Craig S. Derkay

Recurrent Respiratory Papillomatosis: A Review†

Recurrent respiratory papillomatosis (RRP), which is caused by human papillomavirus types 6 and 11, is the most common benign neoplasm of the larynx among children and the second most frequent cause of childhood hoarseness. After changes in voice, stridor is the second most common symptom, first inspiratory and then biphasic. Less common presenting symptoms include chronic cough, recurrent pneumonia, failure to thrive, dyspnea, dysphagia, or acute respiratory distress, especially in infants with an upper respiratory tract infection. Differential diagnoses include asthma, croup, allergies, vocal nodules, or bronchitis. Reports estimate the incidence of RRP in the United States at 4.3 per 100,000 children and 1.8 per 100,000 adults. Infection in children has been associated with vertical transmission during vaginal delivery from an infected mother. Younger age at diagnosis is associated with more aggressive disease and the need for more frequent surgical procedures to decrease the airway burden. When surgical therapy is needed more frequently than four times in 12 months or there is evidence of RRP outside the larynx, adjuvant medical therapy should be considered. Adjuvant therapies that have been investigated include dietary supplements, control of extra‐esophageal reflux disease, potent antiviral and chemotherapeutic agents, and photodynamic therapies; although several have shown promise, none to date has “cured” RRP, and some may have serious side effects. Because RRP, although histologicallybenign, is so difficult to control and can cause severe morbidity and death, better therapies are needed. The potential for a quadrivalent human papilloma vaccine is being explored to reduce the incidence of this disease.

Recurrent respiratory papillomatosis.

Recurrent respiratory papillomatosis (RRP) is the most common benign neoplasm of the larynx in children. Despite its benign histology, RRP has potentially morbid consequences and is often difficult to treat because of its tendency to recur and spread throughout the respiratory tract. Long neglected from an epidemiological standpoint, recent initiatives to better understand this disease process have been launched through coordination between the Centers for Disease Control and Prevention and the American Society of Pediatric Otolaryngology. In this clinical review, I discuss what we currently know regarding the etiology, epidemiology, and transmission of this disease. Clinical features including pertinent aspects of the history, physical examination, airway endoscopy, and other considerations are highlighted. A detailed description of the surgical and anesthetic management of these challenging cases is presented. Adjuvant modalities of surgical and nonsurgical treatment and their indications are discussed. Ongoing research initiatives and the Practice Guidelines of the Recurrent Respiratory Papillomatosis Task Force are also included.

Pediatric tracheotomies: changing indications and outcomes.

Objective/Hypothesis To study the outcomes and complications associated with pediatric tracheotomy, as well as the changing trend in indications and outcomes since 1970.

A Staging System for Assessing Severity of Disease and Response to Therapy in Recurrent Respiratory Papillomatosis

INTRODUCTION Recurrent respiratory papillomatosis (RRP) is a perplexing and frustrating disease for both the families it afflicts and the physicians who care for them. Although RRP is a benign disease of viral etiology (most commonly HPV types 6 and ll), it has potentially morbid consequences owing to its involvement of the airway and the risk of malignant conversion. Treatment of RRP has been mainly surgical over the past half century, relying on operative debulking, although adjuvant medical therapies have been utilized for recalcitrant cases. Among the most frustrating aspects of this disease is the observation that whereas some patients demonstrate limited disease with an infrequent need for intervention, others are confronted with recurrent airway compromise and a repeated need for laser surgery. Although it is considered the most common benign neoplasm of the larynx,l RRP is an orphan disease with an incidence in the United States estimated at between 1500 and 2500 new cases per year.2 Owing to the relative paucity of cases and the complicated nature of their treatment, the

Epidemiology of recurrent respiratory papillomatosis.

Larson DA, Derkay CS. Epidemiology of recurrent respiratory papillomatosis. APMIS 2010; 118: 450–454.

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.

Post-Tonsillectomy Morbidity and Quality of Life in Pediatric Patients with Obstructive Tonsils and Adenoid: Microdebrider vs Electrocautery

OBJECTIVES: To prospectively compare outcomes in children over age 2 with obstructive adenotonsillar hypertrophy when tonsillectomy is performed utilizing an intracapsular microdebrider technique versus low-wattage electrocautery technique. STUDY DESIGN AND SETTING: Prospective, single-blind, randomized controlled trial at a tertiary care childrens hospital. RESULTS: Among the 300 children, those treated with the microdebrider resumed normal activity faster, with a median recovery of 2.5 days, and stopped taking pain medication sooner, with the median time to the last dose of 4 days. The microdebrider group were 3 times more likely to no longer need pain medications at 3 days postoperatively and 2.5 times less likely to be still needing pain medication 7 days postoperatively. They were twice as likely to be at a normal activity level by 3 days postoperatively and were less likely to still not have attained normal activity and normal diet after 7 days. There was no difference between groups in median days to return to normal diet (3.0 to 3.5 days). At 1-month follow-up, children in the microdebrider group were 5 times more likely to have residual tonsil tissue. CONCLUSIONS: Intracapsular tonsillectomy in children with obstructive adenotonsillar hypertrophy results in improved peri-operative outcomes. Residual tonsil tissue is more common with use of the microdebrider; however, the incidence of future obstruction or infection is unknown. EBM rating: A-1b

Pediatric otolaryngology procedures in the United States: 1977–1987

Common pediatric otolaryngology inpatient procedures for the years 1977 through 1987 are analyzed utilizing data provided by the National Hospital Discharge Survey (NHDS) of the National Center for Health Statistics. The data available reveal that adenotonsillar surgery remains the most frequent inpatient surgical procedure performed on all children under age 15 in spite of a decline in both the total number of adenotonsillar procedures and the rate per 100,000 population of greater than two-fold over this 11 year period. The total number of myringotomies with and without insertion of ventilation tubes and the rate per 100,000 children also decreased by greater than threefold during the same time span. Although representative of inpatient, non-institutionalized health care, the NHDS suffers from its lack of data concerning surgery performed in freestanding, ambulatory surgical facilities and military hospitals.

Analyzing Factors Associated with Major Complications after Adenotonsillectomy in 4776 Patients: Comparing Three Tonsillectomy Techniques

Objective: To compare the rates of major complications (postoperative hemorrhage requiring return to the operating room or cauterization in the emergency department and dehydration requiring intravenous fluids or readmission) in a large cohort of children undergoing adenotonsillectomy by three different techniques. Study Design: Case series with chart review, case-controlled study. Setting: Regional childrens hospital. Subjects and Methods: Subjects comprised patients aged 1 to 18 years undergoing adenoidectomy, tonsillectomy, or adenotonsillectomy by microdebrider, coblator, or Bovie over a 36-month period. Major complications identified were compared to two case-matched controls to try to identify patients at risk for major postoperative complications. Results: The overall complication rate was 80 of 4776 (1.7 ± 0.4% [percent ± 95% confidence interval]). Of the 3362 patients who received either an adenotonsillectomy or tonsillectomy alone, 80 had a complication (2.3 ± 0.5%). Major complication rates differed among tonsil removal techniques: 34 of 1235 (2.8 ± 0.9%) coblation; 40 of 1289 (3.1 ± 0.9%) electrocautery; six of 824 (0.7 ± 0.7%) microdebrider (P < 0.001). Postoperative hemorrhage occurred in older children (8.5 vs 5.5 years; P < 0.001), while age did not influence postsurgical dehydration (5.33 vs 5.49 years). The case-control portion of the study did not find any reliable way to identify patients at risk for complications during adenotonsillectomy. Identity of the surgeon was not a confounding independent variable, nor was participation by resident surgeons. Conclusion: In this “real life” teaching hospital surgical setting in which three different techniques of tonsillectomy are routinely performed by a variety of resident and attending surgeons, microdebrider intracapsular tonsillectomy is associated with lower rates of post-tonsillectomy hemorrhage and dehydration when compared to coblation and electrocautery complete tonsillectomy technique.

Surfer's ear: External auditory exostoses are more prevalent in cold water surfers

OBJECTIVE: The study goal was to demonstrate the prevalence and severity of external auditory exostoses (EAEs) in a population of surfers and to examine the relationship between these lesions and the length of time surfed as well as water temperature in which the swimmers surfed. It was hypothesized that subjects who predominantly surfed in colder waters had more frequent and more severe exostoses. METHODS: Two hundred two avid surfers (91% male and 9% female, median age 17 years) were included in the study. EAEs were graded based on the extent of external auditory canal patency; grades of normal (100% patency), mild (66% to 99% patency), and moderate-severe (<66% patency) were assigned. Otoscopic findings were correlated with data collected via questionnaires that detailed surfing habits. RESULTS: There was a 38% overall prevalence of EAEs, with 69% of lesions graded as mild and 31% graded as moderate-severe. Professional surfers (odds ratio 3.8) and those subjects who surfed predominantly in colder waters (odds ratio 5.8) were found to be at a significantly increased risk for the development of EAEs. The number of years surfed was also found to be significant, increasing ones risk for developing an exostosis by 12% per year and for developing more severe lesions by 10% per year. Individuals who had moderate-severe EAEs were significantly more likely to be willing to surf in colder waters than were those who had mild EAEs (odds ratio 4.3). CONCLUSIONS: EAEs are more prevalent in cold water surfers, and additional years surfing increase ones risk not only for developing an EAE but also for developing more severe lesions.