Charles M. Bower

Pediatric obstructive sleep apnea syndrome.

Pediatric obstructive sleep apnea occurs in about 2% of children, and manifests as snoring, difficulty breathing, and witnessed apneic spells. Daytime symptoms include excessive sleepiness with poor performance and behavior problems. Severe forms may be associated with failure-to-thrive or death. The gold standard diagnostic procedure is overnight polysomnography and is indicated in high-risk patients. While most pediatric patients with obstructive sleep apnea can be treated with tonsillectomy and adenoidectomy; uvulopalatopharyngoplasty, tracheotomy, or other procedures are sometimes indicated. Nonsurgical treatment with continuous positive airway pressure is used in some children. Postoperative management in high-risk children includes careful perioperative monitoring and postoperative polysomnography.

Hearing Assessment in Infants and Children: Recommendations Beyond Neonatal Screening

Congenital or acquired hearing loss in infants and children has been linked with lifelong deficits in speech and language acquisition, poor academic performance, personal-social maladjustments, and emotional difficulties. Identification of hearing loss through neonatal hearing screening, regular surveillance of developmental milestones, auditory skills, parental concerns, and middle-ear status and objective hearing screening of all infants and children at critical developmental stages can prevent or reduce many of these adverse consequences. This report promotes a proactive, consistent, and explicit process for the early identification of children with hearing loss in the medical home. An algorithm of the recommended approach has been developed to assist in the detection and documentation of, and intervention for, hearing loss.

Surgical correction of obstructive sleep apnea in the complicated pediatric patient documented by polysomnography

OBJECTIVE Evaluate the effectiveness of surgical treatment of obstructive sleep apnea in a diverse population of children. DESIGN A retrospective case series of pre and post operative polysomnograms (PSG) of pediatric patients with obstructive sleep apnea (OSA). SETTING Tertiary care childrens hospital. PATIENTS 48 patients in whom sleep studies were performed pre-operatively for either an unclear history and/or physical findings or complicated OSA. Thirteen patients had no complicating medical factors, 35 patients had various associated medical problems, including 20 with morbid obesity, five with Down syndrome, four with asthma, two with cerebral palsy, and four other. The average age was 7.5 years with a range of 1.5-20 years. INTERVENTIONS Thirty-one patients had a tonsillectomy and adenoidectomy (T and A) only, 13 had T and A with uvulopalatopharyngoplasty (UPPP), and three had tonsillectomy and UPPP. MAIN OUTCOME MEASURES Pre and postoperative PSG results including apnea/hypopnea index (AHI), percent of sleep with oxygen saturation below 90%, and percent sleep time with end-tidal pCO2 > 50. RESULTS The mean pre-operative (AHI) was 27 +/- 4 (mean +/- S.E.M.) and post operatively was 6 +/- 1 (P < 0.001). Twenty six of 48 (54%) had a postoperative AHI of less than five. Pre-operative percent of sleep with oxygen saturation below 90% was 17.9 +/- 4.5%, post-operatively it was 1.4 +/- 0.1% (P < 0.001). Pre-operative percent sleep time with end-tidal pCO2 > 50 was 22.3 +/- 3.4%, post operatively it was 12.6 +/- 2.9% (P < 0.01). UPPP was performed more commonly in patients with Down syndrome. There was a trend toward more improvement in patients who had T and performed than those undergoing UPPP (post op AHI of 4.7 vs. 7.4 respectively). CONCLUSIONS Tonsillectomy, adenoidectomy and UPPP are effective in the treatment of OSA in a diverse group of pediatric patients. Patients with asthma, cerebral palsy, Down syndrome, morbid obesity, and hereditary syndromes all improved significantly with surgical management.

Pediatric obstructive sleep apnea: the year in review

Purpose of reviewIn recent years several daytime symptoms resulting from pediatric obstructive sleep apnea have been recognized that affect neurobehavioral and cognitive functioning. It is important to identify patients who will benefit from treatment. Up until now the systematic analysis of obstructive sleep apnea in children has been hindered by both variable diagnostic criteria and patient care protocols. This review examines the effects of obstructive sleep apnea in children as well as treatment outcomes. Recent data suggest that some diagnostic modalities may underestimate the prevalence of sleep-disordered breathing in children. Recent findingsA review of the data from the past year shows a significant correlation between obstructive sleep apnea and daytime symptoms. It also shows mitigation of these symptoms with appropriate treatment. The directed history and physical examination continue to be the most effective means of diagnosis in most affected children. The polysomnogram is considered the gold standard for diagnosis but may underestimate the presence of sleep-disordered breathing in children. Some children with the diagnosis of primary snoring will benefit from treatment. SummaryIn view of the profound effects of obstructive sleep apnea in children, it is vital to develop an accurate and universal system for diagnosing and treating these patients. Adenotonsillar hypertrophy is the major cause of obstructive sleep apnea in children. A directed history and physical examination followed by tonsillectomy and adenoidectomy are effective in improving the physical sequelae and quality of life of affected children.

Application of skull base techniques to pediatric neurosurgery

Abstract Techniques for skull base surgery have become well established over the last 10 years. Most of these techniques are used in adult patients for skull base tumors and neurovascular diseases. There are very few large series of pediatric patients in whom skull base approaches have been used, because of the rarity of these conditions. The authors would like to present a relatively large series of 26 pediatric patients who underwent skull base approaches for tumor resection. These tumors involved the anterior cranial base in 5 patients, the medial cranial skull base in 4 patients, and the posterior cranial base in 12 cases. Five patients had tumors that involved two or more fossae. The overall complication rate was 57%, which included temporary cranial nerve palsies, CSF leak and infection. Patients with permanent complications were 8 in number (37%). There was 1 postoperative death from pneumonia approximately 6 weeks after surgery. Complete tumor removal was achieved in 24 of the 26 patients. Skull base tumors in children are often extensive and present significant surgical challenges. Although complete tumor extirpation is the goal in most pediatric patients, this is often achieved only with some morbidity. This paper demonstrates the effectiveness of skull base approaches for these tumors and underscores the high stakes involved.

Flash pump dye laser treatment of laryngeal papillomas.

To evaluate the feasibility and safety of the flash pump dye (FPD) laser for the treatment of laryngeal papillomas, we performed a prospective nonrandomized trial comparing FPD and carbon dioxide (CO2) laser treatment of laryngeal papillomas in a tertiary care childrens hospital. Nine patients from 2 to 20 years of age with severe recurrent laryngeal papillomas were enrolled in the study. All patients underwent CO2 laser debulking of papillomas on the left hemilarynx, with 8 W continuous or pulsed energy. The right hemilarynx was treated with the FPD laser with 12 to 77 pulses at 8 to 12 J, through a custom-designed 90° firing fiber. An end point of blanching and purpura of the papillomas was used. The main outcome measures were the safety and ease of operation with the FPD laser, and decreased papilloma size based on visual inspection at 2 weeks postoperative and at the next laser procedure. Seven patients were irradiated 1 time with an FPD laser, and 2 patients 2 times. No intraoperative complications were noted. One patient developed early postoperative stridor. No patients described more discomfort, and 5 patients described their voice as being the same as or better than it was after prior CO2 laser procedures. Five patients had a 90% or more decrease in size of papillomas on the FPD-irradiated side 2 weeks postoperatively. Three patients had approximately a 50% reduction. A treatment effect was noted in all patients, and was similar to the results noted on the CO2 laser-treated side. Early results with FPD laser treatment of laryngeal papillomas suggest the protocol is relatively safe and feasible. Long-term results are pending. Because the FPD laser coagulates rather than vaporizing tissue, potential advantages may include decreased scarring relative to CO2 laser treatment, and improved patient and operator safety.

Tonsillectomy and adenoidectomy in patients with Down syndrome

Tonsillectomy and adenoidectomy in patients with Down syndrome usually relieves symptoms of upper airway obstruction due to adenotonsillar hypertrophy. A retrospective review of 16 patients with Down syndrome who underwent a tonsillectomy and adenoidectomy was conducted to define early postoperative morbidity, and to evaluate the results of the procedure. Fifteen of 16 patients had upper airway obstruction manifest by adenotonsillar hypertrophy. One had adenoid hypertrophy only. Tonsillectomy and adenoidectomy (13), adenoidectomy (1), tonsillectomy (1), and UP3/adenoidectomy (1) were performed on these patients. Four patients (25%) required observation in an intensive care setting the first night. An average hospital stay of 2.1 days was noted with a range of 0 to 7 days. Significant postoperative apnea was common, and oxygen was used in over 60% of patients. Symptoms were resolved in 69% of patients at last follow up. In conclusion, tonsillectomy and adenoidectomy can be a useful procedure for children with Down syndrome and obstructive sleep apnea, however overnight hospitalization for observation and treatment of persistent apnea is appropriate.

Allergic fungal sinusitis in children

BACKGROUND Allergic fungal sinusitis (AFS) has been characterized in adults presenting with chronic sinusitis. Rare reports allude to a similar disease in children. OBJECTIVE To characterize the features of AFS in children. METHODS Children referred to otolaryngology clinics at Arkansas and LeBonheur Childrens Hospitals for chronic sinusitis during a 12-year period were studied. This retrospective analysis reviews the following: clinical presentation, laboratory evaluations, radiographic and pathologic findings, and surgical intervention. Twenty patients (age range, 7-18 years; mean age, 12.5 years; median age, 16 years) met previously published criteria for AFS. Thirteen patients were male and 7 were female. Thirteen were African American and 7 were white. RESULTS Presentation at diagnosis included the following: atopy (n = 20), nasal symptoms (n = 20), recurrent sinusitis (n = 18), nasal polyps (n = 18), recurrent headaches (n = 12), asthma (n = 11), proptosis (n = 10), and ocular symptoms (n = 10). All had radiographic evidence of sinusitis and allergy to fungal organisms. IgE levels were elevated in 8 of 9 patients, and 10 of 15 patients had eosinophilia. Surgical specimens demonstrated allergic mucin (n = 11), Charcot-Leyden crystals (n = 2), hyphae or fungal debris (n = 9), and fungal growth (n = 17). All patients underwent endoscopic sinus surgery, with 11 requiring multiple surgical procedures. Postoperatively, 19 patients received intranasal and oral steroids, and all had nasal saline washes. Eleven patients (9 who had undergone multiple surgical procedures) were treated with immunotherapy. Relapse was seen in 55% of patients at 1 year of follow-up. CONCLUSION AFS presents with a higher incidence of proptosis in children when compared with adults. Typically, AFS occurs in atopic children with refractory sinus disease, requiring a high index of suspicion for evaluation and aggressive treatment.

Atlantoaxial Subluxation and Cervical Osteomyelitis: Two Unusual Complications of Adenoidectomy:

Grisels syndrome (atlantoaxial subluxation) and cervical osteomyelitis are two unusual complications of adenoidectomy. We present two patients; one with atlanto-axial subluxation following uncomplicated tonsillectomy and adenoidectomy, and one with cervical osteomyelitis following uncomplicated adenoidectomy. Both patients presented with persistent postoperative neck pain. Surgical intervention, as well as long-term intravenous antibiotics, was required. A high index of suspicion, as well as cervical spinal series with flexion-extension views, is necessary for diagnosis. Flexible nasopharyngoscopy and computed tomography of the cervical spine also aided in diagnosis and treatment planning. With early diagnosis and proper treatment, the prognosis is good. Neurologic sequelae were prevented in both of our patients.

Cervical complications following routine tonsillectomy and adenoidectomy.

Purpose of reviewFortunately, patients undergoing adenotonsillectomies have far more complaints than complications. Sore throats, dysphagia, and neck pain are frequent and expected symptoms after surgery. Differentiating these symptoms from early signs of severe cervical complications can be difficult. Such complications are rare but include atlanto-axial subluxation (Grisels syndrome), cervical necrotizing fasciitis, cervical emphysema and cervical oseteomyelitis. Due to the frequency with which adenotonsillectomies are performed, most otolaryngologists will encounter these events during their career. This article is thereby intended to elucidate the early warnings, appropriate diagnostic workup, and therapeutic modalities for cervical complications following adenotonsillectomies. Recent findingsEarly recognition and intervention can prevent devastating morbidity and mortality described with cervical complications. Computed tomography scanning remains the gold standard for diagnosing cervical complications after adenotonsillectomy. Although a range of severity exists in cervical complications, most cases can be managed conservatively with broad spectrum antibiotics, observation, bedrest and immobilization in cases of Grisels syndrome. Cervical necrotizing fasciitis requires a high index of suspicion and urgent management to avoid fatal consequences. SummaryThis is a review of the most frequently encountered, although rare, cervical complications following adenotonsillectomies. It gives the reader an insight into the efficient diagnosis and management of these complications.