Colin Barber

Cervical lymphadenitis due to non-tuberculous mycobacteria: surgical treatment and review

A retrospective study was carried out on 57 children, presenting with non-tuberculous mycobacterial (NTM) lymphadenitis of the head and neck, over a 12 year period. Cultures recovered 56 Mycobacterium avium-intracellulare (MAI), and one Mycobacterium kansasaii. Anti-mycobacterial agents were used in seven patients only. On the basis of the initial operation there were two groups. Group 1 (11 patients) had an excision, and Group 2 (46 patients) had incision and drainage (30 patients), incision and curettage (13 patients), or aspiration (three patients). There was no significant difference in the makeup of these two groups. However, Group 1 had significantly lower number of re-operations than Group 2, P<0.01, and achieved a significantly greater healing rate than Group 2, P<0.001. In Group 2 those who had an excision following failure of the first operation were significantly more likely to heal than those who did not, P<0. 005. Operative excision gives a lower rate of re-operation, and a higher rate of healing than other procedures. The treatment, natural history, clinical presentation, pathogenesis, and diagnosis of NTM cervical lymphadenitis are discussed.

Prospective Study of Subglottic Stenosis in Intubated Neonates

Although numerous retrospective studies have attempted to investigate the incidence, etiology, and pathogenesis of subglottic stenosis, there have been few prospective studies. The retrospective studies focused initially on diagnosed cases, then drew inferences regarding incidence and causality based upon data obtained from review of patient records. In contrast, this prospective study accrued data on all neonates intubated for 48 hours or longer during the 1-year intake period. There were 195 neonates entered in the study; then 36 were excluded, leaving 159 for data analysis. Parameters assessed included age at intubation (mean, 5.7 days), duration of intubation (mean, 12.3 days), and number of times reintubated (mean, 0.79). Results of this prospective study are compared to results from previous retrospective studies.

Tracheal Reconstruction Using Irradiated Homologous Grafts in Rabbits

Management of tracheal stenosis Is troublesome and challenging. Numerous techniques have been used in the past with varying success. The technique of irradiated homograft tracheal cartilage transplantation shows promise for the future in the area of tracheal reconstruction.

What is behind the ear drum? The microbiology of otitis media and the nasopharyngeal flora in children in the era of pneumococcal vaccination

This study aims to describe the microbiology of middle ear fluid (MEF) in a cohort of children vaccinated with Streptococcus pneumoniae conjugate vaccine (PCV7) having ventilation tube insertion. Nasopharyngeal (NP) carriage of otopathogens in these children is compared with children without history of otitis media.

Treatment of subglottic hemangiomas with propranolol: initial experience in 10 infants.

Background:  Subglottic hemangiomas (SGH) are a rare tumour, often associated with significant airway obstruction in infants. Current treatment options, while effective, often expose the infant to potential complications. Emerging evidence suggests a role for the beta blocker propranolol in the initial management of SGH.

A heuristic approach to foreign bodies in the paediatric airway

OBJECTIVES This retrospective study reviews the clinical presentation and management of children with airway FBs in our centre. It suggests a safe and reliable guideline to help differentiate which patients should proceed to investigation with rigid laryngobronchoscopy. METHODS A retrospective review of all case notes of laryngobronchoscopies performed for suspected FB aspiration from January 2003 to August 2013 at a tertiary paediatric institution was undertaken. Patient characteristics, history, clinical examination, radiological findings and outcomes were analysed. RESULTS 158 patients underwent rigid laryngobronchoscopy for suspected FB aspiration between January 2003 and August 2013. The baseline population demographics, the location and type of FBs retrieved were comparable to other similar studies; however, there is a statistically significant higher proportion of Pacific, Maori and Middle Eastern/Latin American/African children compared with the baseline population. Two or more positive findings in the presence of an acute history, any examination or radiology findings is a good indicator to proceed to laryngobronchoscopy with over 99% sensitivity. CONCLUSION In a hospital presentation population, this retrospective study suggests that a guideline to proceed to laryngobronchoscopy in a case of suspected FB aspiration is two out of the three positive findings in the presence of an acute history, any examination or radiology findings. Patients who are stable and who do not have two of the three broad category findings can be considered for conservative management and observed on the ward, however, this is a guideline and must be combined with the clinical expertise of the paediatric airway specialist. Further studies are recommended to investigate contributing factors for the disproportionately higher incidence amongst Pacific, Maori and Middle Eastern/Latin American/African children.

Congenital aberrantly located cutaneous Stensen's duct orifice—a newly described anomaly

A case of a child born with an aberrant, cutaneous Stensens (parotid) duct orifice and ipsilateral preauricular skin tags is reported. This congenital anomaly has been reported in the medical literature only once previously. Possible explanations for pathogenesis of this unusual anomaly are discussed and a simple method of surgical correction is described.

Endoscopic resection of neonatal nasopharyngeal teratoma.

Teratomas are benign tumour in which totipotent cells escape the normal restraints on growth and development. These rare tumours occur at a prevalence of 1 in 4000 births. Teratomas develop most commonly in the sacrococcygeal area, with fewer than 2% occuring in the head and neck region. Nasopharyngeal teratomas are very uncommon, there being fewer than 20 cases published in the English literature to date. The mother of the patient to be discussed was a healthy 39-year-old Caucasian primigravida who at 32 weeks’ gestation was recognized on routine ultrasound to have polyhydramnios. Repeat ultrasound at 34 weeks revealed a cervical mass and so an intrauterine magnetic resonance imaging (MRI) scan was performed, which demonstrated a large obstructing mass within the pharynx. After careful planning, a Caesarian section was performed at 37 weeks. An ex-utero intrapartum tracheostomy was performed immediately after delivery of the head and neck through the abdominal wound (Fig. 1). The nose and oral cavity were filled with tumour. A biopsy was performed in the early neonatal period, and the histopathological differential diagnosis included teratoma and hairy polyp. Apost-partum MRI scan was performed (Fig. 2), and a first debulking of the tumour was undertaken on day 23 of life (weight 3.3 kg). The oral component of the tumour (Fig. 3) was excised and the nasal and nasopharyngeal components were debulked endoscopically. Histology confirmed grade II immature teratoma containing squamous, respiratory and enteric mucosa, as well as fibrous tissue, bone, cartilage, neuroglial and retinal tissue, and 20% immature cells. Two further endoscopic operations were performed over a seven and a half month period. The single complication was when the right internal carotid was punctured in the nasopharynx while tumour was being cleared from tissue around it. Haemostasis was achieved by passing vessel loops around the common carotid artery which controlled bleeding sufficiently to allow bipolar diathermy of the vessel wall and placement of a muscle patch. Subsequently performed magnetic resonance angiography scans were normal. The last MRI scan was essentially normal, with no evidence of residual tumour 3 months after the final operation. At age 17 months, the infant boy is developing normally. Nasopharyngeal teratomas have been traditionally approached externally via a number of routes including transpalatal, transcervical and lateral rhinotomy. A cadaveric study by Baird et al. assessed surgical access of the craniocervical junction via endoscopic oral, nasal and cervical approaches, and concluded endonasal and oral routes allowed wide exposure with large working angles. The advent and subsequent advances in both endoscopic technology and techniques have led to an alternative to open surgery as illustrated by this report. Transoral and transnasal endoscopic

Long-standing inhaled foreign bodies in children: Characteristics and outcome

OBJECTIVE Aspirated foreign bodies in children present a potentially life-threatening condition and can be challenging to diagnose. This study aims to elucidate the characteristics and outcome of children with long-standing aspirated foreign bodies. METHODS Retrospective case series of all cases of confirmed long-standing aspirated foreign bodies (LSAFB) between January 2003 to December 2015 in a single paediatric tertiary-level institution, defined as more than two weeks from choking episode or beginning of symptoms. RESULTS Clinical files and operative records on 227 patients were screened and 35 children were confirmed to have been treated for LSAFB as per definition above. Median time to presentation was 4 weeks (mean 8.8 weeks). Eighty-six percent presented with cough and 51% with dyspnoea. Abnormal chest X-ray findings were found in 28 out 31 patients (90%). Organic foreign bodies (22) were more common than inorganic (14). Intraoperative granulation tissue was demonstrated in 89% of patients and in 46% of patients this was regarded as significant (defined as obstructing more than 50% of the involved airway lumen). Mean length of stay was 2.5 days. Nine patients (26%) had 11 respiratory complications; there were no mortalities. CONCLUSIONS Paediatric LSAFB poses an uncommon diagnostic dilemma as there is often no witnessed history of aspiration event; and signs, symptoms and chest X-Ray findings are often non-specific. Laryngobronchoscopy is made more difficult by the presence of granulation tissue and the sequelae of prolonged non-treatment is a higher rate of chronic respiratory disease.

Retrotracheal Extraskeletal Ewing’s Sarcoma: Case Report and Discussion on Airway Management

Extraskeletal Ewings sarcoma is a rare tumor, and the management of airway compromise in case of cervical Ewings sarcoma has not been established. This report describes the case of a patient with retrotracheal Ewings sarcoma and discusses a successful approach to airway management. A 12-year-old male presented with a 2-week history of sore throat and sleep-disordered breathing and 48 hours of stridor. Imaging confirmed a retrotracheal soft tissue mass with airway compromise. A planned and controlled approach to his airway management resulted in a secure airway prior to definitive treatment.