Differential bacteriology in adenoid disease.

In order to define the differential bacteriology in adenoid disease, adenoids were obtained from 10 children with adenoid hypertrophy and 29 children with chronic adenoiditis. The patients' ages ranged from 18 months to 13 years. After removal of the adenoids, the surface organisms were destroyed by alcohol and flame disinfection. One gram of tissue was sampled for aerobic and anaerobic culture. There was an average of 4.8 isolates per specimen, with 4.2 aerobes and 0.6 anaerobes. The most common isolates were: Haemophilus influenzae (84%), diphtheroids (66%), non-pathogenic Neisseria species (66%), alpha-hemolytic streptococci (64%) and non-hemolytic streptococci (59%). Anaerobes were present in 56% of all cases. The distribution of organisms was similar, regardless of clinical diagnosis. Only eight (21%) of the 39 cases had 'significant' (> or = 10(5) organisms/gm) colony counts. Our study detected no difference in either organism distribution or in total colony counts in chronic adenoiditis vs. adenoid hypertrophy.

Malignant nasopharyngeal tumors in children.

From 1964 to 1984, 25 children with malignant tumors of the nasopharynx were seen, and their progress was followed at The Hospital for Sick Children in Toronto. Two types of malignancies: rhabdomyosarcoma and lymphoepithelioma were most prevalent with eight cases apiece. The presenting signs and symptoms were related to local and/or regional manifestations of disease. No child presented with signs or symptoms related to distant metastatic disease. The diagnosis and treatment of this series of patients are described briefly. The advent of combined treatment modalities in the past decade has improved the prognosis for nasopharyngeal tumors, especially for the rhabdomyosarcomas; in general, however, survival rates are still poor, approximating 50%.

Randomized surgical adjuvant trial of interferon alfa-n1 in recurrent papillomatosis.

Sixty-six patients with recurrent respiratory papillomatosis of juvenile onset were treated for six months with interferon alfa-n1 (Wellferon) in a randomized crossover trial. Half received interferon alfa-n1 intramuscularly at a dosage of 5 megaunits per square meter daily for 28 days and then thrice weekly for five months, followed by six months of observation. The other half were observed for six months and then treated. Operations were performed every two months to assess disease extent by a scale developed for this purpose. The score for the patients during the first observation period was stable. There was a statistically significant lowering of score in patients receiving interferon alfa-n1 during both periods of drug administration. Eight of 57 patients with assessable airway disease achieved complete remission, as did one additional patient with disease limited to the nasopharynx. No patients achieved complete remission during six months of observation alone. This difference was statistically significant. Patients without tracheostomy were significantly more likely to achieve remission than those with a tracheostomy. The patients who were observed after discontinuation of the drug therapy showed a significant rise in score within four months. Symptoms of toxicity included transient fever, fatigue, nausea, and headache. Elevations in serum aspartate aminotransferase levels occurred in 64% of the patients. There was an inverse correlation between age and the ability to tolerate the medication. The dose studied may be close to the maximum tolerated dose. It appears that interferon alfa-n1 as an adjuvant to routine surgical management is effective in slowing the growth of respiratory papillomas.

Interferon alfa-n1 (Wellferon) in juvenile onset recurrent respiratory papillomatosis: results of a randomized study in twelve collaborative institutions.

Sixty-six patients with clinically severe juvenile-onset recurrent respiratory papillomatosis (RRP) were entered into a 12-month randomized crossover study to evaluate interferon alpha-n1 Wellferon (WFN) as an adjuvant to CO2 laser surgical excision. Eligibility required disease onset to be before age 16, and an endoscopic excision requirement of at least three operations in the 6 months immediately prior to entry. Patients were randomized to Observation versus WFN at a dose of 5 MU/m2 daily for 28 days and three times weekly for 5 months. The patient groups were comparable in extent of disease at entry. Total extent of disease was determined by a composite score derived from the number of diseased anatomic sites and extent of surface area and lumen encroachment present at each site. Standard endoscopic excisions were performed every 2 months and clinical courses compared on a basis of composite scores determined at each endoscopy. Statistically significant improvement occurred in the patient group which received WFN. We conclude that interferon alpha n-1 is an effective adjuvant to surgery in RRP management.

Choanal atresia and associated anomalies.

The authors have studied 130 cases of choanal malformation. They found 53 bilateral atresias, 51 unilateral atresias and 26 cases of choanal stenosis. Fifty-seven of these cases were associated with other anomalies and 38 had at least two features of the CHARGE association (C, colobomas; H, heart defects; A, atresia choanae; R, retarded growth; G, genito-urinary defects; E, ear defects). The pathogenesis of choanal atresia in regard to the abnormal migration of neuroectodermal cells is discussed.

Laryngeal problems in children.

Some diseases of the larynx that now are rare were common in 1950, when the author began the practice of pediatric otolaryngology. These include laryngeal tuberculosis, bulbar poliomyelitis, and acute exanthemata. The management of laryngotracheitis and supraglottitis has altered markedly, with the mortality reduced drastically. The advent of the operating microscope and carbon dioxide laser has broadened the efficacy of laryngeal surgery. Subglottic stenosis continues to be a challenge despite new operations. Laryngeal transplant may be the answer to some intractable diseases.

Traumatic bronchial injuries in children.

Between 1975 and 1981 five children (three girls and two boys) from 3 to 11 years were treated for blunt chest trauma with major tears in two areas of the right main bronchus. All were hit or run over by motor vehicles and were in acute respiratory distress. All suffered right pneumothoraces; three did not respond to a chest tube with suction. Four of five children had subcutaneous emphysema, and two had fractured ribs on the ipsilateral side; three children also had contralateral chest injuries. Four had major extrathoracic injuries. Three children required early repair, while two needed late treatment. All five patients recovered well and have remained healthy from 5 to 10 years after injury. These cases serve as illustrations for a review of a survey of the literature.

Cricoid resection and thyrotracheal anastomosis in the growing primate.

Although many procedures have been described for the correction of subglottic stenosis in the infant and child, none has been universally satisfactory. Cricoid resection and thyrotracheal anastomosis have been successful in adults, and we considered that the same techniques could be applied to correct subglottic stenosis in infants and children. A feasibility study was undertaken using young primates as a surgical model. The operation in each was accomplished uneventfully, although one animal later developed a complication possibly due to the use of a tissue adhesive. In practice, this complication could have been corrected without compromising the surgical outcome.

Vocal cord palsy in pediatric practice: a review of 71 cases.

Seventy-one cases of vocal cord palsy were seen over a 20-year period at the Hospital for Sick Children in Toronto. Forty-four percent of the cases had a bilateral vocal cord palsy. The etiology, management and outcome of all the cases are reviewed. Of the acquired vocal cord palsies, 64% recovered spontaneously. Only 29% of the congenital vocal cord palsies recovered spontaneously. An important consideration in the management of children with vocal cord palsy is the possibility of late spontaneous recovery or compensation. There should, therefore, be no hurry to perform surgical procedures to permanently lateralize the vocal cords or arytenoids.

Laryngeal foreign bodies in children.

Laryngeal foreign bodies (F.B.) in children are relative rare, especially in infants under one year of age, and the diagnosis and removal are difficult. The history, the clinical and radiologic findings can be misleading. Seventeen patients with laryngeal F.B. (10 of them under one year of age) are presented, and the diagnostic problems and treatment are discussed. Foreign bodies were either objects of a sharp and thin quality, e.g. an eggshell fragment, or large, e.g. a piece of meat, causing apnea and death.

Anesthesia for laryngeal laser surgery in the infant and child.

Currently available anesthetic techniques for laryngoscopy and bronchoscopy are briefly evaluated. Recently reported complications from the literature are reviewed. Satisfactory anesthetic techniques are shown to be limited by the physical dimensions of the instruments as well as the extreme limitations of the flow capacity of the small airway itself. The technique used at the Hospital for Sick Children for the past ten years is described. It is based upon spontaneous respiration with inhalation anesthesia, supplemented by topical lidocaine (Xylocaine). Size and age of the patient are not limiting factors. The safety and effectiveness of this technique are supported by representative blood gas studies as well as the clinical records of over 400 cases.

Esophageal hiatal hernia in infants and children.

Although prior to 1950 esophageal hiatal hernia (EHH) in children was a seldom recognized entity, it has since then become well known. The symptoms in children are considerably different from those in adults. The cause of EHH is still somewhat in doubt. The term gastroesophageal reflux (GER) is often applied as a diagnosis where the diagnosis is uncertain. The authors have reviewed case histories of 56 patients admitted to the Hospital for Sick Children, Toronto, from 1972 to 1980. A comparison is made with 101 cases admitted between 1952 and 1960. It is our firm belief that all patients with symptoms of GER should be esophagoscoped for definitive diagnosis as well as for assessment of the esophagus. Because there is a high rate of respiratory complications in infants and children with GER, bronchoscopy should be carried out concurrently with the esophagoscopy. Infants with GER are at risk from the possibility of aspiration and it is possible that an unknown number of sudden infant death syndrome is due to this factor. The majority of patients with EHH can be managed by a medical regime. Those with esophageal strictures are treated by dilatation but many require surgical correction.

Anesthesia and pediatric endoscopy.

An inhalation anesthetic technique applicable to all kinds of endoscopy in children is described. It provides maximum visualization for the endoscopist, permits pressurization of the airway, does not require exceptional or unusual skills, and can be successfully managed by an anesthetist utilizing universally recognized techniques of inhalation anesthesia.

Laryngeal surgery in the pediatric patient.

The primary concern in laryngeal surgery in the infant and child is to relieve airway obstruction, rather than phonation. Because airway obstruction above the larynx may stimulate or be confused with laryngeal pathology, these are described as the signs and symptoms of laryngeal disease. Although tracheotomy in the infant is frequently said to be a cause of a long-term problem, the procedure can be carried out in the smallest premature quite safely and without an extubation problem. The author's method of performing the operation is described. Most laryngeal surgery in the child is performed by the endoscopic approach, special scopes being used for special purposes. In addition to conventional instrumentation the cryoprobe and CO2 laser and employed. The author's method of treating glottic and subglottic stenosis is outlined.

Treatment of subglottic hemangioma with the carbon dioxide laser.

Congenital subglottic hemangioma is a potentially life-threatening lesion usually presenting in the first three months of life. Over the years, multiple treatment modalities have been advocated. However, none has been uniformly successful, and morbidity and mortality remain high. With the advent of the carbon dioxide surgical laser, it soon became apparent that this was an ideal tool for the pediatric larynx. The already documented properties of the laser have led to the application of this form of tissue destruction in 11 patients with subglotic hemangioma. This modality has proven to be a safe, effective and rapid means of treating this troublesome lesion.