDRSGE surgery suggested that those children with severe impairment of volitional motor function and profuse drooling tended to have a poorer outcome following surgery compared to those with milder impairments.

Nasal obstruction in children with craniofacial malformations.

The etiology, patient evaluation and management of nasal obstruction in children with craniofacial malformations is broadly discussed. Specific reference is made to the experience by the senior author (WSC) with respect to nasal surgery in 29 of these patients during the 12 years from 1987 to January 1st, 1998.

Nasal growth after external septoplasty in children.

OBJECTIVE: To assess the impact of external septoplasty surgery on nasal growth in children. DESIGN: Twelve anthropometric measurements (9 linear and 3 angular) were obtained in patients who previously underwent external septoplasty surgery for severe nasal obstruction caused by septal deviation anterior to the nasal spine. Surgery consisted of excision, refashioning, and reinsertion of the quadrilateral cartilage. From these 12 measurements, 5 proportional indexes were calculated, and then all measurements and proportions were compared with previously published norms. Follow-up measurements were taken at least 2 years after surgery (average, 3.4 years). SETTING: The Hospital for Sick Children, Toronto, Ontario, a tertiary care children's hospital. PARTICIPANTS: Twenty-eight patients who underwent external septoplasty surgery between the ages of 6 and 15 years. RESULTS: The principal measurements of the face and nose were within 1 SD of the normative mean for the majority of those in the study group. This was true for nasal height, nasal tip protrusion, nasal width, columella width, columella length, upper face height, face height, face width, inclination of the upper face, inclination of the nasal dorsum, and inclination of the columella. Values for 4 of the 5 proportional indexes were also overwhelmingly in the normal range. Twenty-nine percent of nasal dorsum measurements and 57% of nasal dorsum indexes were more than 2 SDs from the mean, indicating a predominance of short nasal dorsums. CONCLUSIONS: External septoplasty does not affect most aspects of nasal and facial growth, but it may negatively influence growth of the nasal dorsum. Prospective studies are needed to clarify this issue.

Otoplasty. Clinical protocol and long-term results.

OBJECTIVE: To evaluate the long-term results after otoplasty on prominent ears. DESIGN: Between 1988 and 1993, ear protrusion was measured preoperatively and postoperatively in pediatric patients undergoing otoplasty by means of a standard protocol based on the Frankfort horizontal line. Patients were asked to return for follow-up measurements a minimum of 1 year after surgery. At the time of follow-up, a patient satisfaction survey was completed by the patients and their families. SETTING: The Hospital for Sick Children, Toronto, Ontario, a tertiary care children's hospital. PARTICIPANTS: Thirty-one of 51 patients returned for follow-up an average of 3.7 years after surgery. RESULTS: One third of ears returned to their original position, one third of ears stayed in a position equal to the immediate postoperative position, and one third of ears had final positions between the preoperative and post-operative positions. At the superior rim, an average of 58% of the operative medialization was lost. Good to excellent ear-to-ear symmetry was obtained in 78% of patients who returned for follow-up. Retrospective chart review showed a revision surgery rate of 3%; stitch granulomas were removed in 9% of patients. The patient satisfaction survey found that 85% of patients were happy or very happy with their ears. CONCLUSIONS: With time, a substantial loss of correction can be expected in most (but not all) patients who undergo otoplasty, particularly at the upper pole. Overall, patients and their families are happy with the results of otoplasty surgery.

Congenital cystic adenomatoid malformation of the lung referred as 'airway foreign body'.

Congenital cystic adenomatoid malformation of the lung is an uncommon anomaly. Two patients with this condition were recently referred to the Otolaryngology Service at The Hospital for Sick Children, Toronto, Ontario, for bronchoscopic evaluation of the airway to rule out a foreign body. Although history did not disclose a clear episode of aspiration in either case, chest radiographs showed unilateral lobar hyperinflation with mediastinal shift, consistent with foreign body obstruction. We report two cases to introduce congenital cystic adenomatoid malformation to the English otolaryngology literature and to increase awareness of it among otolaryngologists.

Laser aryepiglottoplasty for the treatment of neurasthenic laryngomalacia in cerebral palsy.

Patients with cerebral palsy usually suffer from lack of coordination in the neuromuscular mechanism in their upper airway and digestive tract. Difficulty in swallowing and aspiration are common problems in these patients, and stridorous breathing sometimes develops as a secondary symptom. Laryngoscopic examination revealed that redundant tissue in the aryepiglottic fold area was the cause of stridor and upper airway obstruction in four patients with cerebral palsy. We report on these four patients in whom laser reduction of the redundant mucosa led to dramatic improvements in stridor. Secondary benefits to family members and others were equally impressive.

Congenital nasal pyriform aperture stenosis as a presenting feature of holoprosencephaly.

Congenital nasal pyriform apertures stenosis (CNPAS), a recently recognized uncommon cause of nasal airway obstruction, can be a life-threatening circumstance in the neonate. This study's experience with six cases confirmed the suggestion that CNPAS represents a manifestation of holoprosencephaly. Management of this condition depends firstly on the overall prognosis of the patient and secondly the severity of obstruction. Patients with poor overall prognosis should be managed conservatively with an oropharyngeal airway. In patients with a good outlook, the choice of treatment is conservative for those with less severe obstruction and surgical correction for those with complete obstruction. The ability to pass a No. 5Fr catheter (O.D. 1.67 mm) may be a guide to the choice of treatment. An increase in awareness among otolaryngologists on the nature of CNPAS is necessary to improve overall management of such patients.

Sinusitis in patients with cystic fibrosis.

The management of sinus disease in children with cystic fibrosis is reviewed, based on a literature review and clinical experience in The Hospital for Sick Children, Toronto. Diagnostic and treatment approaches are discussed, with emphasis given to indications for surgical therapies. Great importance is given to the preservation of normal nasal anatomy whenever possible to minimize the possibility of iatrogenic injuries occurring, especially when revision surgery is required.

Electrocautery-induced ignition of tonsillar packing.

A recent case of ignition of a bismuth-subgallate pack during routine tonsillectomy prompted this investigation of local oxygen levels. Similar conditions were reproduced in the laboratory to determine their influence on the flammability of materials commonly used to aid in haemostasis. Cotton tonsil packs soaked in saline, adrenalin, or adrenalin and bismuth were compared. During spontaneous ventilation through an age-appropriate uncuffed endotracheal tube, an air leak rarely occurred. However, when assisted ventilation was used, an airway leak produced an elevated oxygen concentration in 8 of 10 children. This was associated with increased combustibility of the packs, regardless of solution mixture. The addition of bismuth further increased combustibility. Partially saturated packs appeared to be more combustible than fully saturated packs.

External septorhinoplasty in children: patient selection and surgical technique.

The external or open septorhinoplasty is used in children as young as 6 years of age. The primary indication for this procedure is the presence of nasal septal pathology anterior to the anterior nasal spine causing significant nasal airway obstruction. Meticulous attention to technique, especially the construction of a "new" septum, is essential for a successful outcome.

External septorhinoplasty in children: Outcome and effect on growth of septal excision and reimplantation.

Outcome and effect on nasal growth of external septorhinoplasty was evaluated in 32 children. All had septal disease anterior to the nasal spine. In all cases, the cartilaginous septum was totally excised, refashioned, and then reinserted. Sixteen children with follow-up for more than 2 years were identified. Nine children had preoperative and postoperative nasal airflow studies and demonstrated a reduction in total nasal airway resistance, from a mean untreated value of 6.1 cm of water per centimeter per second preoperatively to a mean of 2.5 cm of water per centimeter per second postoperatively. IN 10 of these 16 children, six postoperative anthropometric measures and one index were determined, and these measurements were within the range of age- and sex-specific normative data from the Craniofacial Measurements Laboratory at the Hospital for Sick Children, Toronto, Ontario.

Evaluation and management of the drooling patient.

Drooling, or sialorrhea, may appear to be a most mundane problem but in fact can be a condition with a wide spectrum of etiologies. Unhappily, drooling also may lead to several unfortunate medical and psychosocial outcomes for the affected patient. The senior author (WSC) has had a 13 year interest in the treatment of drooling patients. This paper is essentially a distillation of the experience gained in managing these patients. Since 1979 he has participated in a team (which includes an otolaryngologist, a dentist and a speech pathologist) that attends these patients and makes recommendations in a consensus fashion. This team concept, as well as historical and physiologic background material, will be discussed below.