Bernard R. Marsh

Infantile Subglottic Hemangiomas an Update

Between 1913 and 1985, 323 cases of infantile subglottic hemangiomas have been reported in the English language literature. The purpose of this study is to review these cases, to report The Johns Hopkins Hospital experience with ten additional cases, and to compare the various methods of treatment in an attempt to identify the regimens associated with the best outcome. The majority of the patients presented before the age of 6 months with respiratory distress, most commonly inspiratory stridor. There was a 2:1 female to male preponderance. The diagnosis was established by endoscopy in the majority and confirmed by biopsy in one third, without serious bleeding complications. A plethora of treatment methods have been described, including the following: corticosteroids, tracheotomy, radiation therapy, radioactive implant therapy, surgical excision, cryotherapy, and carbon dioxide laser. These methods were reviewed and their results compared to our own. We conclude that several methods are effective, each having its advantages and disadvantages. We believe that immediate tracheotomy should be performed in cases with severe airway obstruction. Smaller lesions may be vaporized with the carbon dioxide laser without tracheotomy if postoperative care is provided in a pediatric intensive care unit. Corticosteroids may be used alone or in combination with other modalities. External radiation therapy and injection of sclerosing agents are not advised.

Transbronchial needle aspiration for diagnosis of lung cancer.

Thirty-two consecutive patients with mediastinal lesions suggestive of bronchogenic carcinoma underwent transbronchial needle aspiration. Eighteen of 20 patients (90 percent) with proved bronchogenic carcinoma had malignant cytology specimens or tissue fragments. Of 12 patients with normal cytology specimens, six were subsequently proved to have nonneoplastic disease. Transbronchial needle aspiration appears to offer a sensitive and specific alternative to more invasive surgical techniques used in the diagnosis of malignancies with mediastinal involvement.

Indications for Open Surgical Removal of Airway Foreign Bodies

Airway foreign bodies can usually be extracted by skillful application of endoscopic techniques. We report our experience in the management of 2 infants in whom sharp, pointed objects dictated consideration for an open surgical approach. Clinical presentation and treatment options will be discussed in the successful management of these 2 patients, one with a crab claw in the subglottis and the other with an electronic diode in the lung. Extensive training and a full complement of modern instruments are required, but in highly selected cases, an open surgical procedure entails less risk than endoscopic extraction.

Flexible fiberoptic bronchoscopy. Its place in the search for lung cancer

The use of sputum cytology has demonstrated that conventional bronchoscopic equipment often fails to permit localization of earlier, more peripheral tumors. The flexible fiberbronchoscope now opens up new bronchial horizons but does not replace rigid instruments. Our experience in 300 fiberoptic studies has suggested certain guidelines for determining in which patients the flexible equipment should be used and in which conventional instruments are preferred. By means of a comprehensive endoscopic study, we successfully localized eight “sputum positive,” radiologically occult bronchogenic carcinomas. The fiberbronchoscope is essential in searching the segments for subtle changes of early cancer. These findings are documented by a color television system. A detailed pathological study demonstrates the importance of preoperative marginal biopsies in excluding carcinoma in situ which may extend some distance from even small tumors. In 94 patients with cancer we located 85 (90%) by direct visualization and/or bronchoscopic specimens. Sixty-eight (72%) involved primarily the segmental or more peripheral areas while main bronchus tumors were large and suggested spread from a more distal site of origin. The fiberbronchoscope has greatly extended our capabilities, allowing a better understanding of early lung cancer and greatly improved localization.

Psychogenic upper airway obstruction presenting as refractory wheezing

1. Brooks JG. Apnea of infancy and sudden death syndrome. Am J Dis Child 1982;136:1012-23. 2. Oren J, Kelly DH, Shannon DC. Identification of high-risk group for sudden infant death syndrome among infants who were resuscitated for sleep apnea. Pediatrics 1986;77:495-9. 3. Stein IM, Shannon DC. The pediatric pneumogram: a new method for quantitating apnea in infants. Pediatrics 1975;55:599-603. 4. Rosen CL, Frost JD Jr, Harrison GM. Infant apnea: polygraphic sleep studies and follow-up monitoring. Pediatrics 1983;71:731-6. 5. Rosen CL, Frost JD Jr, Bricker T, et al. Two siblings with recurrent cardiorespiratory arrest: Munchausen syndrome by proxy or child abuse? Pediatrics 1983;71:715-20. 6. Meadow R. Munchausen syndrome by proxy: the hinterland of child abuse. Lancet 1977;2:343-5. 7. Emery JL. Families in which two or more cot deaths have occurred. Lancet 1986;1:313-5.

Laryngotracheal Reconstruction for Subglottic Stenosis

Laryngotracheal reconstruction (LTR) has been employed for the treatment of severe laryngotracheal stenosis for the past 6 years at Johns Hopkins Hospital. Thirty-one children underwent LTR with costal cartilage grafting, 24 of whom had Aboulker stents placed. Short stents were used in 22 patients. Six patients received definitive treatment in a single-stage LTR; 1 child had no stent placed. Twenty-six (84%) of the 31 patients were decannulated. It was concluded that decannulation can be obtained in selected patients with the short Aboulker stent or single-stage LTR. A new classification system for laryngotracheal stenosis, based on objective measurements and the separate analysis of posterior glottic fibrosis, was developed. The proposed classification system allows recommendations for treatment. Moreover, it can be easily reproduced and may facilitate comparison of results.

The Problem of the Open Safety Pin

The open safety pin lodged in the stomach or esophagus presents a challenge to surgical judgment and technical skill. Most foreign bodies causing trouble lodge in the esophagus. Once in the stomach, uneventful passage can be expected in 80 to 90% of cases. Active intervention is reserved for those where intestinal performation is likely or where there is failure to progress. We have used the fiberesophagoscope to remove three open safety pins from the stomachs of two patients whose symptoms and threat of perforation required intervention. The microbiopsy forceps was used successfully to retrieve the open pins, but a newly developed grasping forceps for use with the fiberesophagoscope now provides a more secure hold on such foreign bodies. Rigid instruments retain their value for selected cases, but the flexible equipment now provides an important advance in the management of the open safety pin in the stomach.

Bipolar Cautery for the Fiberoptic Bronchoscope

a bipolar electrocautery probe for use through the fiberbronchoscope has been designed and has proven useful in treating small endobronchial lesions and bleeding sites.

Multifactorial dysphagia — Looking for a second, treatable cause

Even when the cause of dysphagia seems obvious, it is important to conduct a thorough evaluation of the problem, including dynamic imaging of swallowing. In this case, a patient with a 35-year history of dysphagia following bulbar poliomyelitis was found by cinepharyngoesophagography to have an obstructing high esophageal web, as well as marked pharyngeal muscle dysfunction. Dilation of the web led to resolution of dysphagia, despite persistent pharyngeal weakness.

Otolaryngology–Head and Neck Surgery at Johns Hopkins: The First 100 Years (1914–2014)

Early Days of Otolaryngology at Johns Hopkins As The Johns Hopkins Hospital opened in 1889 (Fig. 1), the Outpatient Department was organized under the direction of William S. Halsted. Nine divisions were initially formed: 1) the Department of General Medicine, directed by William Osler; 2) the Department of Diseases of Children, directed by William Osler and W.D. Booker; 3) the Department of Nervous Diseases, directed by William Osler and H.M. Thomas; 4) the Department of General Surgery, directed by William S. Halsted and John M.T. Finney; 5) the Department of Genitourinary Diseases, directed by William S. Halsted and James Brown; 6) the Department of Gynecology, directed by Howard A. Kelly and Hunter Robb; 7) the Department of Ophthalmology and Otology, directed by Samuel Theobald and Robert L. Randolph; 8) the Department of Laryngology, directed by John N. Mackenzie; and 9) the Department of Dermatology, directed by R.B. Morrison. From the beginning, there was controversy about how these departments were run. Most of the physicians were private practitioners and served without any compensation for their clinical or teaching efforts. The space provided to see patients was crowded, poorly equipped, and understaffed. William S. Halsted assigned no public beds to the clinical staff; therefore, many surgical procedures were done in the clinic exam rooms, with the patients discharged after ether anesthesia. All otolaryngology cases that required the main operating rooms were referred to the general surgery staff and operated on by John M.T. Finney, Joseph C. Bloodgood, or the resident surgeons. Thus, surgeons with little if any otolaryngology training performed the surgery, whereas staff members who were experienced in the field were excluded from the operating room. This system was kept in place until 1912. As was commonly the practice at that time, otology and laryngology were relegated to separate departments. It was not unusual for physicians of that time to specialize in diseases of the eyes, ears, nose, and throat. Such was the case with Samuel Theobald, an 1867 graduate of the University of Maryland School of Medicine, Baltimore, who studied in Vienna and London before practicing in Baltimore. He was appointed to the Johns Hopkins staff in 1896 and continued to head the ophthalmology section of surgery until his retirement in 1925. Later, he was a founder of the Baltimore Eye, Ear, and Throat Charity Hospital, one of the predecessors of Greater Baltimore Medical Center (GBMC). Robert L. Randolph was also a University of Maryland graduate, receiving his MD in 1884. He sought training in Vienna and was for a time the assistant to the chief of the Vienna Polyclinic Ophthalmology Department. After returning to Baltimore, Randolph was appointed to the Johns Hopkins staff in 1896 and served until his death in 1919, by which time he was an associate professor of clinical ophthalmology and otology. Randolph had a wide reputation for innovative lectures and clinical instruction. John N. Mackenzie was among several individuals in Baltimore who during the late 19th century became interested in laryngology. He graduated from the University of Virginia School of Medicine, Charlottesville, in 1876. After study at Metropolitan Throat Hospital and Dispensary of New York, he traveled abroad in 1879, studied in Vienna and Munich, and then served as chief of clinic in laryngology under Morrell Mackenzie (not related) at the Hospital for Diseases of the Throat and Chest in London. Morrell Mackenzie, perhaps the leading European laryngologist of his generation, managed the infamous affair of Kaiser Friedrich III’s laryngeal cancer in the 1880s. John N. Mackenzie was appointed to the Johns Hopkins staff in 1889. From the Department of Otolaryngology–Head and Neck Surgery, The Johns Hopkins University (H.W.F., I.P., I.L., W.K., D.T., P.F., S.L., B.M., S.B., J.C., A.L., P.B., D.W.E.), Baltimore, Maryland; the Department of Otolaryngology–Head and Neck Surgery, University of Pennsylvania (D.K.), Philadelphia, Pennsylvania; the Departments ofOtorhinolaryngology–Head and Neck Surgery and Pediatrics Albert Einstein College of Medicine Montefiore Medical Center (R.R.), New York, New York; the Department of Otolaryngology–Head and Neck Surgery, University of California at Los Angeles (F.L.), Los Angeles, California; and the Department of Otolaryngology–Head and Neck Surgery, Oregon Health Sciences University (P.F.), Portland, Oregon, U.S.A. Editor’s Note: This Manuscript was accepted for publication on June 15, 2015. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to David W. Eisele, MD, FACS, Department of Otolaryngology–Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Johns Hopkins Outpatient Center 6th Floor, Baltimore, MD 21287. E-mail: deisele1@jhmi.edu