C.A.J. Prescott

Tracheostomy in children — The Red Cross War Memorial Children's Hospital experience 1980–1985

During the 6 years (1980-1985) at The Red Cross Childrens Hospital 293 children required a tracheostomy during treatment of a variety of disorders. Of these children 44% were under 1 year of age. Indications are discussed of which the commonest was LTB. Of the 3500 children seen with laryngotracheobronchitis (LTB) 4.6% had a tracheostomy--28% of those requiring airway intervention. Overall 67% of the children were decannulated within 10 weeks and 92% within a year. For 56% one or more further procedures prior to decannulation were required, including 34 children who required a laryngotracheoplasty. Obstructing stomal granulation tissue had to be removed from 51 children and suprastomal collapse was a cause of decannulation failure in 52 children. Use of an expiratory valve as an aid to decannulation is discussed. Five children died of tracheostomy airway complications and 25 children of a medical disorder. One complication, laryngeal incompetence, was particularly associated with herpetic laryngeal ulceration. Staphylococcus aureus and Hemophilus influenzae were the main organisms cultured in the early weeks, with Pseudomonas and Streptococcus species predominating later.

A survey of ear and hearing disorders amongst a representative sample of Grade 1 schoolchildren in Swaziland

A representative sample of Grade 1 (first year school entry) schoolchildren in Swaziland were surveyed during a single week to determine the prevalence of ear and hearing disorders: 79.8% had both normal ears and normal hearing, 16.8% had an ear disorder, but 80% of them had normal hearing. The most common disorder was impacted wax, with a prevalence rate of 74/1000. Middle ear disorders were common and the prevalence rate for children with active middle ear disease was 30/1000 (17/1000 having a hearing loss), and for children with inactive ear disease, the prevalence was 21/1000 (5/1000 having a hearing loss); 8/1000 children were found to have a sensorineural hearing loss, 5.3/1000 unilateral and 2.1/1000 bilateral. Improved treatment of acute otitis media, which is also common in the pre-school age group, could reduce the sequelae of the disorder, which has a deleterious effect on hearing and impairs educational achievement once the children enrol at school.

Relationship between the clinical course and HPV typing of recurrent laryngeal papillomatosis. The Red Cross War Memorial Children's Hospital Experience 1982–1988

During the period 1982-1988, 20 new cases of laryngeal papillomatosis in children were seen at The Red Cross War Memorial Childrens Hospital. HPV typing of biopsy specimens was performed. Their clinical course was reviewed and age at presentation ranged from 1 to 10 years. There was no correlation between age and either aggression or a prolonged clinical course. HPV DNA was identified in all 20 cases (100%). Fifteen (75%) were HPV Type 11 and 5 (25%) were HPV Type 6. There were no mixed infections. HPV Type 6 infection was more clinically aggressive than HPV Type 11 infection. The intensity of the virus signal in the biopsy specimens was not in general indicative of the clinical behavior of the disease, although two children with particularly strong intensity exhibited aggressive disease. It is suggested that identification of HPV type 6 infection has prognostic significance.

Peristomal complications of paediatric tracheostomy.

Failure of decannulation after paediatric tracheostomy, once the underlying disorder has resolved, is almost always due to peristomal complications. Granulation tissue formation in the raw tissue of the stoma and its subsequent fibrosis requires removal (50 of the 293 tracheostomies from the Red Cross War Memorial Childrens Hospital). It is suggested that this can be avoided by creating a formal skin-to-trachea stoma at the time of tracheostomy. Suprastomal depression of the anterior wall of the trachea (52/293) appears to be unavoidable when using standard tracheostomy tubes. Localised stomal site tracheomalacia and stenosis (numbers of this complication are unknown) results from damage to cartilage of the trachea either by incision or by necrosis from pressure of the tracheostomy tube. Trauma to the cartilage needs to be minimised by careful design of the tracheal incision. It is suggested that consideration should be given to creating a formal tracheostomy stoma for any paediatric tracheostomy that is likely to be required for more than a short period of time.

Idiopathic facial nerve palsy in children and the effect of treatment with steroid

During a 10-year period 228 children were seen with Bells Palsy. In half of them the palsy was incomplete. Overall the recovery rate was 96%. There was a strong female preponderance but no difference in incidence between right of left sides. Twenty-eight reported a previous episode of facial palsy. When separated into categories based on clinical assessment and evidence of nerve fibre degeneration it was evident that all children without degeneration recovered. Those with incomplete palsies recovered in about half the time taken by those with complete palsies. Only two thirds of those children in whom degeneration was evident recovered. One hundred children were treated with a course of high dose steroid. This did not influence recovery either by improving recovery rate or by decreasing the time period to recovery.

Tympanoplasty surgery at the Red Cross War Memorial Children's Hospital 1986–1988

Results of tympanoplasty surgery over a 3 year period in 96 children aged 2-12 years were analysed to better define indications for surgery and prognostic factors. Nineteen percent had a hearing loss associated with a dry perforation--grafts were successful in 84% and 71% improved hearing to less than 20 dB. Forty-two percent had a hearing loss but also troublesome recurrent infection--grafts were successful in 88% but only 65% improved hearing to less than 20 dB. Thirteen percent had troublesome recurrent infection--grafts were successful in 79%. Twenty-two percent had uncontrolled infection, a cortical mastoidectomy together with myringoplasty produced a 75% take rate. Graft take was not affected by age, type of surgery, infection status or perforation size. Poor nutritional status and postoperative infection both had negative tendencies. In this small series there was a 10% re-perforation rate.

Peak nasal inspiratory flow measurement: an investigation in children

Theoretically measurement of peak nasal inspiratory flow (PNIF) has promise as a method to objectively evaluate children with nasal airway obstruction. This study establishes normative data for children up to 8 years of age. PNIF increases linearly from a mean value of 30 l/min in early infancy up to a mean value of 80 l/min at age 8 years, apart from a dip at 3 years. There is a reasonably linear incremental rise with increasing height and weight. However, since results depend on both the degree of co-operation of the child and on the subjective impression of the observer as to when a maximal inspiratory effort has been made, there may be drawbacks to its use as a routine clinical method of nasal airway obstruction assessment.

Is diagnostic tonsillectomy indicated in all children with asymmetrically enlarged tonsils

OBJECTIVES The aims of the study were: (i) to determine the necessity for diagnostic tonsillectomy in children with asymmetrically enlarged tonsils; (ii) to determine the accuracy of clinical assessment of tonsillar asymmetry; and (iii) to determine how to manage children with clinical tonsillar asymmetry in a developing-world practice. METHODS A prospective study was carried out at Red Cross War Memorial Childrens Hospital in Cape Town, over an 8-month period. All children undergoing tonsillectomy or adenotonsillectomy had a clinical assessment of tonsil symmetry done, and all tonsil and adenoid specimens were examined histologically. The maximum diameter and volume of the resected tonsils were measured. A comparison was done of true tonsil asymmetry in patients with asymmetrical tonsils and a subgroup of matched controls with symmetrical tonsils. RESULTS A total of 344 tonsils were analysed (172 patients). The 13 patients (7.6%) diagnosed as having clinically asymmetrically enlarged tonsils had no significant pathological diagnosis. In the patients with symmetrical tonsils there were 2 abnormal pathological findings (tuberculosis of the adenoids and T-cell lymphoma of the tonsils and adenoids). In the clinically asymmetrical tonsil group, true tonsillar asymmetry was 3 mm (maximum diameter), and 2.2 cm(3) (volume), compared with 1.9 mm and 1.5 cm(3) in the symmetrical tonsil group. When patients with clinical tonsillar asymmetry and symmetry were compared, the difference in maximum diameter (p = 0.62) and volume (p = 0.73) was not significantly different. CONCLUSIONS Clinical tonsillar asymmetry is usually apparent rather than real. The incidence of significant pathology in children with asymptomatic, asymmetrical tonsils is low. Diagnostic tonsillectomy is indicated in children with asymmetrically enlarged tonsils associated with constitutional symptoms, cervical lymphadenopathy, rapid tonsil enlargement or significant tonsillar asymmetry.

Factors that influence successful decannulation after surgery for laryngo-tracheal stenosis in children

The process to decannulation requires attention to details from the time of initial tracheostomy, through the pre- and peri-operative period up until the decannulation event. Important points to consider during this process are: a formal tracheostomy rather than a tracheotomy; other potential sites of obstruction than the laryngeal stenosis; gastroesophageal reflux; prevention and control of infection and the use of prophylactic antibiotics; method and type of suture material; stenting; movement and method of feeding. Decannulation itself requires attention to removal of granulation tissue and control of tracheomalacia and tracheostenosis.

Medium term fate of cartilage grafts from children after laryngo-tracheoplasty

Cartilage grafts or biopsies of such grafts were obtained from six children who had undergone laryngo-tracheoplasty surgery at times ranging from 10 to 38 months after surgery. The histological appearance of the grafted cartilage was of gradual degeneration with chondrocyte necrosis and replacement of cartilage matrix by fibrous tissue.