Postoperative hemorrhage after tonsillectomy: use of ketorolac tromethamine.

Recent reports have associated an increased incidence of bleeding after tonsillectomy with the perioperative use of ketorolac tromethamine. To review this association, we examined the hospital and office records of 310 pediatric patients who underwent tonsillectomy with or without adenoidectomy at our institution during a 2-year period. Of these patients, 213 received ketorolac administered as a single dose at the conclusion of the procedure. The remaining 97 patients did not receive ketorolac. The frequency of postoperative hemorrhage was not found to differ significantly between these 2 groups (2.3% vs. 3.1% respectively, P = 0.71). Furthermore, the average time to discharge after surgery was significantly shorter in those patients who received ketorolac than in those who did not (8.5 hours vs. 12.5 hours, respectively, P < 0.0001). The frequency of overnight hospital stays was also significantly lower in those patients who received ketorolac (16.0% vs. 31.6%, respectively, P < 0.01). Concern over the potential for increased hemorrhage after tonsillectomy has led several authors to caution against the use of ketorolac in this setting. In our study, however, the use of ketorolac was not found to increase the incidence of posttonsillectomy hemorrhage and furthermore was associated with a significant decrease in the length of hospital stay as well as a decreased likelihood of overnight hospital stay after surgery.

Sublingual contiguous thyroglossal and dermoid cysts in a neonate.

Thyroglossal duct cysts and dermoid cysts are two distinct lesions which can occur in the midline of the head and neck region. Different embryologic explanations for these two lesions have traditionally been accepted. Recent evidence, however, hints at an association between them. We present here a case in which both of these cysts occurred together in an unusual anatomic location, along with a discussion of the possible relationship between these two pathologic entities.

Pericardial patch tracheoplasty for severe tracheal stenosis in children: intermediate results.

Between 1982 and 1990, 15 children have undergone pericardial patch tracheoplasty, 13 for complete tracheal rings and 2 for acquired tracheal stenosis. Eleven had complete tracheal rings from the thoracic inlet or the cricoid to the carina. Diagnosis was by bronchoscopy (15), computed tomography (10), and magnetic resonance imaging (3). As first described by Idriss in 1984, the surgical technique uses a median sternotomy approach, extracorporeal circulation, bronchoscopic guidance, and the use of pericardium as a tracheal patch. There was one perioperative death of mediastinitis (operative survival, 93%). There were two late deaths caused by complications of tracheostomy (1) and direct laryngoscopy and bronchoscopy (DLB) (1). Follow-up is complete in 12 intermediate-term survivors and ranges from 0.4 to 8.2 years (mean, 4.2 +/- 2.9 years). Five children required multiple DLBs with dilation and excision of granulation tissue; one of these patients underwent tracheoplasty revision 5 months after the initial procedure for residual tracheal rings, and four of these children have had tracheostomies, two temporary and two currently (4 months, 7 years). Seven children had widely patent tracheas observed at follow-up DLB with little or no residual stenosis after tracheoplasty. All survivors are currently asymptomatic, except for the two children with tracheostomies. Pericardial patch tracheoplasty offers effective therapy with relatively low operative mortality for infants and children with severe long segment tracheal stenosis. On intermediate-term follow-up, nearly all survivors are essentially free of symptoms of residual tracheal stenosis.

Anterior nasal stenosis secondary to accessory nasal bones.

Choanal atresia may result from a posterior or anterior obstruction of the airway. Treatment is predicated on an accurate identification of the underlying pathological condition by means of physical examination, fluoroscopy, and computed tomographic scan. Expeditious surgical management after appropriate diagnosis appears to result in effective relief of the obstruction.

Tracheoplasty with pericardial patch for extensive tracheal stenosis in infants and children.

Five infants with long tracheal stenosis were operated upon by means of a pericardial patch tracheoplasty. The approach was through a median sternotomy with extracorporeal circulation for respiratory support. In four, the obstruction was due to complete rings; in the other, there was an associated tracheal trauma which had occurred during resuscitation. This patient requires prolonged stenting with a tracheostomy tube. All others are asymptomatic postoperatively, with the longest follow-up being 22 months. There were no deaths or infections. We conclude from this experience that median sternotomy provides an excellent approach to the trachea, that autogenous pericardium is advantageous, and that there is no need for prolonged tracheal stenting in most patients.

Cicatricial pemphigoid in a 6-year-old child: report of a case and review of the literature.

Cicatricial pemphigoid has been documented previously in only four patients under the age of 20 years. We report a 6-year-old male who had erosions of the oral and genital mucosa, conjunctivitis, hoarseness, dysphagia, recurrent vomiting, and weight loss. Upper airway obstruction due to a chronically inflamed and scarred epiglottis necessitated tracheostomy. Biopsy of tissue from a solitary cutaneous lesion demonstrated a subepidermal bulla. Direct and indirect immunofluorescence confirmed a diagnosis of cicatricial pemphigoid. Therapy was begun consisting of prednisone, 2 mg per kg per day, in combination with dapsone, 2 mg per kg per day. He did not improve until the prednisone dosage was increased to 4 mg per kg per day.

Pharyngolaryngeal web. Report of a new anomaly.

Within the last several months we have seen two patients with pharyngolaryngeal webs. The webs extend from the lateral borders of the epiglottis to the lateral and posterior pharyngeal walls framing the glottis with a "keyhole" type of effect. No web of this kind has ever been documented in the literature to our knowledge. These children suffer from intermittent airway obstruction, probably secondary to tethering of the epiglottis. These webs are very difficult to identify without the panoramic view of the hypopharynx which is afforded by the fiber-illuminated endoscopic telescopes. We recommend that endoscopy of neonates include observation of the hypopharynx with the endoscopic telescope as well as with the open laryngoscope.