Allan B. Seid

Management of the extubation problem in the premature child. Anterior cricoid split as an alternative to tracheotomy.

Long-term endotracheal intubation is a widely established means of giving ventilatory support in the newborn period. Though such long-term intubation is well tolerated by the premature infant, laryngeal complications do occur and extubation may be impossible even though the initial disease process for which the intubation was performed has resolved. In such a situation, careful endoscopic evaluation of the upper respiratory tract is advocated to identify the site of the problem. If subglottic edema or mucosal ulceration in the subglottic area is the site of the damage and if, during endoscopic evaluation immediately following removal of the endotracheal tube, the subglottic area starts to narrow because of edema formation or edema fluid filling up compressed granulation tissue, then a split of the cricoid in the midline anteriorly, leaving the endotracheal tube in as a stent, appears to be a preferable alternative to performing a tracheotomy. Of 12 consecutive patients, 9 have been successfully extubated.

Fourth branchial pouch sinus: Principles of diagnosis and management

The fourth branchial pouch sinus is a congenital anomaly which most frequently manifests itself by recurrent episodes of neck abscess or acute suppurative thyroiditis. This lesion usually becomes symptomatic before the age of 10 years and is more common than has previously been suspected. It has been found on the left side in 93% of the 28 cases reported in the English literature. Barium swallow during periods of quiescence and nasopharyngoscopy have frequently been successful in identifying the presence of these embryological remnants. Definitive therapy consists of total excision of the sinus tract, which can be facilitated by direct endoscopic placement of a Fogarty® catheter into the sinus lumen before surgical exploration. The embryological basis for the occurrence of these sinuses is discussed.

Pediatric airway manifestations of gastroesophageal reflux

Gastroesophageal reflux (GER) in children may be classified as physiologic or pathologic, depending on its degree and consequences. There are many head and neck complications of GER in pediatric patients, but most numerous are the airway manifestations, including stridor, recurrent croup, exacerbation of subglottic stenosis, laryngeal irritation with or without laryngospasm, chronic cough, and obstructive apnea. Diagnosis may be difficult unless there is a high index of suspicion for GER and awareness of the concept of “silent” GER. We present the common pediatric airway manifestations of GER, illustrated by case reports, and provide a paradigm to assist in the diagnosis and management of children with airway compromise associated with GER.

Laser division of the aryepiglottic folds for severe laryngomalacia

Laryngomalacia is an entity of ill-defined etiology. The clinical situation is one of inspiratory stridor present at birth, or within the newborn period. The stridor may increase in severity for the first several months of life and thereafter spontaneously begins to resolve. In the majority of cases the condition resolves spontaneously by approximately two years of age. This report will present the surgical management of severe laryngomalacia in infants using the carbon dioxide laser to surgically divide the aryepiglottic fold with resolution of the laryngomalacia.

Evaluation of tonsils and adenoids in sleep apnea syndrome

Peripheral Sleep Apnea syndrome has been associated with enlarged tonsils and adenoids as well as other abnormalities which may cause upper airway obstruction in children. A multidisciplinary approach is used at the Sleep Disorder Center of Cincinnati General Hospital to evaluate the role of tonsils and adenoids in sleep apnea.

Gastroesophageal reflux and ENT disorders in childhood

Among controversies in pediatric otorhinolaryngology, the role of gastroesophageal reflux (GER) in inflammatory disorders of the upper airway remains of major concern. A laryngeal involvement by GER was demonstrated in adults and a correlation with GER has been found in pediatric populations with recurrent croup. However, although considered statistically significant, these results concern a few patients only and are inconclusive for a causal relationship. In addition, pH monitoring, often considered as the gold standard for the diagnosis of GER disease, has failed in giving normal values in ENT disorders. Eventually, upper pharyngeal and nasal involvements by GER and GER-related otitis media or otalgia have been suggested by some authors. In the 6th International Congress on Pediatric Otolaryngology, the Symposium on GER was designed to help physicians in improving their knowledge of the data from the literature and their understanding of the involved mechanisms. Bearing in mind the potential severity of GER disease, the audience also heard and debated the most up-to-date methods of assessing GER and treating it in patients with possibly related otorhinolaryngological symptoms. Here is the summary of this symposium.

Surgical therapy of obstructive sleep apnea in children with severe mental insufficiency

Obstructive sleep apnea is the underlying cause of a variety of pediatric maladies, including pulmonary hypertension and failure to thrive. In children, unlike adults, obstruction secondary to lymphoid hyperplasia is often encountered; adenotonsillectomy restores airway patency. Patients who fail this procedure, such as children with cerebral palsy and associated muscular hypotonia, may face tracheotomies. We report on 10 pediatric patients with severe mental insufficiency and obstructive sleep apnea in whom palatal hypotonicity and lack of adenotonsillar hypertrophy was identified. Uvulopalatopharyngoplasty was performed in conjunction with adenotonsillectomy to enlarge the diameter of the nasopharyngeal inlet with successful resolution of the obstructive symptoms in eight patients. The remaining two children required more surgery. This procedure is presented as a possible alternative to tracheotomy in selected patients.

Panel discussion: the management of advanced laryngotracheal stenosis. Management of combined advanced glottic and subglottic stenosis in infancy and childhood.

Severe glottic and subglottic stenosis in infants and children is a formidable disease for a child and a difficult reconstructive problem for the surgeon. Twelve consecutive patients are described in this series, 7 of whom had complete airway obstruction; 9 patients have been extubated with satisfactory voices. Long‐term follow‐up indicates no cases of decreased development of the larynx.

Cervicofacial mycobacterial adenitis in children: Endemic to san diego?†

Nontuberculous mycobacteria (NTM) are an important cause of cervicofacial lymphadenitis in children. A dramatic increase has been seen in confirmed cases of NTM lymphadenitis in San Diego in the past few years. This report encompasses a span of 2 years 9 months, during which 22 children had confirmed NTM infection and another 14 had necrotizing granulomatous lymphadenitis in whom the specific diagnosis of NTM could not be made. This apparent increase in the prevalence of NTM as compared to previous reports in the literature suggests a possible endemic risk for NTM in the San Diego area. These cases are reviewed and our diagnostic and surgical approach to possible NTM infection is described. We also discuss possible explanations for the increasing occurrence of NTM in the San Diego area.

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.