Charles M. Myer

Proposed grading system for subglottic stenosis based on endotracheal tube sizes.

The classification of airway stenoses has been a problem for many years. As a result, both intradepartmental and interdepartmental comparisons of airway sizes remain difficult. It follows that comparisons of therapeutic maneuvers are even more difficult. A system is proposed that is simple, reproducible, and based on a readily available reference standard. Endotracheal tubes, which are manufactured to high standards of precision and accuracy, can be used to determine the size of an obstructed airway at its smallest point. The endotracheal tube that will pass through the lumen, if one exists, and tolerate normal leak pressures (10 to 25 cm H2O), can be compared to the expected age-appropriate endotracheal tube size. By using the outside diameters of the endotracheal tubes, the maximum percentage of airway obstruction can be determined. We present a conversion of tube size to the proposed grading scale: grade I up to 50% obstruction, grade II from 51% to 70%, and grade III above 70% with any detectable lumen. An airway with no lumen is assigned to grade IV.

Activity-Adjusted 24-Hour Ambulatory Blood Pressure and Cardiac Remodeling in Children with Sleep Disordered Breathing

Questions remain as to whether pediatric sleep disordered breathing increases the risk for elevated blood pressure and blood pressure–dependent cardiac remodeling. We tested the hypothesis that activity-adjusted morning blood pressure surge, blood pressure load, and diurnal and nocturnal blood pressure are significantly higher in children with sleep disordered breathing than in healthy controls and that these blood pressure parameters relate to left ventricular remodeling. 24-hour ambulatory blood pressure parameters were compared between groups. The associations between blood pressure and left ventricular relative wall thickness and mass were measured. 140 children met the inclusion criteria. In children with apnea hypopnea index <5 per hour, a significant difference from controls was the morning blood surge. Significant increases in blood pressure surge, blood pressure load, and in 24-hour ambulatory blood pressure were evident in those whom the apnea hypopnea index exceeded 5 per hour. Sleep disordered breathing and body mass index had similar effect on blood pressure parameters except for nocturnal diastolic blood pressure, where sleep disordered breathing had a significantly greater effect than body mass index. Diurnal and nocturnal systolic blood pressure, diastolic blood pressure, and mean arterial blood pressure predicted the changes in left ventricular relative wall thickness. Therefore, sleep disordered breathing in children who are otherwise healthy is independently associated with an increase in morning blood pressure surge, blood pressure load, and 24-hour ambulatory blood pressure. The association between left ventricular remodeling and 24-hour blood pressure highlights the role of sleep disordered breathing in increasing cardiovascular morbidity.

Congenital nasal pyriform aperture stenosis.

Congenital nasal pyriform aperture stenosis is an unusual and previously undescribed cause of nasal airway obstruction in the newborn. The nasal pyriform aperture is narrowed due to bony overgrowth of the nasal process of the maxilla. This anomaly may produce signs and symptoms of nasal airway obstruction in newborns and infants similar to those seen in bilateral posterior choanal atresia. Computed tomography confirms the diagnosis and delineates the anomaly. A series of six patients with nasal pyriform aperture stenosis is presented. Four patients were treated with surgical enlargement of the nasal pyriform aperture via a sublabial approach. One patient was repaired via a transnasal approach, and one patient did not undergo surgical intervention. Follow‐up reveals normal nasal airway and facial growth in all patients. Mildly symptomatic patients with congenital nasal pyriform aperture stenosis may be treated expectantly, while severely symptomatic patients benefit from repair via the sublabial approach.

Pediatric laryngotracheal reconstruction with cartilage grafts and endotracheal tube stenting: The single‐stage approach

Laryngotracheal reconstruction (LTR) comprises five stages: 1, characterization of the stenosis; 2, expansion of the lumen; 3, stabilization of the enlarged lumen framework; 4, healing of the surgical site; and 5, decannulation. Single‐stage LTR (SS‐LTR) combines and compresses stages 3 through 5 (stabilization, healing, and decannulation) into a brief period of postoperative intubation.

Complications of adenotonsillectomy in children under 3 years of age.

Adenotonsillectomy in children may be performed safely on an outpatient basis in the majority of cases without an increase in complication rates. However, very young children comprise a unique patient subpopulation with regard to adenotonsillar surgery. Surgical indications in older children tend to be dominated by chronic recurrent infections, whereas younger children usually require surgery for chronic upper airway obstruction related to adenotonsillar hypertrophy. This study was undertaken to evaluate the adenotonsillectomy patient population under 3 years of age. Complication rates related to airway problems, hemorrhage, and dehydration were determined. Children under 3 years of age demonstrated an increased incidence of postoperative airway complications, manifested by oxygen desaturation and transient upper airway obstruction. It is recommended that adenotonsillectomy be performed on such patients on an inpatient basis with close postoperative monitoring including pulse oximetry.

Pediatric Aerodigestive Foreign Body Injuries Are Complications Related to Timeliness of Diagnosis

Foreign body (FB) injury from aspiration or ingestion is a common pediatric health problem. Diagnosis relies on clinical judgment plus medical history, physical examination, and radiographic evaluation. A multi‐institutional review of 1269 FB events revealed that 85% were correctly diagnosed following a single physician encounter. However, 15% of the children had an elusive diagnosis(>1 week), despite previous evaluation. Delays in diagnosis were seven times more likely to occur in aspirations than in ingestions. Secondary injuries(e.g., pneumonia and atelectasis) occurred in 13% of airway FBs but in only 1.7% of esophageal FBs. Plain radiographs were used in 82% of children, and special studies (e.g., fluoroscopy) in only 7%. We conclude that diagnosis of FB injury in children is frequently achieved at the initial evaluation but that continued surveillance by follow‐up visits to health care facilities from parents and other caretakers is important, to reduce pulmonary injuries.

Laryngeal and laryngotracheoesophageal clefts: role of early surgical repair.

An uncommon congenital anomaly of the developing aerodigestive tract is the congenital laryngeal cleft and its extension, the congenital laryngotracheoesophageal (LTE) cleft. Because of the subtle findings sometimes seen with clefts confined to the larynx, the diagnosis may be difficult. The potential problems of airway obstruction and repeated aspiration frequently associated with laryngeal and LTE clefts mandate early surgical repair. Over the past 3 years, 14 patients with congenital laryngeal or LTE clefts have been managed at Childrens Hospital Medical Center, Cincinnati, Ohio. This report details our experience and philosophy regarding the diagnosis and management of the condition, and presents the histopathologic findings of a case of complete LTE cleft in which surgical repair was delayed and death resulted.

Surgery for Pediatric Subglottic Stenosis: Disease-Specific Outcomes

To set the foundation to develop a disease-based, operation-specific model to predict the outcome of pediatric airway reconstruction surgery, we performed a retrospective database review of children operated on at a single, tertiary-care childrens hospital. Over the 12-year period 1988 to 2000, a total of 1,296 airway reconstruction procedures were performed. Out of these, charts were identified for 199 children who underwent laryngotracheal reconstruction for a sole diagnosis of subglottic stenosis. Children were excluded from the study if their disorder included supraglottic, glottic, or upper tracheal disease. The main outcome measures were Myer-Cotton grade-specific decannulation and extubation rates, including both operation-specific and overall results. There were 101 children who underwent double-stage laryngotracheal reconstruction. The operation-specific decannulation rates for Myer-Cotton grades 2, 3, and 4 were 85% (18/21), 37% (23/61), and 50% (7/14) (χ2 analysis, p =.0007). The overall decannulation rates were 95% (20/21), 74% (45/61), and 86% (12/14) (χ2 analysis, p =.04). There were 98 children who underwent single-stage laryngotracheal reconstruction. The operation-specific extubation rates for Myer-Cotton grades 2, 3, and 4 were 82% (37/45), 79% (34/43), and 67% (2/3) (χ2 analysis, p =.63). The overall extubation rates were 100% (45/45), 86% (37/43), and 100% (3/3) (χ2 analysis, p =.03). Logistic regression analysis showed no effect of age (less than or greater than 2 years of age) on operation-specific or overall outcome parameters. We conclude that laryngotracheal reconstruction for pediatric subglottic stenosis remains a challenging set of procedures in which multiple operations may be required to achieve eventual extubation or decannulation. Children with Myer-Cotton grade 3 or 4 disease continue to represent a significant challenge, and refinements of techniques are being examined to address this subset of children. Disease-based, operation-specific outcome statistics are the first step in the development of a meaningful predictive model.

Second Primary Tumors in Head and Neck Cancer Patients

XAVIER LEÓN, ALFIO FERLITO, CHARLES M. MYER III, UMBERTO SAFFIOTTI, ASHOK R. SHAHA, PATRICK J. BRADLEY, MARGARET S. BRANDWEIN, MATTI ANNIKO, RAVINDHRA G. ELLURU and ALESSANDRA RINALDO From the Department of Otolaryngology, Hospital de Santa Creu i Sant Pau, Barcelona, Spain, Department of Otolaryngology—Head and Neck Surgery, University of Udine, Udine, Italy, Department of Pediatric Otolaryngology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland , USA, Head and Neck Service, Memorial Sloan–Kettering Cancer Center, New York, New York, USA, Department of Otorhinolaryngology —Head and Neck Surgery, Queen’s Medical Centre, Nottingham, UK, Department of Otolaryngology and Pathology, Mount Sinai School of Medicine, New York, New York, USA and Department of Otolaryngology—Head and Neck Surgery, University Hospital, Uppsala, Sweden

Voice problems after pediatric laryngotracheal reconstruction: videolaryngostroboscopic, acoustic, and perceptual assessment

Children with laryngotracheal stenosis undergo laryngotracheal reconstruction (LTR) to permit tracheostomy decannulation. We conducted voice assessments of 8 pediatric LTR patients with voice problems. Perceptual ratings and acoustic measures were taken in 5 patients and videolaryngoscopy/laryngostroboscopy was conducted in all 8. Results of perceptual evaluation were abnormal for hoarseness, breathiness and pitch. Acoustic analysis revealed a markedly decreased fundamental frequency of phonation, diminished frequency range, decreased vocal intensity, and shortened maximum phonation time. Videolaryngostroboscopic findings are summarized as follows: 2 patients had severe glottal insufficiency, 3 patients had vocal fold asymmetry in stiffness and position, and 3 patients demonstrated phonation using supraglottal structures. Use of the stroboscope contributed to diagnosis in 3 of 8 patients. Reverse (inhalatory) phonation was observed in three patients. Concomitant articulation problems were exhibited frequently. Sentence production was shortened by the decreased phonatory duration. When coupled with the abnormal voice quality, speech intelligibility was significantly affected. Voice problems following decannulation were observed to persist as a long-term difficulty in some LTR patients.