Postsurgical follow-up of children with tympanostomy tubes: results of the American Academy of Otolaryngology-Head and Neck Surgery Pediatric Otolaryngology Committee National Survey.

Postsurgical follow-up of children with tympanostomy tubes is becoming a contentious issue in this era of managed care. Primary care providers believe themselves to be capable of evaluating these children. Otolaryngologists, on the other hand, have more specialized equipment available to them (suction apparatus, otomicroscopes, audiology devices, etc) for treating suppurative infections and monitoring the tympanic membrane for structural changes. In addition, the otolaryngologist is placed in an uncomfortable legal and ethical position if access to the patient with a tube-related complication is denied by the primary care provider. Attempts to develop an American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) policy statement have been hampered by a lack of data on the incidence and severity of tube-related complications and the role that otolaryngologists can play in reducing these sequelae. A survey designed by the AAO-HNS Pediatric Otolaryngology Committee was distributed to 1000 board-certified otolaryngologists and all members of the American Society of Pediatric Otolaryngologists and the American Academy of Pediatrics-Otolaryngology Section regarding current practice patterns and practitioners' experiences with tympanostomy tube complications. Specific information regarding complications that could have been avoided with earlier otolaryngology referral was also obtained. The results of the survey and its implications for AAO-HNS policy are presented.

Congenital anomalies of the larynx and trachea.

A variety of congenital anomalies arise within the laryngeal or tracheal airway. Symptoms primarily include airway obstruction, hoarseness, and difficulty feeding. The diagnosis is typically made by a combination of clinical presentation, physical examination, and endoscopic evaluation. Definitive intervention may be necessary requiring endoscopic or open laryngeal surgery. Some of the more common congenital laryngeal and tracheal anomalies are discussed with respect to their diagnostic evaluation, clinical presentation, and management.

Single central maxillary incisor with nasal pyriform aperture stenosis--CT diagnosis prior to tooth eruption.

Two children with nasal pyriform aperture stenosis had the diagnosis of single central maxillary incisor made with CT scanning prior to tooth eruption and the clinical appreciation of this finding. The surgical and clinical implications of this diagnosis will be presented.

Risk factors for hearing loss from meningitis in children: the Children's Hospital experience.

OBJECTIVES: To identify statistically significant risk factors for hearing loss in children with meningitis, determine the overall incidence of hearing loss in a large group of children with confirmed meningitis, and quantify the percentage of children with progressive or fluctuating hearing loss after meningitis. DESIGN: Retrospective analysis. PATIENTS AND OTHER PARTICIPANTS: Four hundred thirty-two children admitted to the Children's Hospital, Birmingham, Ala, from January 1, 1985, to December 31, 1995, with the diagnosis of meningitis. RESULTS: Of 432 children with meningitis, 59 (13.7%) had the development of hearing loss. Of these 59 children, 46 (78.0%) had stable sensorineural hearing loss and 13 (22.0%) had either progressive or fluctuating hearing loss. Of the variables examined using multiple logistic regression backward-elimination modeling, only 5 appeared to be significantly associated with the development of hearing loss: computed tomographic scan evidence of increased intracranial pressure (estimated odds ratio [OR] = 2.3), male sex (OR= 1.9), the common logarithm of glucose levels in the cerebrospinal fluid (OR = 0.58), Streptococcus pneumoniae as the causative organism (OR= 2.1), and the presence of nuchal rigidity (OR = 1.9). In the children with progressive hearing loss, the time for progression varied from 3 months to 4 years before hearing stabilized. CONCLUSIONS: In this study of children diagnosed as having meningitis, hearing loss developed in 59 (13.7%). Forty-six (78.0%) of these children with hearing loss had stable auditory thresholds over time, and 13 (22.0%) exhibited deterioration or fluctuation of acuity over time. Evidence of increased intracranial pressure by computed tomographic scan, male sex, low glucose levels in the patients' cerebrospinal fluid, S pneumoniae as the causative organism, and the presence of nuchal rigidity appear to be significant predictors for future hearing loss.

High-risk human papillomavirus types and squamous cell carcinoma in patients with respiratory papillomas.

Respiratory papillomas (RPs) are benign, virally induced tumors of the larynx and respiratory epithelium that may obstruct the airway and tend to recur frequently. RPs are thought to be the result of infection with the human papillomaviruses (HPVs) types 6 and 11. We surveyed archival RP specimens to determine whether there were correlations of HPV type with patient characteristics or clinical course. Paraffin-embedded papilloma specimens of 45 different patients were analyzed. We assessed HPV types using the polymerase chain reaction with E6 consensus primers, hybrid capture assays (high or low risk), and dot blot hybridization of generic E6 PCR products with E6 type-specific oligonucleotide probes. The presence and type of HPV were correlated with patient data from a retrospective chart review. We found that RPs may have either low- or high-risk HPV types and some contain multiple HPV types. Respiratory infection with high-risk HPV apparently introduces a long-term risk of squamous cell carcinoma development, even in the absence of conventional cofactors. Low-risk HPV infection may also act in association with these cofactors to promote carcinogenesis. Our data also show a racial imbalance in RP that may indicate a difference in genetic resistance and/or susceptibility to HPV infection and the development of RP.

Pharyngeal fibrovascular polyp in a child.

Fibrovascular polyp of the upper aerodigestive tract is an uncommon tumor that may present in pediatric patients with symptoms ranging from dysphagia to asphyxiation and death. We present a unique case of a pediatric patient with an asymptomatic fibrovascular polyp noted as an incidental finding on a cervical ultrasound evaluation. This lesion extended from the posterior tonsillar pillar and prolapsed freely into the nasopharynx and esophagus. The literature relevant to this case is reviewed, and the etiology, pathophysiology, and management principles are discussed.

Isolated epithelial cysts of the uvula in children: a report of three cases.

Epidermoid cysts are unusual benign cysts that occur in the oral cavity less than 2% of the time. Epidermoid cysts isolated to the uvula are rare. A review of the literature has revealed only three confirmed cases of isolated uvular epidermoid cysts. We present a series of three such cases, two of which presented with significant symptomatology. The diagnosis and management of these unusual lesions will be discussed, as well as the differential diagnosis.

Unilateral choanal atresia: initial presentation and endoscopic repair.

The purpose of this study was to investigate the severity of presenting symptomatology in patients with unilateral choanal atresia and to assess the surgical results of patients undergoing transnasal endoscopic repair. A retrospective review of all patients with choanal atresia presenting to the author between 1990 and 1997 was performed, identifying 13 patients with unilateral choanal atresia. These patients were analyzed with respect to presenting symptomatology, preoperative computed tomography scans, appearance, type of surgical repair, and surgical results for patients undergoing endoscopic transnasal repair. Eleven patients underwent successful endoscopic transnasal repair, one patient underwent conversion to transpalatal repair after an unsuccessful attempt at transnasal endoscopic repair and one patient underwent a planned transpalatal repair. Eleven patients who underwent repair by transnasal endoscopic technique have all done well with follow-up ranging from 3 months to 7 years. Although the symptomatology of unilateral choanal atresia is not as dramatic as bilateral choanal atresia, significant airway symptomatology may be present, especially in children presenting at a very young age. It appears that transnasal repair of unilateral choanal atresia is an excellent treatment modality with excellent postoperative surgical results.

Paediatric Airway Clinic: an 18-month experience.

OBJECTIVE: The management of paediatric airway disease is an integral aspect of paediatric otolaryngology. Recently, paediatric tertiary referral centres have developed centres of excellence for various aspects of paediatric care. The Pediatric Otolaryngology Airway Clinic at The Children's Hospital of Alabama, was developed as a regional referral centre for the management of children with difficult airway problems. Primary participants include the paediatric otolaryngologist, the airway management nurse, and the speech pathologist, in addition to other health care personnel. Over an 18-month period, 195 patients were seen in the clinic. The purpose of this study was to assess both the demography and the airway pathology in this patient population-specifically evaluating presenting diagnoses, diagnostic evaluation techniques, surgical intervention, geographic and racial distribution, insurance coverage, and referral patterns. CONCLUSION: This multidisciplinary approach to the management of children with chronic tracheotomies and other conditions involving the airway provides a unique environment that optimizes care for these complex patients.

Erbe constant voltage electrocautery versus conventional variable voltage electrocautery for tonsillectomy in children.

This prospective, randomized study was performed to compare postoperative pain, blood loss, and procedure time using the Erbe electrocautery device and conventional electrocautery. The Erbe device differs from conventional cautery devices in that it produces constant voltage and variable wattage whereas conventional devices produce variable voltage and constant wattage. This means that the conventional devices allow voltage surges and constant wattage no matter what type of tissue is encountered. The Erbe device has the inherent capability to maintain constant voltage, i.e. no surging as well as varying wattage according to tissue resistance. This, in theory, allows the Erbe device to impose less tissue damage and, theoretically, less postoperative pain. Fifty-seven patients 5-21 years of age who were scheduled for adenotonsillectomy were enrolled in the study. Results indicated less postoperative pain, although blood loss appeared to be increased compared to conventional electrocautery. The Erbe electrocautery device appears to be a viable device to perform tonsillectomy in children.

Methods of sedation for auditory brainstem response testing.

Young children and those who are mentally impaired frequently require sedation to attain accurate results when testing for auditory brainstem response (ABR). There have been no previous studies of appropriate methods of sedation, and there is no consensus on pharmacotherapy, monitoring equipment, facilities, or personnel necessary for safe and effective ABR testing. To obtain a national census of current practice, we sent a survey to 149 free-standing children's hospitals in the US. A prospective study was also conducted to assess the effects of sedation utilized to perform ABR testing at The Children's Hospital of Alabama. Oral chloral hydrate (50 mg/kg) was administered for sedation in an outpatient setting with a registered nurse and audiologist present, while vital signs, skin color, and oxygen saturation were continuously monitored. The cost of testing in an audiology or other outpatient suite was compared with the cost of performing the study in the operating room. Results of the survey illustrated the present lack of national uniformity in sedation administered, as well as various problems and complications encountered with such testing. We found that 50 mg/kg chloral hydrate administered in this setting is safe and effective for children requiring sedation for audiologic testing. Further, the ability to perform ABR's in an outpatient suite in a monitored setting is more cost-effective than testing in the operating room.

Endoscopic vs external drainage of orbital subperiosteal abscess.

Periorbital cellulitis is frequently limited to the preseptal region. However, there may be associated postseptal inflammation and orbital subperiosteal abscess (SPA). Surgical management of orbital SPA includes open drainage through an external ethmoidectomy approach, although recently the use of endoscopic techniques has been reported. This study was undertaken to evaluate postseptal cellulitis and orbital SPA in patients with periorbital cellulitis and to assess the safety and effectiveness of endoscopic management of orbital SPA. From 1989 through 1994, 158 patients were admitted with a diagnosis of periorbital cellulitis. Nineteen of these patients were diagnosed with postseptal orbital inflammation, and 14 underwent surgical drainage via an external approach, an endoscopic approach, or a combination of both. Issues addressed include (1) the role of sinus disease as the cause of periorbital cellulitis; (2) the role of computed tomographic scanning; (3) the effectiveness of aggressive medical therapy; and (4) the results of endoscopic drainage of orbital SPA compared with the external approach.

Open surgical excision of subglottic hemangioma in children.

Subglottic hemangioma is an unusual entity which may involute spontaneously without aggressive surgical intervention; although tracheotomy is sometimes necessary. The actual time course for involution is not clear by reviewing the literature [1,14]. Numerous treatment modalities are described for the treatment of this condition, including tracheotomy, CO2 laser ablation and intralesional steroid injection with or without endotracheal intubation. Surgical resection of subglottic hemangioma is an option which is described in the literature and may be utilized in certain selected cases. We present seven cases of subglottic hemangioma treated at three institutions which were resected via a crico-tracheotomy approach. Postoperative follow-up for these patients range from 6 months to 4.5 years. Although conservative measures are still advocated as the treatment of choice for subglottic hemangioma, open surgical resection may be indicated in selected cases resulting in a satisfactory outcome.

Upper airway obstruction in Sturge-Weber and Klippel-Trenaunay-Weber syndromes.

Sturge-Weber syndrome is a rare congenital angiomatosis of unknown cause that is defined by the following triad: facial port-wine stain, leptomeningeal vascular anomalies, and choroidal vascular lesions associated with glaucoma. Klippel-Trenaunay-Weber syndrome is a related disease with questionable hereditary factors diagnosed by the following triad: superficial nevus of the lower extremity, ipsilateral varicose veins, and hypertrophy of the soft and bony tissues of the lower limb. The two conditions rarely have been reported to coexist. Upper airway obstruction is not a prominent feature of either of these two diseases. We present two patients with both of these angiomatoses in whom severe upper airway obstruction necessitated tracheotomy.

Alternatives in the management of aneurysmal bone cysts of the mandible.

Aneurysmal bone cyst (ABC) is an unusual expansile lesion of bone which may arise within the mandible on rare occasions. This lesion may arise with very few signs or symptoms. Surgical treatment consists of complete excision or curettage. The recurrence rate may be high in lesions which are incompletely excised. Three cases of aneurysmal bone cysts in children will be presented, demonstrating the wide variation of clinical presentation. One case required an extensive mandibular resection, necessitating the first reported microvascular mandible reconstruction for this entity in a pediatric patient.