Dual-probe pH monitoring for the assessment of gastroesophageal reflux in the course of chronic hoarseness in children.

The purpose of our study was to assess gastroesophageal reflux (GER) by dual-probe pH monitoring in children suffering from chronic hoarseness for more than six months. Seventeen children (aged between 2 and 12 years, 10 boys and 7 girls) were enrolled. All children underwent a laryngoscopy and a 24-hour dual-probe pH monitoring. At both sensor, distal and proximal esophageal, a pathological GER was defined as the presence of episodes of acid reflux with pH < 4 during a fraction of the total recording time greater than 5.2 percent. The computer considered the child was supine when asleep and upright when awake. Laryngoscopy revealed interarytenoid erythema and/or edema with vocal cord nodules or granulomas in 13 cases (76.4%), isolated vocal nodules or granulomas in three cases (17.6%) and a normal appearance in one case (5.8%). At both sensors, the majority of refluxes occurred when the child was upright, as analyzed by the percentage of time the intra-esophageal pH was below four (% time pH < 4), number of refluxes, reflux episodes/hour and longest reflux episode, p < 0.05 between upright and supine for each parameter. The median total % time pH < 4 on the proximal and distal probes was respectively 1.62 percent (95% CI 1.50-3.79) and 11.49 percent (95% CI 8.81-27.17), p < 0.0003. Among the 17 hoarse children, a pathological GER was observed in 12 (70.5%) at the distal sensor and in three (17.5%) at both sensors. Among the 16 hoarse children with abnormal findings on laryngoscopy, two (12.5%) had diagnosed pathological GER at the proximal and 11 (68.7%) at the distal sensor. The only child with normal findings on laryngoscopy exhibited a pathological GER at both sensors. Our results suggest that chronic hoarseness is associated with a pathological GER. The majority of these documented refluxes occurred when the child was awake.

Iatrogenic pharyngoesophageal perforation in premature infants.

BACKGROUND: Premature infants are particularly at risk of iatrogenic pharyngoesophageal perforation. It is a rare occurrence but when it does occur it often mimics esophageal atresia. In the light of 10 patients treated in our service and those reported in the literature we have highlighted the diagnostic difficulties and discussed the appropriate management. PATIENTS: Between 1980 and 1995, we treated 10 premature neonates for pharyngoesophageal perforation. Six of these neonates weighed less than 1500 g. Esophageal atresia was the primary diagnosis in 4 cases. The pharyngoesophageal perforation was caused by repeated airway intubation in 3 cases and by overenthusiastic routine postpartum suctioning or nasogastric tube (NGT) insertion in 7 others. Severe respiratory distress occurred in 7 neonates. A plain chest x-ray revealed a large right pneumothorax in 3 cases and an aberrant NGT in 3 other cases. Four neonates had a contrast esophagography and 4 neonates underwent endoscopy. Five cases were treated surgically. In 3 of these, esophageal atresia was the presumptive diagnosis and the perforation was only diagnosed intraoperatively via a right thoracotomy. One neonate required suturing of the perforation and another had a gastrostomy. In all 5 cases a mediastinal drain was left in situ. The 5 remaining neonates were treated conservatively with broad spectrum antibiotics, total parenteral nutrition, a silastic NGT and pharyngeal aspiration. One of these neonates had previously had a laparotomy for a colonic perforation. There was a good outcome in 4 neonates, one of whom required instrumental dilatation for an esophageal stricture. Bronchopulmonary dysplasia developed in 3 cases and necrotizing enterocolitis in 1 other case. Two neonates died. CONCLUSION: An iatrogenic perforation is often difficult to diagnose and can easily be confused with esophageal atresia. Clinical findings, a plain chest x-ray, an esophagography and endoscopy are helpful. Surgery can be avoided in most instances. The outcome is not always favorable especially as premature neonates are at risk of severe concomitant pathology.

Nasal fossae dimensions in the neonate and young infant: a computed tomographic scan study.

OBJECTIVE: To determine normal values in the size of nasal fossae to better delineate the concept of nasal stenosis in young infants with nasal obstruction and without choanal atresia. DESIGN: Case series. SETTING: Referral center. PATIENTS: Consecutive sample of 62 infants (aged 0 to 6 months) with no craniofacial anomalies who underwent conventional axial computed tomography scans for a neurologic disorder. INTERVENTION: From computer-stored images, the slices taken at the level of the nasal fossae floor and those just above were examined. The length and 10 measurements of the width of the nasal fossae were used to determine normal values. RESULTS: Most measurements, even the length of the nasal fossae, were positively correlated to the age of the patient (R = .44). In the age 0 to 2 months group, the median length was 29.35 mm (range, 21.3-40.4 mm). It was 31.5 mm in the age 4 to 6 months group (range, 25.3-36.9 mm). The anterior bony aperture seems to be the most accurate distance for the assessment of neonatal nasal fossae stenosis. Its median width was 13.5 mm (range, 8.8-17.2 mm). Large variations characterized the dimensions of the middle nasal fossae and the choanae: median values were 7.6 mm (range, 4.9-13.5 mm) and 14.3 mm (range, 10.8-19.0 mm), respectively. CONCLUSIONS: This study defined the normal range of variation for the main dimensions of the nasal fossae in the horizontal plane. These can be used as a basis for determining nasal stenosis in cases of neonatal obstruction.

[Chronic laryngitis in children: the role of gastroesophageal reflux]. / Laryngite chronique chez l'enfant: place du reflux gastro-oesophagien.

UNLABELLED: Gastro-oesophageal reflux (GOR) is associated with a number of inflammatory ENT disorders in the adult and is correlated with recurrent croup in the child. AIM: To estimate the frequency of GOR in a population of children consulting for chronic laryngotracheal symptoms. METHOD: The study included 17 children, aged between 2 and 14 years (mean: 7 years) all of whom suffered from dysphonia or a chronic cough. After a clinical ENT examination, each child had a fibreoptic laryngoscopy and a long duration pH-study lasting between 18 and 24 hours. RESULTS: Pathological GOR was discovered in 10 children, i.e. 59%. Overall the number of refluxes per study varied from 6 to 816 (mean 156). The vast majority of these refluxes occurred when the child was awake. CONCLUSION: In our series of children with chronic laryngotracheal disorders, at least 59% were shown to suffer from pathological GOR.

Squamous cell carcinoma of the trachea in an infant: a case report.

Primary malignant tumours of the trachea are extremely rare in infants. This report describes an 11-month-old boy suffering from severe dyspnea with a 5-month history of stridor and 'bronchitis'. A hard mass could be palpated below the right lobe of the thyroid gland. Roentgenograms and endoscopy showed an exophytic tumour filling more than 80% of the tracheal lumen. A tracheal resection and a subtotal thyroidectomy with primary anastomosis was performed. An invasive squamous cell carcinoma of the trachea was diagnosed. This is the first reported case in an infant in the English literature. A local recurrence was found on MRI 19 weeks later. The infant died at 16 months of age.

Hoarseness and gastroesophageal reflux in children.

The importance of a hoarse voice or voice change in children has not been stressed in the literature in the same way as it has been in adults. We present 21 children who had been suffering from chronic hoarseness for more than three months and had on fibre-optic laryngoscopy findings suggestive of gastroesophageal reflux. None of them had complained of gastroesophageal symptoms. Twenty-four hour pH monitoring revealed that 13 (62 per cent) of these children had gastroesophageal reflux, seven (33 per cent) having gastroesophageal reflux more than three times the upper limit of normal. The pH graphs highlighted frequent refluxes, ranging from 0.4 to 37.4 refluxes per hour (median of 7.3 refluxes/hour). The majority of these refluxes occurred when the child was awake as opposed to asleep, with a median of 14.8 refluxes/hour and 0.9 refluxes/hour respectively (p = 0.0009). The refluxes were classically of short duration. This study suggests that gastroesophageal reflux plays a direct role in the pathogenesis of chronic laryngitis and hoarseness in children.

Non-endoscopic techniques for the evaluation of the pediatric airway.

In children with stridor, a detailed evaluation of the airway is often required to assess precisely its anatomical and functional status. Various methods of assessment have been developed and airway management may include, as well as rigid and flexible endoscopy, the use of imaging techniques such as plain X-rays, a barium oesophagogram, ultrasound, a CT scan, a magnetic resonance image (MRI) and an angiogram, as well as respiratory function tests including acoustic rhinometry and flow volume loops or even pH monitoring. This article aims to highlight the valuable information these alternative techniques can provide.

[Gastroesophageal reflux and dysphonia in children]. / Reflux gastro-oesophagien et dysphonie chez l'enfant.

UNLABELLED: With the exception of congenital anomalies, the aetiology of dysphonia in children is often unknown. Yet, in adults, GOR has been shown to play an important role. 22 children (aged between 2 and 14 years, 14 boys and 8 girls), who had been suffering from a chronic dysphonia for more than six months were seen at consultation. After a clinical ENT examination including a fibreoptic laryngoscopy, each child had a long duration pH-study that lasted approximately 24 hours. Using the classical criteria for GOR, a pathological GOR was discovered in 14 children, ie 64%. Analysis of the pH traces revealed that the vast majority of refluxes occurred when the child was awake. CONCLUSION: more than 64% of children suffering from chronic dysphonia had pathological GOR. The pH traces highlighted that the majority of these refluxes occurred when the child was awake.