The effect of intranasal fentanyl on the emergence characteristics after sevoflurane anesthesia in children undergoing surgery for bilateral myringotomy tube placement.

UNLABELLED: Children undergoing placement of bilateral myringotomy tubes (BMT) often exhibit pain-related behavior (agitation) in the postanesthesia care unit. We compared the emergence and recovery profiles of pediatric patients who received sevoflurane with or without supplementary intranasal fentanyl for BMT surgery. By using a prospective, double-blinded design, 150 children 6 mo to 5 yr of age, scheduled for routine BMT surgery, were anesthetized with sevoflurane (2%-3%) in a 60% N(2)O/O(2) gas mixture. Patients were randomized to receive equal volumes of intranasal saline (Control), 1 microg/kg fentanyl or 2 microg/kg fentanyl. A blinded observer evaluated each patient using a previously described 4-point agitation scale and the Steward recovery scale. Response to parental presence was observed after a score of six (full recovery) was achieved on the Steward recovery scale. There were no significant differences among the three groups regarding age, weight, surgeon, duration of anesthesia, or ear condition. Recovery times and emergence characteristic scores were not statistically different. Agitation scores were significantly reduced in the 2-microg/kg Fentanyl group as compared with the Control group (P = 0.012). Fentanyl 2 microg/kg is recommended to reduce the incidence of agitation seen in these patients. IMPLICATIONS: We examined the use of nasally administered fentanyl for the relief of agitation or discomfort after placement of bilateral myringotomy tubes in 150 children ages 6 mo to 5 yr using a prospective, double-blinded design. Fentanyl 2 microg/kg was found to reduce the incidence of agitation in these patients.

Perioperative airway complications following pharyngeal flap palatoplasty.

This study was performed to determine the incidence and types of perioperative airway complications after pharyngeal flap palatoplasty. We conducted a retrospective chart review of 88 patients who underwent correction of velopharyngeal insufficiency between April 30, 1983, and April 30, 1997, in a tertiary care hospital. Some degree of airway obstruction developed in 7 patients. One child developed laryngobronchospasm and required immediate endotracheal intubation. He was successfully extubated without sequelae. Another patient developed severe obstructive sleep apnea and required flap revision. A third patient was found asystolic and apneic. She was immediately intubated; however, she subsequently died. Two patients aspirated blood, presumably resulting in pneumonia. They were managed with parenteral antibiotics. Another child developed worsening sleep apnea and required flap revision. One patient developed nasal obstruction that resolved with time. Airway compromise in patients who undergo pharyngeal flap palatoplasty can be a potentially fatal complication. Careful surveillance should be maintained over patients with underlying neurologic, craniofacial, or cardiopulmonary disorders.

Pediatric gastroesophageal reflux and laryngopharyngeal reflux.

Pediatric gastroesophageal reflux (GER) and laryngopharyngeal reflux (LPR) have gained better recognition over the past few years. GER and LPR usually present as regurgitation, emesis, epigastric pain, failure to thrive, esophagitis, or stricture. Many patients suffer respiratory disorders associated with reflux. Classification of reflux, pathophysiology, manifestations of reflux, diagnosis, and management of the disease are discussed in this article.

Changing trends in neonatal subglottic stenosis.

OBJECTIVES: To determine whether there are any changes in the incidence and management of neonatal subglottic stenosis (SGS). METHODS: A retrospective chart review of 416 infants who were admitted to the neonatal intensive care unit of the Children's National Medical Center between July 1, 1995, and June 30, 1996, was carried out. The incidence of airway obstruction requiring anterior cricoid split or placement of tracheotomy tube was determined and compared with the incidence studied 10 years ago at the same institution. RESULTS: One of 416 neonates required surgical intervention for airway obstruction caused by SGS, for an overall neonatal SGS incidence of 0.24%. When only the neonates who were intubated for 48 hours or longer were considered, the incidence of SGS was 0.49% (1/204). In neonates who were intubated for 48 hours or longer and survived, the incidence of SGS was 0.63% (1/160). This is in comparison with the incidences of 0.65% (3/462), 1.5% (3/195), and 1.9% (3/159), respectively, seen in a study done at the Children's National Medical Center 10 years ago. Five infants in this current study required placement of a tracheotomy tube for reasons other than SGS. Two infants needed tracheotomy tube placement for micrognathia, and 3 others for central hypotonia, an omphalocele that required multiple surgical procedures, and choanal atresia with a serious heart anomaly, which was a manifestation of CHARGE association. None of these 5 infants had evidence of SGS at rigid endoscopy preceding the tracheotomy tube placement. CONCLUSION: The incidence and management of neonatal SGS remain unchanged during this study period when compared with those of 10 years ago.

Airway abnormalities in patients with Arnold-Chiari malformation.

OBJECTIVES: The goal was to determine the incidence and types of airway abnormalities in patients with Arnold-Chiari malformation (ACM). METHODS: The study was a retrospective chart review of 24 patients with ACM who were evaluated and treated between November 1991 and August 1997. RESULTS: Eighteen (75%) and 6 (25%) of the 24 patients had types I and II ACM, respectively. Three (12.5% of 24 patients) of the type II ACM patients had vocal cord impairment: 1 bilateral paralysis, 1 bilateral paresis, and 1 unilateral paralysis. None of the type I ACM patients had vocal cord impairment. Tracheotomy was necessary in 3 of the 24 patients and all in patients with type II ACM. Central sleep apnea was found in 5 of 6 type II ACM patients, but not in any of the type I ACM patients. CONCLUSIONS: Vocal cord impairment and sleep apnea were found in 12. 5% and 21%, respectively, of this ACM population. When type II ACM patients were considered separately, the incidences of vocal cord impairment and sleep apnea were 50% and 83%, respectively. Type II ACM patients tend to have a higher incidence of airway abnormalities and other neurologic dysfunctions. Flexible fiberoptic laryngoscopy is recommended in the airway evaluation of ACM patients. Early recognition, diagnosis, and management of these abnormalities may be lifesaving.

Posterior glottic stenosis.

Posterior glottic stenosis in children is not uncommon and must be differentiated from vocal cord paralysis when there is posterior glottic fixation. Procedures aimed at increasing the airway lumen by tissue excision have not been uniformly successful. Chronic aspiration and poor voice results have been reported. Expansion of the posterior glottis yields excellent results. Tracheotomy decannulation without aspiration and return of vocal cord mobility in children who have vocal cord fixation with achievement of a functional voice can be expected from widening the laryngeal framework. Scar incision without excision reduces the denuded laryngeal surface. The laryngeal framework is widened by anterior and posterior cricoid split and by stenting. Posterior cartilage grafting reduces scar tissue build-up and the duration of stenting.

In vitro regulation of expression of cartilage-derived morphogenetic proteins by growth hormone and insulinlike growth factor 1 in the bovine cricoid chondrocyte.

OBJECTIVES: To delineate the endogenous growth factors that regulate cricoid cartilage growth at the molecular level. Specifically, to attempt to establish the presence of cartilage-derived morphogenetic proteins (CDMPs), cartilage-specific members of the bone morphogenetic protein family, in newborn bovine cricoid chondrocytes and to assess the expression of these endogenous growth factors with the addition of exogenous growth hormone or insulinlike growth factor 1 in an in vitro chondrocyte culture model. METHODS AND DESIGN: Basic science molecular biologic research methods, including high-density monolayer and explant chondrocyte cultures with extraction of messenger RNA and quantitation via Northern blot hybridization via radiolabeled complementary DNA probes. SETTING: Intramural basic science research laboratory. RESULTS: Both CDMP-1 and CDMP-2 were found in newborn cricoid chondrocytes. Addition of exogenous growth hormone did not appear to influence the expression of CDMP-1 or CDMP-2. Addition of exogenous insulinlike growth factor 1 appeared to down-regulate the expression of CDMP-1 but had no effect on the expression of CDMP-2. No major differences in CDMP level of expression were noted between high-density monolayer cultures vs explant cultures. No tissue specificity differences were noted in regulation of CDMPs between cricoid and articular chondrocytes. CONCLUSIONS: Our preliminary studies indicate the presence of endogenous morphogenetic proteins in newborn bovine cricoid chondrocytes. These novel polypeptide hormones (CDMP-1 and CDMP-2) have not been previously reported in laryngeal cartilage chondrocytes. Change in level of transcription of these morphogenetic proteins under various in vitro conditions suggests that these proteins are subject to regulation and/or play a regulatory role in cricoid chondrocyte growth and differentiation. Further experimentation is needed to confirm these findings.

Pitfalls in laryngotracheal reconstruction.

OBJECTIVE: To determine the causes of laryngotracheal reconstruction (LTR) failures. DESIGN: Retrospective chart review. SETTING: Tertiary care children's hospital. PATIENTS: Seventeen pediatric patients who underwent revision LTR from October 1, 1986, to December 31, 1998. INTERVENTION: Laryngotracheal reconstruction. MAIN OUTCOME MEASURE: Decannulation. RESULTS: Seventeen patients required a total of 42 LTRs for decannulation. There were 17 primary LTRs and 25 revision LTRs. The primary LTRs were done either at our or other institutions. Two patients died after initial LTR failed, one because of tracheotomy tube plugging and the other because of a severe respiratory syncytial virus pneumonia. All 15 remaining patients have been decannulated. There were 27 failed LTRs with 17 being primary and 10 revision LTR failures. In 3 of the 27 failed procedures, no obvious causes for failure could be found. In the remaining 24 procedures, 1 or more factors that contributed to LTR failure could be found. Poor preoperative evaluation with subsequent failure to address the airway lesion was seen in 6 procedures. Intraoperative reasons for LTR failure included inappropriate choice of graft in 2 procedures; inappropriate stent in 7; inappropriate stent length in 1; and inappropriate duration of stent in 8. In 6 procedures, the airway abnormalities identified at endoscopy were not adequately addressed at LTR. Postoperative factors for failure were poor follow-up in 2, anterior suprastomal collapse in 2, and slipped or broken stent in 2. Other factors that contributed to LTR failures included intractable gastroesophageal reflux disease in 1 procedure and keloid formation in 5. CONCLUSIONS: Although some LTRs may fail secondary to factors that are not under the surgeon's control, many LTR failures can be avoided by accurate preoperative and intraoperative assessment of the stenosis, correct choice of surgical procedure, and close postoperative monitoring.

Clinical applications of transiently evoked otoacoustic emissions in the pediatric population.

Our objectives were 1) to determine whether transiently evoked otoacoustic emissions (TEOAEs) are affected by the status of the tympanic membrane (TM) and middle ear (ME) as determined by clinical examinations and tympanograms; 2) to determine the efficacy of TEOAEs in detecting hearing loss; and 3) to determine the relative effects of the ME status and hearing loss on TEOAEs. In a prospective observational study in a tertiary care children's hospital, 89 patients (169 ears; 9 ears eliminated from analyses) were examined by 2 attending pediatric otolaryngologists for otologic conditions and underwent audiologic evaluations including TEOAEs from August 1994 through May 1995. The main outcome measures were presence or absence of TEOAE whole reproducibility (WR) and reproducibility (R) at 2 kHz. Statistical analyses showed that of the 8 ME and TM conditions evaluated (normal, TM perforation, pressure equalization [PE] tube, TM retraction, tympanosclerosis, TM atrophy, ME effusion, surgery other than PE tube insertion), only the presence of ME effusion and normal examination findings had a significant effect on the results of WR and R at 2 kHz. Of the 6 different types of tympanograms evaluated (A, B, C, AD, As, B with large volume), type A, B, and C tympanograms had a significant effect on WR and types A and B had a significant effect on R at 2 kHz. Hearing losses > or = 25 dB hearing level (HL) at any of the 5 frequencies (0.25, 0.5, 1, 2, and 4 kHz) were well predicted by the absence of WR and R at 2 kHz. When clinical examination and impedance data were evaluated simultaneously with hearing status, hearing status had a greater effect on WR and R at 2 kHz. We conclude that type B and C tympanograms and the presence of ME effusion (which reflect abnormal ME status) have an adverse effect on TEOAEs. However, the presence of hearing loss is the most significant predictor of TEOAE results. The TEOAE WR and R at 2 kHz are effective in identifying patients with normal hearing and with hearing losses > or = 25 dB HL.

Laryngotracheal stenosis in children.

The diagnosis of laryngotracheal stenosis should be suspected in children with stridor, feeding difficulties, or atypical croup. Only half of the children with congenital laryngotracheal stenosis require tracheotomy, and many of these children can be decannulated following uncomplicated surgical therapy. In contrast, tracheotomy-dependent patients with acquired laryngotracheal stenosis require more extensive surgical intervention, which should be carried out as early as possible to provide the best opportunity for developing normal oral communication.

Management of oropharyngeal trauma in children.

OBJECTIVE: To determine the indications for admission, requisite imaging studies, and urgent medical or surgical intervention. DESIGN: We retrospectively reviewed the charts of 26 children (age range, 5 months to 14 years) who were seen by the otolaryngology service in the emergency department at the Children's National Medical Center, Washington, DC, from 1985 to 1993 and who were diagnosed as having oropharyngeal trauma. We specifically looked for common findings in the history and physical examination on initial presentation to predict the necessary steps in evaluation and management. SETTING: Tertiary care pediatric referral center. RESULTS: Indications for admission were (1) concern about neurologic injury, (2) concern about vascular injury, (3) radiographic evidence of retropharyngeal free air or abscess, (4) pneumomediastinum, and (5) unreliable adult supervision at home. Six patients required surgery; 3 underwent retropharyngeal aspiration or incision and drainage procedures; 2 required neck explorations; and 1, who had an impaled foreign body in the parapharyngeal space, underwent surgical extraction. There were no vascular, neurologic, or other permanent injuries. CONCLUSIONS: Oropharyngeal trauma may result in palatal and posterior pharyngeal wall injury requiring closure of lacerations and management of retropharyngeal free air. Rarely does an injury lead to retropharyngeal abscess or significant pneumomediastinum. Lateral oropharyngeal injuries require increased concern about potential neurovascular impairment. However, neither the mechanism of injury nor the degree of injury correlates with the potential for neurovascular sequelae. Since neurovascular involvement may not become clinically apparent until days or weeks after the incident, admission for observation alone should be based on the distance from the patient's home to the hospital and on the level of reliable adult supervision. Indications for medical and surgical treatment of internal carotid artery thrombosis remain controversial.

Pneumomediastinum and pneumothorax from blunt cervical trauma in children.

Minor blunt cervical injuries in children are relatively common occurrences leading to serious sequelae in only rare circumstances, yet sufficient impact of even a seemingly minor event may lead to a significant posterior tracheal wall laceration, resulting in pneumomediastinum with or without pneumothorax. Three cases demonstrate how the mechanism of injury does not always match either the severity of initial presentation or the consequent necessary level of emergent management. Pneumomediastinum without pneumothorax often can be treated conservatively; however, the onset of massive pneumomediastinum and pneumothorax may necessitate both tracheotomy and tube thoracostomy as initial treatment.

Ideal timing of pediatric laryngotracheal reconstruction.

OBJECTIVE: To determine whether there is an ideal age at which to perform a laryngotracheal reconstruction (LTR) in the pediatric population. DESIGN: Prospective observational study. SETTING: Tertiary care children's hospital. PATIENTS: Forty-eight patients aged 48 months or younger with laryngotracheal stenosis who underwent 50 LTRs from October 1, 1986, to June 30, 1995. Patients were divided into 2 groups: group 1, aged 8 through 24 months (22 patients); group 2, aged 25 through 48 months (26 patients). INTERVENTION: Endoscopy and LTR. MAIN OUTCOME MEASURES: Successful decannulation. RESULTS: Statistical analysis showed that (1) patients in group 2 had more severe degree of laryngotracheal stenosis as determined by duration of stenting with no difference in multiple sites of stenosis or type of repair required to correct laryngotracheal stenosis and (2) patients in group 2 were more likely to have successful decannulation. CONCLUSION: Laryngotracheal reconstruction at a younger age (< 25 months) is important for a child's speech and language development as well as for eliminating the morbidity and mortality associated with a tracheotomy. However, LTR at a younger age is associated with a higher risk of failure despite lesser degree of pathology. Therefore, although we still recommend LTR at a younger age since it may be beneficial for a child's speech and language development and avoidance of tracheotomy complications, this recommendation may be at the price of LTR failure and requirement for revision procedures.

Assessment and management of laryngotracheal stenosis.

Laryngotracheal stenosis should be suspected in children with recurrent, prolonged, or atypical croup; a history of endotracheal intubation; or a history of stridor, feeding difficulties, and failure to thrive. Tracheotomy-dependent patients with acquired laryngotracheal stenosis are candidates for surgical intervention to provide the child with the earliest opportunity to develop normal oral communication.

Projected societal needs in pediatric otolaryngology.

With the recent increase in pediatric otolaryngology fellowship training programs, fellows are being trained in record numbers and there is concern about the possibility that the supply of these physicians will soon exceed societal needs. This study was conducted to determine the number of fellowship-trained pediatric otolaryngologists that would meet the needs of society and when this need will be met. Information was collected from national organizations and from a survey of fellowship training programs. A hospital-based practitioner model was used to predict societal needs based on the anticipated changes in patient care, mainly managed-care capitated systems. The projected societal need is 382 pediatric otolaryngologists. If current fellowship training levels continue, this need will be met in just over 7 years.

Balancing pediatric otolaryngology training for fellows and residents at a children's hospital.

OBJECTIVE: To determine the feasibility of providing surgical, endoscopic, and patient contact experience of high educational value at a children's hospital sufficient for adequately training contemporaneously both residents in otolaryngology-head and neck surgery and fellows in pediatric otolaryngology. DESIGN: Retrospective review of operating room case logs and assignment of cases based on arbitrary perception of inherent case complexity and skill and experience that are required to manage the case. SETTING: Tertiary care children's hospital located in a major metropolitan area. MAIN OUTCOME MEASURES: (1) Volume of surgical and endoscopic cases assigned retrospectively to junior resident, senior resident, or fellow. (2) Score on newly developed self-assessment skill list in pediatric otolaryngology. RESULTS: During 1 year, there were 3224 surgical and endoscopic procedures performed in the operating room. Of the total number of procedures, only 44 (1.4%) were designated as being exclusively assigned for hands-on experience to a fellow, but 380 (11.8%) were appropriate for both a senior resident and a fellow and therefore were apportioned in an alternating fashion. A self-assessment instrument has been developed to assess competency and comfort in the management of otolaryngic disorders, both surgical and nonsurgical, in children. CONCLUSIONS: The volume and assortment of surgical and endoscopy cases at a tertiary care children's hospital can provide the basis for a rich, practical hands-on experience for residents and fellows. Since few surgical or endoscopic cases require pediatric fellowship training for mastery, becoming a pediatric otolaryngologist depends on acquiring skills and competence that exceed the technical skills acquired in the operating room.

The effect of gastroesophageal reflux on laryngotracheal reconstruction.

OBJECTIVES: To determine the need for preoperative evaluation for gastroesophageal reflux disease (GERD) in all children undergoing laryngotracheal reconstruction (LTR) and to assess the effect of GERD on the outcome of LTR. DESIGN: Prospective, single-blind observational study. SETTING: Tertiary care children's hospital. PATIENTS: Seventy-four pediatric patients with laryngotracheal stenosis who underwent LTR at the Children's National Medical Center, Washington, DC, from October 1, 1986, through August 31, 1994. INTERVENTION: Evaluation for and treatment of GERD, LTR, endoscopy, and removal of granulation tissue. MAIN OUTCOME MEASURES: Successful decannulation and number of endoscopies required to remove laryngeal and tracheal granulation tissue. RESULTS: Seventy-four patients underwent 82 LTRs. The senior surgeon was blinded to the status of GERD evaluation and treatment. Four groups were identified: 37 patients (40 LTRs) with no preoperative evaluation for GERD; 10 patients (11 LTRs) with normal findings on preoperative evaluation for GERD; seven patients (nine LTRs) with abnormal findings on preoperative evaluation for GERD but who failed to receive appropriate treatment; and 20 patients (22 LTRs) with abnormal findings on preoperative evaluation for GERD who received appropriate therapy. Severity and extent of stenosis as determined by multicentricity of stenosis, type of repair, and duration of stent were similar in the four groups. The effect of GERD and its treatment on the outcome of LTR was measured by the number of endoscopies necessary for removal of granulation tissue following reconstruction and successful decannulation. Statistical analyses indicate that (1) all children do not require preoperative evaluation for GERD; (2) neither the presence of GERD nor its treatment are major factors in determining the outcome of LTR. CONCLUSION: Preoperative evaluation for GERD and its treatment do not favorably affect the outcome of LTR.

Laryngomalacia. The search for the second lesion.

OBJECTIVES: To determine the necessity of rigid endoscopy in the diagnosis and management of laryngomalacia and its associated synchronous airway lesions (SALs), to analyze the incidence of SALs associated with laryngomalacia and their significance, and to determine the need for epiglottoplasty in management of laryngomalacia. DESIGN: Retrospective medical chart review. SETTING: Tertiary care children's hospital. PATIENTS: Two hundred thirty-three patients with a primary diagnosis of laryngomalacia on flexible fiberoptic laryngoscopy treated at the Children's National Medical Center, Washington, DC, from January 1, 1984, to June 30, 1994. INTERVENTION: Evaluation and treatment of laryngomalacia and associated SAL by flexible fiberoptic laryngoscopy, radiographic studies, rigid endoscopy, and other surgical procedures. MAIN OUTCOME MEASURES: Resolution of airway symptoms from laryngomalacia and associated SAL. RESULTS: Ninety patients (38.6%) underwent rigid endoscopy, and 12 patients (5.2%) required epiglottoplasty. Synchronous airway lesions were discovered in 44 patients (18.9%). Eleven patients (4.7%) had SALs that wre considered clinically significant; nine (3.9%) of these required surgical intervention. CONCLUSIONS: Rigid endoscopy in evaluation of an infant with laryngomalacia is rarely necessary. Clinically significant SALs requiring surgical intervention are uncommon. Surgical intervention for laryngomalacia also is rarely necessary.