Christopher J. Hartnick

Clinical consensus statement: tracheostomy care.

Objective This clinical consensus statement (CCS) aims to improve care for pediatric and adult patients with a tracheostomy tube. Approaches to tracheostomy care are currently inconsistent among clinicians and between different institutions. The goal is to reduce variations in practice when managing patients with a tracheostomy to minimize complications. Methods A formal literature search was conducted to identify evidence gaps and refine the scope of this consensus statement. The modified Delphi method was used to refine expert opinion and facilitate a consensus position. Panel members were asked to complete 2 scale-based surveys addressing different aspects of pediatric and adult tracheostomy care. Each survey was followed by a conference call during which results were presented and statements discussed. Results The panel achieved consensus on 77 statements; another 39 were dropped because of lack of consensus. Consensus was reached on statements that address initial tracheostomy tube change, management of emergencies and complications, prerequisites for decannulation, management of tube cuffs and communication devices, and specific patient and caregiver education needs. Conclusion The consensus panel agreed on statements that address the continuum of care, from initial tube management to complications in children and adults with a tracheostomy. The panel also highlighted areas where consensus could not be reached and where more research is needed. This consensus statement should be used by physicians, nurses, and other stakeholders caring for patients with a tracheostomy.

Prevalence of Noise-Induced Hearing-Threshold Shifts and Hearing Loss Among US Youths

OBJECTIVE: We investigated trends in noise-induced threshold shifts (NITSs), high-frequency hearing loss (HFHL), and low-frequency hearing loss (LFHL). METHODS: A total of 4310 adolescents 12 to 19 years of age completed audiometric testing during National Health and Nutrition Examination Surveys in 1988–1994 and 2005–2006. NITS criteria were audiometric patterns of decreased 3- to 6-kHz thresholds but preserved 0.5- to 1-kHz and 8-kHz thresholds; HFHL and LFHL criteria were high and low pure-tone averages, respectively, of >15 dB HL. RESULTS: There were no significant increases in NITSs (odds ratio [OR]: 0.81 [95% confidence interval [CI]: 0.53–1.22]; P = .29), HFHL (OR: 1.21 [95% CI: 0.87–1.69]; P = .25), or LFHL (OR: 1.37 [95% CI: 0.77–2.45]; P = .28) between survey periods. However, a significant increase in the prevalence of NITSs occurred among female youths (11.6% [95% CI: 9.0%–14.1%] vs 16.7% [95% CI: 13.2%–20.3%]; P < .0001). The overall prevalence of exposure to loud noise or listening to music through headphones in the previous 24 hours increased from 19.8% (95% CI: 17.6%–22.1%) to 34.8% (95% CI: 31.0%–38.5%; P < .0001). In 2005–2006, female youths had a similar prevalence of exposure to recreational noise (23.6% [95% CI: 19.6%–27.6%] vs 27.7% [95% CI: 23.6%–31.8%]; P < .0001) and a lower prevalence of hearing-protection use (3.4% [95% CI: 1.6%–5.3%] vs 10.3% [95% CI: 7.3%–13.2%]; P < .0001) compared with male youths. CONCLUSIONS: Increased exposure to recreational noise and minimal use of hearing protection might have lead to an increase in NITS prevalence among female youths.

Congenital laryngeal anomalies. Laryngeal atresia, stenosis, webs, and clefts.

The physician who is called upon to evaluate stridor in the newborn must be familiar with common congenital lesions of the larynx. Congenital stridor is a symptom of an underlying problem that must be accurately diagnosed to be properly and effectively managed. This requires a complete history and physical examination to discover the type of stridor and its association with feeding difficulties or cyanosis. Careful evaluation of the cry is important. Radiologic examinations are of great value in providing additional information concerning laryngeal anomalies. The mainstay of diagnosis is endoscopic examination. Familiarity with these anomalies, their symptoms, diagnostic methods, and treatment will provide for better care of the pediatric patient with stridor.

Development and Maturation of the Pediatric Human Vocal Fold Lamina Propria

Objective: To identify characteristic patterns of maturation of the human vocal fold lamina propria as it develops into a mature structure.

Initial experience using propranolol as the sole treatment for infantile airway hemangiomas

The objective of this study is to describe the initial use of propranolol as the sole treatment for focal infantile airway hemangiomas, and to report on available literature describing the use of propranolol for airway lesions. This retrospective case series was carried out at a tertiary pediatric medical center. We obtained the following results: two children demonstrated significant response to oral propranolol therapy and avoided not only invasive surgical procedures, but also long-term administration of oral corticosteroids. This is the first report of treating infantile airway hemangiomas with only propranolol without additional surgical intervention or corticosteroid use. Review of literature reveals initial case series with similar, successful results using propranolol as an adjuvant treatment along with other medications and surgical interventions. We conclude that the initial use of propranolol as the sole treatment for infantile airway hemangioma is promising. Literature review reveals that propranolol as the sole treatment for most head and neck hemangiomas shows significant promise based on early case reports. Further studies are needed to determine the long-term effectiveness, dosing strategies, and side effect profile of propranolol treatment for hemangiomas.

NEUROTROPHIC EFFECTS OF BDNF AND CNTF, ALONE AND IN COMBINATION, ON POSTNATAL DAY 5 RAT ACOUSTIC GANGLION NEURONS

The neuronal survival promoting ability of brain derived neurotrophic factor (BDNF), and ciliary neurotrophic factor (CNTF), individually and in combination, was evaluated in dissociated cell cultures of postnatal day 5 (P5) rat acoustic ganglia. The neuritogenic promoting effect of these same neurotrophic factors was examined in organotypic explants of P5 rat acoustic ganglia. The results showed that BDNF was maximally effective at a concentration of 10 ng/mL in promoting both survival and neuritogenesis of these postnatal auditory neurons in vitro. CNTF was maximally effective at a concentration of 0.01 ng/mL at promoting both survival and neuritogenesis in the acoustic ganglion cultures. BDNF had its strongest effect on neuronal survival while CNTF was most effective in stimulating neurite outgrowth. These two neurotrophic factors, when added together at their respective maximally effective concentrations, behave in an additive manner for promoting both survival and neuritic outgrowth by the auditory neurons.

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.

NT-3 combined with CNTF promotes survival of neurons in modiolus-spiral ganglion explants

AUDITORY neurons depend upon the integrity of both their peripheral (auditory hair cells) and central (cochlear nucleus) targets for survival. One proposed trophic mechanism is the production of neurotrophin-3 (NT-3) by auditory hair cells. Modiolus-spiral ganglion explants from adult rats that closely mirror cell-cell interactions and in vivo tissue relationships within this ganglion provide a model for testing trophic factors. Brain derived neurotrophic factor (BDNF), NT-3 and ciliary neuro-trophic factor (CNTF) were tested for their ability, both individually and in combination, to support neuronal survival. NT-3 was the strongest individual promoter of survival, while CNTF (a cytokine) with NT-3 (a neurotrophin) was the most effective combination for promoting the survival of auditory neurons.

Surgery for Pediatric Vocal Cord Paralysis: A Retrospective Review

To determine the outcome of surgical procedures for bilateral vocal cord paralysis in children, we performed a retrospective review of children under 18 years of age with bilateral vocal cord paralysis and a previous tracheotomy who underwent a primary procedure at a single tertiary care institution with an aim of decannulation. The primary outcome measure was the operation-specific decannulation rate (OSDR). The overall decannulation rates, as well as morbidity rates, were also recorded. Fifty-two children met the inclusion criteria (mean age at time of primary surgery, 6.2 years; SD, 5 years). Vocal cord lateralization procedures combined with a partial arytenoidectomy achieved the highest OSDR (17/24 or 71%). This OSDR was statistically higher than the OSDRs for CO2 laser cordotomy or arytenoidectomy procedures (OSDR, 5/17 or 29%, p = .008), for isolated arytenoidopexy procedures (OSDR, 1/4 or 25%, p = .000004), or for posterior costal cartilage graft procedures (OSDR, 3/5 or 60%, p = .0004). Neither of the 2 children who underwent isolated arytenoidectomy achieved primary decannulation. The incidence of aspiration following posterior cartilage graft procedures was 15% (2/15). Subanalysis by age failed to reveal differences in OSDR. We conclude that vocal cord lateralization procedures with partial arytenoidectomy afford the highest OSDR among primary procedures for pediatric vocal cord paralysis. The CO2 laser procedures, while having limited success as a primary procedure, are effective for revision.

Pediatric fiberoptic endoscopic evaluation of swallowing.

Pediatric dysphagia is the presenting feature of many underlying diagnoses. Between July 1993 and July 1999, 643 fiberoptic endoscopic evaluations of swallowing (FEES) were performed on 568 patients. The median age of the population was 2.5 years (range, 3 days to 21 years). The principal medical and surgical diagnoses of the patients at the time of presentation to the FEES clinic were prospectively recorded: 36% of the patients presented with a diagnosis of structural abnormalities of the upper aerodigestive tract or airway; 26% with neurologic diagnoses; 12% with gastroenterological disorders; 8% with genetic syndromes; 7% with pulmonary dysfunction; 5% with prematurity; 3% with cardiovascular anomalies; and 2% with metabolic problems. The patients were classified according to the following feeding regimens: 9% normally fed; 38% orally fed with limitations; 13% orally fed, but with required supplemental tube feedings; and 40% prohibited from taking nutrition orally. The FEES enabled the following classification of feeding abnormalities: 15% had normal feeding; 56% exhibited behavioral abnormalities, including sensory-based feeding disorders; 15% exhibited structural abnormalities; 16% exhibited neurologic abnormalities; 1.5% exhibited metabolic abnormalities; and 0.5% exhibited cardiorespiratory abnormalities. The unique aspects of pediatric dysphagia are highlighted, and the role of FEES in the workup of this challenging aspect of pediatric otolaryngology is discussed.