Management of supraglottic dysgenesis presenting as laryngomalacia.

Laryngomalacia is a common source of stridor and can lead to significant upper airway obstruction and feeding disturbances in infants. We describe a unique case of supraglottic dysgenesis presenting as laryngomalacia featuring a prominent "s-shaped" epiglottis with both posterior edges fused to the right aryepiglottic fold/arytenoid complex. Although this anomaly is not accounted for in any of the current laryngomalacia classification schemes, modified laser supraglottoplasty was a satisfactory approach leading to successful decannulation. Laryngeal embryology and possible timing of the pathogenesis of this rare occurrence are reviewed as well.

A prospective study of the effect of gastroesophageal reflux disease treatment on children with otitis media.

OBJECTIVES: To demonstrate improvements in validated quality-of-life measures for otitis media and gastroesophageal reflux disease (GERD) and an objective score for pediatric reflux obtained by fiberoptic laryngoscopy after treatment with antireflux precautions and therapy in children diagnosed as having either recurrent acute otitis media or otitis media with effusion and GERD. DESIGN: Prospective, before-and-after intervention study. SETTING: Hospital-based pediatric otolaryngology practice. PARTICIPANTS: Population-based sample of 47 patients (mean age, 19.5 months). INTERVENTION: Standard antireflux therapy for 2 consecutive 12-week periods. MAIN OUTCOME MEASURES: Otitis Media 6-Item quality-of-life survey, Infant GERD Questionnaire-Revised, GERD Symptom Questionnaire for Young Children, Pediatric Reflux Finding Score, and speech awareness threshold. RESULTS: Follow-up data were available for 37 patients. Mean (SD) change scores for Otitis Media 6-Item quality-of-life survey were 1.6 (1.1) at visit 2 and 1.5 (1.1) at visit 3 (P < .001 and P = .004, respectively). Change scores were significantly improved for Infant GERD Questionnaire-Revised and GERD Symptom Questionnaire for Young Children at visit 2 and for Infant GERD Questionnaire-Revised at visit 3. Mean (SD) change scores for the Pediatric Reflux Finding Score were 6.4 (4.9) at visit 2 and 8.0 (7.2) at visit 3 (P < .001 and P = .03, respectively). Hearing loss was significantly improved following therapy, as were laryngeal findings of reflux on fiberoptic laryngoscopy. Otitis media was considered by the examining physician to be clinically improved in 28 of 37 children (76%; 95% confidence interval, 60%-87%) at visit 2 and in 6 of 10 children (60%; 95% confidence interval, 31%-83%) at visit 3. Nine children (19.1%) required myringotomy tube placement. CONCLUSIONS: Children with otitis media with effusion or recurrent acute otitis media and GERD have improved quality of life following treatment with antireflux therapy. Control of gastroesophageal reflux may play a role in the management of otitis media and avoidance of tympanostomy.

Laryngomalacia: a classification system and surgical treatment strategy.

Laryngomalacia, the most common congenital laryngeal anomaly, is not a single disease entity but rather a variety of entities along a spectrum of underlying pathophysiologies. Based on our study of 10 children who were surgically treated for laryngomalacia in an urban tertiary care center, we have developed a system of classifying laryngomalacia on the basis of its different underlying pathophysiologic processes. Type I laryngomalacia is characterized by a foreshortened or tight aryepiglottic fold. Type 2 disease is defined by the presence of redundant soft tissue in the supraglottis. The type 3 designation applies to cases caused by other etiologies, such as underlying neuromuscular disorders. While the three types are not mutually exclusive, each should be considered as a separate disease entity with a final common clinical presentation. Each type requires a specific approach to surgical repair.

Chiari Type I malformation and upper airway obstruction in adolescents.

Chiari Type I malformation is characterized by cerebellar tonsil herniation through the foramen magnum. Manifestations may include new-onset upper airway obstruction. We describe two patients who had bilateral vocal cord paralysis and Chiari Type I malformation. These cases highlight the importance of suspecting a neurologic abnormality such as Chiari malformation in new-onset upper airway obstruction and/or bilateral vocal cord paralysis in adolescents in the absence of an obstructive lesion, though the development of cranial neuropathies or radiographic evidence may be delayed. Establishing a proper diagnosis is critical as Chiari I malformation can be treated with neurosurgical decompression, with possible improvement.

Treatment of pediatric sinusitis.

The successful management of RS in children relies on careful diagnosis, recognition of causative factors, and judicious yet adequate antibiotic usage. Refractory cases will require surgical therapy, with adenoidectomy as the first-line intervention and ESS reserved for those cases refractory to adenoidectomy. This overall approach will improve quality of life and prevent complications in children with RS.

Perioperative adenotonsillectomy management in children: current practices.

OBJECTIVE: To determine the current practices of preoperative evaluation, surgical techniques, and postoperative treatment of pediatric adenotonsillectomy. STUDY DESIGN: Forty-one-item survey measuring the frequency of different evaluations, procedures, and treatments performed, including selected case scenarios, with all items scored on a five-point ordinal scale ranking frequency. METHODS: The entire membership of the American Society of Pediatric Otolaryngology (ASPO) and active fellows and members of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) residing in New York state were anonymously surveyed through mail-in questionnaires. RESULTS: History alone was the most frequent modality for diagnosing both adenoid enlargement and obstructive sleep apnea. The most common preoperative laboratory test ordered before an adenotonsillectomy is a complete blood cell count; ASPO members ordered fewer preoperative laboratory tests than AAO-HNS members. Unipolar cautery is the most frequently used tonsillectomy technique, and curettage followed by cautery is the most popular adenoidectomy technique. Steroids are the most common intraoperative medication administered during an adenotonsillectomy, and office visits remain the most frequently used methods of assessing adenotonsillectomy patients postoperatively. CONCLUSIONS: Although there are statistically significant trends uncovered by the survey, the results reflect a lack of consensus regarding adenotonsillectomy management. Further randomized controlled trials or large-scale outcomes projects are much needed to evaluate critically the current practices of pediatric adenotonsillectomies. Additional efforts may also be required to use the information from these studies in effecting changes in actual practice patterns, moving us toward a more evidence-based paradigm of treating pediatric adenotonsillar disease.