Bruce H. Matt

A comparison of ibuprofen versus acetaminophen with codeine in the young tonsillectomy patient.

OBJECTIVE To compare the use of ibuprofen with the use of acetaminophen with codeine for posttonsillectomy management. BACKGROUND We were not satisfied with our traditional pain-management practice for tonsillectomy patients. We hoped to find a new approach for improved patient comfort and avoid scheduled, abusable drugs such as codeine. DESIGN Intervention, prospective, randomized control trial. Follow-up was 1 month. SETTING University referral center; institutional pediatric practice, ambulatory. PATIENTS 110 children undergoing tonsillectomy with or without other procedures. Consecutive patients were offered participation. Enrollees were randomly assigned to one of two classes and analyzed with the initial assignment. No patients withdrew for adverse effects, although 12 in group 2 used codeine and 5 of those used acetaminophen, whereas 2 in group 1 received ibuprofen. INTERVENTIONS Patients received either acetaminophen with codeine (group 1) or ibuprofen (group 2) for postoperative pain control. MAIN OUTCOME MEASURES The main outcomes, determined before initiation of the study, were assessment of (1) postoperative bleeding, (2) pain, (3) efficacy of relief of pain by drug, (4) nausea, (5) emesis, (6) readmission to hospital, (7) average temperature, and (8) highest temperature after surgery. RESULTS The only statistically significant difference is less nausea in patients receiving ibuprofen (p = 0.0049). Of note, no difference existed in postoperative bleeding, pain, or temperature control. CONCLUSIONS Ibuprofen is at least as effective as acetaminophen with codeine for postoperative pain control in children after tonsillectomy.

Anterior pericardial tracheoplasty for congenital tracheal stenosis: Intermediate to long-term outcomes

BACKGROUND Although several techniques for the treatment of long-segment stenosis of the trachea have been reported, including slide tracheoplasty, rib grafting, and use of a pericardial patch, the optimal repair remains controversial because of a lack of midterm to long-term follow-up data. METHODS To assess the intermediate and long-term outcomes of patients having repair with anterior pericardial tracheoplasty, we reviewed case histories of 12 patients (1984 to present). The median age was 6.7 months (range, 1 to 98 months), and the median weight was 6.0 kg (range, 0.97 to 42 kg). All patients underwent anterior pericardial tracheoplasty through a median sternotomy during partial normothermic cardiopulmonary bypass. An average of 13 tracheal rings (range, five to 23) were divided anteriorly, and a patch of fresh autologous pericardium was used to enlarge the trachea by 1.5 times the predicted diameter for patient age and weight. RESULTS There was one hospital death, and all but 2 patients are long-term survivors. All but 1 current survivor remain asymptomatic, with no bronchoscopic evidence of airway obstruction or granulation on the pericardial patch. All survivors examined have normal tracheal growth and development, with a median follow-up of 5.5 years (range, 1 to 11 years). CONCLUSIONS Anterior pericardial tracheoplasty for congenital tracheal stenosis provides excellent results at intermediate to long-term follow-up.

Calvarial bone grafting of facial defects

Bony defects of the face continue to challenge the reconstructive surgeon. Traditional sources of autologous bone from the rib or pelvis have been associated with the limitations of pain at the donor site, the need for a second operative field, variable “take” of the graft with poor eventual survival and, ultimately, less than optimal reconstruction. Calvarial bone grafting provides a readily accessible source of bone from an inconspicuous donor site, usually within the same operative field. The morbidity is minimal. The calvarial bone graft is especially useful in repair of the frontal sinus, orbital floor, nasal and malar regions, as well as in certain instances of cleft palate with alveolar involvement.

Surgical management of obstructive sleep apnea in infants and young toddlers

Objective: Review surgical management of obstructive sleep apnea (OSA) in infants and young toddlers compared with a medically treated group. Study Design: Case series with chart review of children younger than 24 months treated at a tertiary pediatric hospital between 2000 and 2005. Subjects and Methods: Surgical treatment included adenotonsillectomy, adenoidectomy, and tonsillectomy. Polysomnography results, comorbidities, and major complications were recorded. The change in apnea-hypopnea index (AHI) before and after treatment was analyzed. Logistic regression analysis reviewed effects of comorbidities and OSA severity on complications. Results: A total of 73 children met inclusion criteria. The surgical treatment group (AHI) improved posttreatment: mean AHI change was 9.6 (95% CI, 5.8-13.4). The medical treatment group did not improve posttreatment: mean AHI change was −3.0 (95% CI, −15.1 to 9.1). The difference in AHI change between surgical and medical groups was 12.56 (95% CI, 2.7-22.4). An independent t test found this difference to be statistically significant (P = 0.01). Eleven (18%) patients suffered significant postoperative surgical complications; 55 surgical patients and 8 medical patients had comorbidities. There were no long-term morbidities or mortalities. Conclusions: AHI in the surgically treated group significantly improved. The complication rate for a tertiary pediatric hospital population that included patients with multiple comorbidities was acceptable.

Clinical spectrum and risk of PHACE syndrome in cutaneous and airway hemangiomas.

OBJECTIVE To describe the clinical presentation and risk of PHACE syndrome in infants with large facial hemangiomas and concomitant airway hemangiomas. DESIGN The study involved a case series of infants with cutaneous hemangiomas and airway hemangiomas extracted from a prospective multicenter cohort study. Data regarding clinical features, diagnosis, treatment, and clinical course were obtained from medical charts and physician intake forms. All patients were evaluated for PHACE syndrome using a standardized protocol. SETTING Six academic pediatric dermatology clinics. PATIENTS The study included 17 patients younger than 1 year who were diagnosed as having large (>22 cm(2)) facial hemangiomas and airway hemangiomas. RESULTS Thirteen patients (76%) had hemangiomas in the bilateral mandibular distribution. Other observed facial patterns included limited involvement of the lip and chin, unilateral reticular frontotemporal and preauricular hemangiomas, and large unilateral hemifacial hemangiomas. Fourteen patients (82%) had symptomatic airway involvement. All symptomatic patients had subglottic airway hemangiomas. The airway hemangioma was circumferential in 10 patients (58%) and more focal in distribution in 7 patients (42%). All patients were treated with oral prednisolone. Eleven patients required additional multimodal therapy. Eight patients (47%) met the criteria for PHACE syndrome. CONCLUSIONS Airway hemangiomas represent a potentially fatal complication of infantile hemangiomas. Our data highlight cutaneous presentations in patients with subglottic hemangiomas and large (>22 cm(2)) cutaneous hemangiomas. PHACE syndrome was detected in 8 such patients (47%) in our series.

Wegener's granulomatosis, acute laryngotracheal airway obstruction and death in a 17-year-old female: case report and review of the literature☆

OBJECTIVE To alert practitioners to the risk of sudden airway obstruction and death in patients with Wegeners granulomatosis. DESIGN Case report and literature review. SETTINGS University and Community hospitals. PATIENT A 17-year-old white female. INTERVENTION (1) evaluation and treatment for mental status changes over 2 months. (2) Evaluation and surgical biopsy of nasal septal perforation under general anesthesia at a university childrens hospital. (3) Evaluation and observation at a community hospital 2 days later. (4) autopsy. RESULTS Serology performed 3 days ante-mortem revealed (at 2 days post-mortem) cytoplasmic anti-neutrophil cytoplasmic antibody positive at 1:128. Autopsy was significant for microscopic fibrosis and granulomas in the kidneys and essentially total obstruction of the subglottis and upper trachea by a 3.5 x 1 x 1 cm mass of fibrosis and granulomas overlying circumferentially necrotic mucosa. This mass was centered on the crico-tracheal junction. CONCLUSIONS Wegeners granulomatosis can lead to proliferative tissue growth with acute airway obstruction in the larynx and trachea, and death. Any patient with WG under age 20, as well as patients with WG and laryngotracheal symptoms (e.g. strider, hoarseness, wheezing) would benefit from evaluation of the airway.

Aneurysmal bone cyst of the maxilla : case report and review of the literature

Aneurysmal bone cyst (ABC) is a rare benign lesion of the head and neck. A case of an ABC in a 12-year-old female is presented, the twentieth reported such case in the maxilla. Literature review shows ABC are common in the long bones; only 2% are in the head and neck. Of the 77 lesions in the head and neck found in the literature, 31 (40%) are in the mandible, 20 (26%) are in the maxilla (including this case) and the remainder mainly in the skull. Current recommended treatment is curettage with enucleation first if technically possible.

Plunging ranula in an infant

This unusual case extends the age range of persons with plunging ranula to include those with congenital neonatal submandibular masses. The congenital nature of plunging ranula has not been widely discussed. Clinical diagnosis can be reinforced by diagnostic imaging (CT, MRI) if the mass extends into or abuts the sublingual space. Definitive treatment (generally excision) leads to resolution of the mass and prevention of recurrence.

Lingual tonsillectomy in a child with obstructive sleep apnea: a novel technique.

We report on a case of lingual tonsillar hyperplasia contributing to refractory obstructive sleep apnea in a 5‐year‐old patient. We describe a novel technique utilizing suspension laryngoscopy and a laryngeal angled shaver to remove obstructive lingual tonsillar tissue. We review the available techniques for lingual tonsillectomy and propose theoretical advantages to the novel approach.

Enhancement of expansion of guinea pig skin by local delivery of an anticontractile agent using a new bilumen expander

We have shown previously that anticontractile agents used with tissue expanders provide significantly more rapid expansion in an animal model than in controls without these agents. We describe an improved method of delivery involving a perforated concentric envelope enclosing a tissue expander (type 2) in place of the single circumferential perforated catheter (type 1) used previously by us. Eleven guinea pigs received a type 1 expander and ten received a type 2 expander. The anticontractile agent theophylline was delivered in saline around each expander, and all the expanders from both groups were inflated to a similar pressure every three days for twelve days. Significantly greater expansion, in terms of total volume delivered to the expander, was noted using the type 2 expander. We conclude that the concentric device offers further improvement, probably as a result of more uniform distribution of the agent in the tissue around the expander.