Carlos Gonzalez

Synchronous airway lesions in infancy.

Stridor in the young infant is evaluated by careful laryngoscopy. When a lesion of the larynx is diagnosed, the necessity and risk of bronchoscopy are challenged. To assess the need for careful examination of both the upper and lower respiratory tract, a 2-year retrospective study was performed at the Childrens Hospital of Pittsburgh. Of 103 infants who underwent diagnostic laryngoscopy and bronchoscopy for airway obstruction, stridor, or both, 18 (17.5%) had two or more synchronous airway lesions detected. Laryngoscopy alone, without further workup of the entire respiratory tract (ie, bronchoscopy, radiographic studies) may fail to detect concurrent disorders in infants with airway obstruction.

Postoperative risk following uvulopalatopharyngoplasty for obstructive sleep apnea.

A study was conducted to assess oxygenation and respiratory changes on the first and second postoperative nights after uvulopalatopharyngoplasty (UPPP) for obstructive sleep apnea (OSA). Twelve patients were postoperatively evaluated with 8-hour nocturnal polysomnography on four occasions: (1) PREOP—night before UPPP, (2) POPN1—first postoperative night, (3) POPN2—second postoperative night, and (4) 3MOS—3-month follow-up study. Results demonstrate that apnea Index (Al) and respiratory disturbance Index (RDI) were significantly Improved at 3MOS from PREOP levels: Al (p < 0.01) and RDI (p < 0.05). There were no statistical differences from PREOP to POPN1 or POPN2 for Al, RDI, lowest oxyhemoglobin saturation (LSAT), or number of desaturations (#DESAT). One of twelve patients dropped LSAT >10% from PREOP to POPN1 or POPN2 (82% PREOP to 71% POPN2). Patients were grouped by PREOP LSAT ⩾80% or <80%, and the postoperative change In LSAT was evaluated by comparing PREOP to a value averaging POPN1 and POPN2. Patients with LSAT ⩽80% decreased by 2.6%; patients with LSAT <80% Improved by 6.2%. This change in LSAT between groups was statistically different (p = 0.02). These data suggest that in the majority of patients, preoperative indices remain unchanged for at least 2 days after surgery, even for patients who demonstrated improvement at 3 months. However, worsening does occur in some patients. On the basis of the results of this study and clinical experience with the postoperative course, a selective management protocol is outlined.

Effects of Aerosolized Dexamethasone on Acute Subglottic Injury

Aerosolized dexamethasone was used in a two-phase study to determine the possible effects on acute subglottic injury in the ferret animal model. In phase 1, equivalent subglottic injuries were made in 10 animals by using the brush technique, and the animals were divided into two groups. The treatment group received aerosolized dexamethasone at 2, 4, and 6 hours postinjury. All animals were examined 2, 4, 6, and 24 hours after the injury. The clinical condition of each animal was evaluated and their airways were measured. The animals were then painlessly killed and the larynges were frozen, sectioned, and photographed at 1-mm intervals. A computer-linked digitizer pad was used to measure the subglottic dimensions. The results show a trend for the treated animals to have a larger subglottic airway as compared to the untreated (control) group. The phase 1 study suggests that there may be an improvement in the subglottic airway when treated acutely with aerosolized dexamethasone. In phase 2, 20 additional animals were studied by using the same methods of injury and treatment as in phase 1. The subglottic airways of these animals were evaluated with histomorphometric analysis on fixed histologic sections. A statistically significant difference was found between the subglottic airways of the treated and untreated animals favoring treatment with aerosolized dexamethasone. Aerosolized dexamethasone appears to be beneficial in preserving the subglottic airway after injury, possibly secondary to decreasing the edema associated with injury.

Laryngotracheal involvement in epidermolysis bullosa

Epidermolysis bullosa (EB) is a rare hereditary skin disease of infancy that can involve the mucous membranes of the oral cavity. Laryngotracheal involvement is rare. The disease is characterized by bullae formation in response to minor trauma. There are at least 18 described types of EB, however, there are 3 basic categories. These are simplex (with disruption above the basement membrane), dystrophic (in which disruption is below the basement membrane), and junctional (in which the split is within the lamina lucida). The prognosis of the different types ranges from early death usually secondary to overwhelming sepsis, to long term survivals with lack of growth retardation or significant dystrophic scarring. Presently, survival appears to be the only reliable criteria for distinguishing the benign and lethal forms of EB. Airway obstruction secondary to laryngotracheal involvement should be considered in any child with epidermolysis bullosa presented with symptoms of respiratory distress. Because there are few predictive prognostic indicators in the neonatal period, tracheotomy should be considered early in an effort to prevent further laryngeal injury from intubation, in those patients that will survive.

Duration of intubation in children with acute epiglottitis.

Nasotracheal intubation has been demonstrated to be effective in supporting the airways of children with acute epiglottitis. Length of intubation and criteria used for extubation are still controversial. A 6-year retrospective review at Childrens Hospital of Pittsburgh identified 100 cases of acute epiglottitis, which were initially managed with nasotracheal intubation. Extubation was based on direct laryngeal inspection performed in the operating room (1979–1981) and, more recently, in the intensive care unit (1982–1984). Length of intubation decreased from 63.8 hours in 1979 to 42.1 hours in 1984. The percent of children intubated longer than 48 hours decreased from 69% to 22% in the same time period. These data indicate that a shorter period of intubation is aided by daily laryngeal inspection in the ICU. We propose a staging system for acute epiglottitis to aid in the decision to safely extubate these children.

Chondrosarcoma of the facial skeleton in a child.

CASE REPORT A 3-year-and-ll -month-old black child was taken to his local pediatrician with a history of nasal congestion for I /2 years that had progressed to total nasal obstruction for I year. During the 6 months before admission. the parents noted progressive swelling of the right side of the nose and eventual proptosis. Sinus radiographs obtained revealed a soft tissue density in the right nasal cavity that extended into the maxillary sinus and right ethmoidal sinus. with displacement of the globe. The patient was referred to Walter Reed Army Medical Center for definitive therapy. His evaluation included CT scan and MRI (Figs . I and 2). The soft tissue mass was found to extend from the floor of the nasal cavity into the right maxillary and ethmoidal sinuses, displacing the globe anterolaterally and the nasal septum to the left. The mass abutted, but did not invade the cribriform plate. The right palate was displaced inferiorly. Ophthalmologic consultation was obtained. The patient was noted to have intact vision with normal extraocular mobility; there was 4 mm of scleral show of the right globe with

Endobronchial tuberculosis in children. A case report and review

Unilateral obstructive emphysema seen on chest X-ray in a pediatric patient is usually associated with a foreign body in a bronchus. We present a 31-month-old female who presented with a 2-week history of increasing expiratory stridor. Endoscopic examination revealed a polypoid mass in the right main bronchus. Biopsies and cultures were consistent with endobronchial tuberculosis. We review the presentation and treatment of tuberculosis in children. Endobronchial tuberculosis is a rare complication of pulmonary tuberculosis which may result in stenosis of the bronchus.

A case of facial diplegia associated with acute bilateral otitis media

A 32-month-old toddler developed facial diplegia in association with a bout of acute bilateral otitis media. After 28 days of antibiotic therapy and placement of tympanostomy tubes, the patient demonstrated 100% symmetrical recovery. A brief discussion of the pathophysiology is included.

Complication of acute epiglottitis

Acute airway obstruction secondary to supraglottic inflammation is a regional manifestation of epiglottitis in children. Pneumonia, meningitis, cervical adenitis and septic shock are systemic manifestations which can complicate the course of acute epiglottitis. Prompt airway control and institution of appropriate high dose i.v. antibiotics are both important to continue to decrease the morbidity and mortality associated with the regional and systemic manifestations of acute epiglottitis in children.

Endotracheal Tube Safety with the Erbium: Yttrium Aluminum Garnet Laser

The erbium: Yttrium aluminum garnet (Er:YAG) laser operates in the infrared spectrum at a wavelength of 2.94 μm. The absorption coefficient for water at this wavelength is approximately 10 times that of the carbon dioxide laser. It is anticipated that this laser will produce more precise surgical ablation with decreased surrounding tissue destruction. The results of impacting endotracheal tubes with the Er:YAG laser are presented. The CO2 laser was used as a reference. Metallic tape that was not perforated by the CO2 laser after 240 seconds of continuous exposure at 20 W was perforated by the Er: YAG laser with use of 15 pulses of 1 J per pulse. Silver foil tape with a Merocel lining was resistant to perforation by both the CO2 laser and the Er: YAG laser. As new laser wavelengths become available and are applicable to otolaryngology, modification of current safety standards will be necessary.