D.M. Albert

The changing indications for paediatric tracheostomy

OBJECTIVE To investigate whether the incidence and indications for paediatric tracheostomy in this unit have changed over recent years. METHODS All paediatric tracheostomies performed between 1993 and 2001 were identified from our departmental database. The indications for these were ascertained by retrospective case note review. RESULTS Over the 9-year period studied 362 tracheostomies were performed, the number increased slightly between the first and second half of the period, with peaks in 1997 and 1999. The commonest indication was prolonged ventilation due to neuromuscular or respiratory problems. CONCLUSIONS This large series shows that the increase in frequency of paediatric tracheostomy performed in this unit over the past decade has been due to conditions such as subglottic and tracheal stenosis, respiratory papillomatosis, caustic alkali ingestion and craniofacial syndromes. Conditions in which tracheostomy are now less common are subglottic haemangioma and laryngeal clefts. Prolonged ventilation remains the commonest indication overall.

Updated surgical experience with bone-anchored hearing aids in children.

BACKGROUND We present the results of a retrospective review of children undergoing implantation with bone-anchored hearing aids (BAHAs) at the Great Ormond Street Hospital for Children. METHODS The case notes of 71 children undergoing BAHA placement at the Great Ormond Street Hospital for Children between December 1990 and August 2002 were reviewed. Outcome measures included hearing thresholds, incidence of fixture loss, skin reaction and need for revision. Quality of life outcomes were also measured. RESULTS Eighty-five ears had been implanted. Fifty-four per cent of children had experienced no complications, 42 per cent had required revision surgery and 26 per cent had experienced fixture loss at some point. Young age at implantation was associated with an adverse outcome. Trauma and failure of osseointegration had been the commonest reasons for failure. A skin reaction around the abutment had occurred at some point in 37 per cent of children but had persisted for longer than six months in only 9 per cent; this had been associated with fixture loss. The use of fixture site split skin grafts had reduced problems with skin hypertrophy and hair overgrowth. Hearing thresholds when using BAHAs had been comparable to those when using bone conduction hearing aids. However, BAHAs had significant additional benefits in terms of sound quality, ease of use and overall quality of life. CONCLUSION Bone-anchored hearing aids provide significant benefits over other types of hearing aid, both audiologically and in terms of quality of life. Careful selection of candidates and meticulous follow up are required in order to minimize complications.

Surgical Experience With Bone-Anchored Hearing Aids In Children†

Titanium osseointegrated implants for boneanchored hearing aids (BAHAs) have been in use since 1977. A series of 32 children who received implantation since 1990 is reported. The report focuses on the surgical aspects of BAHAs, predisposing factors, and prevention of complications in an unusual pediatric population. The records of 32 children who had undergone two‐stage implantation of a BAHA were retrospectively reviewed. The majority of the patients had craniofacial abnormalities. Of the 32 implantees, 29 use their BAHA at present. Five children failed to achieve osseointe‐gration, and eight patients have had revision surgery for lost abutments, trauma, or chronic skin problems. There were no differences between preimplantation and postimplantation bone or air conduction thresholds. The pediatric BAHA carries with it a unique set of challenges and problems but can be successfully implanted and maintained.

Management and outcome of choanal atresia correction

OBJECTIVES Outcome analyses of factors that may either maximize success or predict a better outcome following choanal atresia correction. METHODS A retrospective review of children undergoing choanal atresia correction at Great Ormond Street Hospital for Children, London between January 1990 and April 1998. Children with unilateral or bilateral choanal atresia were studied. In all cases, correction was by a transnasal approach under endoscopic control. A 120 degrees Hopkins rod telescope was used to visualize the atretic plate from the nasopharynx. Straight urethral sounds were used to perforate the plate followed by use of an air drill to remove the bony component. Portex endotracheal tubes were subsequently inserted as nasal stents. RESULTS Sixty-five children (19 M, 46 F: age range 1 day to 17 years) presented with choanal atresia and the outcomes for 46 were included in the study. Twenty-six patients (40%) had other major anomalies. In children with unilateral atresia neither duration of stenting nor presence of facial anomalies had an impact on outcome. Of those children with bilateral choanal atresia and associated facial anomalies (n=9), 56% were asymptomatic following correction. In children with isolated bilateral choanal atresia (n=19), 74% were asymptomatic following correction; 29% (n2.3 kg (n3. 5 mm (n=6) had an 83% chance of a good outcome. Those patients stented with a tube </=3.5 mm (n=22) had only a 64% success rate. None of the patients who were stented for at least 12 weeks remained symptomatic. CONCLUSIONS Neonates with bilateral choanal atresia who were stented for at least 12 weeks with the largest Portex tube that comfortably passed through the anterior nares had the best outcome. If they had either associated anomalies or low weight at surgery, they were less likely to become asymptomatic. For patients with unilateral choanal atresia, neither the presence of facial anomalies nor stent duration had an impact on outcome.

Branchial anomalies in children

BACKGROUND Branchial cleft anomalies are the second most common head and neck congenital lesions seen in children. Amongst the branchial cleft malformations, second cleft lesions account for 95% of the branchial anomalies. This article analyzes all the cases of branchial cleft anomalies operated on at Great Ormond Street Hospital over the past 10 years. METHODS All children who underwent surgery for branchial cleft sinus or fistula from January 2000 to December 2010 were included in this study. RESULTS In this series, we had 80 patients (38 female and 42 male). The age at the time of operation varied from 1 year to 14 years. Amongst this group, 15 patients had first branchial cleft anomaly, 62 had second branchial cleft anomaly and 3 had fourth branchial pouch anomaly. All the first cleft cases were operated on by a superficial parotidectomy approach with facial nerve identification. Complete excision was achieved in all these first cleft cases. In this series of first cleft anomalies, we had one complication (temporary marginal mandibular nerve weakness. In the 62 children with second branchial cleft anomalies, 50 were unilateral and 12 were bilateral. In the vast majority, the tract extended through the carotid bifurcation and extended up to pharyngeal constrictor muscles. Majority of these cases were operated on through an elliptical incision around the external opening. Complete excision was achieved in all second cleft cases except one who required a repeat excision. In this subgroup, we had two complications one patient developed a seroma and one had incomplete excision. The three patients with fourth pouch anomaly were treated with endoscopic assisted monopolar diathermy to the sinus opening with good outcome. CONCLUSION Branchial anomalies are relatively common in children. There are three distinct types, first cleft, second cleft and fourth pouch anomaly. Correct diagnosis is essential to avoid inadequate surgery and multiple procedures. The surgical approach needs to be tailored to the type of anomaly of origin of the anomaly. Complete excision is essential for good outcomes.

Laryngeal ultrasound to assess vocal fold paralysis in children

The purpose of this study was to assess the practicality and validity of laryngeal ultrasound to establish vocal fold movement in children with suspected vocal fold palsy. Fifty-five consecutive patients (age range three days to 12 years) with suspected vocal fold palsy underwent both laryngoscopy and laryngeal ultrasound. Ultrasonographic findings correlated with endoscopic findings in 81.2 per cent of cases. This, however, rose to a concordance rate of 89.5 per cent in patients aged over 12 months. Laryngeal ultrasound is well-tolerated, safe and non-invasive and the authors feel that it is a useful adjunct to endoscopy in the diagnosis of vocal fold palsy.

Subglottic cysts: the Great Ormond Street experience

OBJECTIVE Subglottic cysts are a relatively rare, non-malignant cause of airway obstruction. In this study we reviewed the details of the patients who were treated for subglottic cysts in our department in order to evaluate the presentation and treatment of patients with this condition. METHODS We performed a retrospective case note analysis of 55 patients with subglottic cysts. Case notes were examined to determine the following details for each patient: date of birth, gestational age at birth, history and length of intubation, age at presentation, presenting symptoms, findings on endoscopy, treatment given for subglottic cysts, recurrence(s) of cysts after initial treatment, and follow up for a minimum of 6 months post diagnosis. RESULTS Fifty five patients were identified, 35 male, 20 female. Ninety four percent were born prematurely at 24-31 weeks gestation. All patients were intubated in the neonatal period. The median duration of intubation for all patients was 10 days (range 1-126). Fifty one patients underwent intervention for their subglottic cysts at their initial, diagnostic microlaryngoscopy and bronchoscopy (MLB), and recurrent cysts occurred in 22 cases. A total of 82 procedures for cyst removal were performed, using either the carbon dioxide laser or microinstruments. Subglottic stenosis was a commonly associated feature in our series of patients, being present in 38 patients. Eleven of the 14 patients who presented to our department with tracheostomies in situ were decannulated after removal of their subglottic cysts. CONCLUSIONS This review of the largest series of patients with subglottic cysts reported to date, reinforces our view that such cysts are rare but potentially reversible causes of upper airway obstruction, and that they result from injury to the larynx as a result of endotracheal intubation. Treatment of the cysts will often be sufficient to correct the obstructed airway allowing successful extubation or decannulation of a tracheostomy. Patients who have had subglottic cysts treated should have access to long-term follow up as there is a tendency for these cysts to recur.

A review of the current management of infantile subglottic haemangioma, including a comparison of CO2 laser therapy versus tracheostomy

OBJECTIVES We reassessed the current practice and treatment options used in the management of subglottic haemangiomas (SGHs), including the place for open submucosal surgical excision, and have compared the results of different therapeutic modalities used for SGHs. METHODS The two studies were conducted as separate exercises; (1) a retrospective review of 36 patients collected over a recent 8-year period to assess the current practice and treatment options in use; (2) a retrospective comparative study of a previous cohort of 51 patients with SGHs treated in one of four groups: (a) tracheostomy alone, (b) tracheostomy and CO(2) laser, (c) systemic steroids and CO(2) laser (no tracheostomy) and (d) intralesional steroid injection, CO(2) laser therapy, or both, followed by intubation. RESULTS Systemic steroids were the most commonly used modality of treatment. Resolution of the SGH was achieved in 89% of cases at a mean follow up duration of 34 months. However, tracheostomy was required in 58% of cases, with a mean time from diagnosis to decannulation of 30 months. The time to resolution of SGHs does not appear to be reduced by laser therapy compared with treatment by tracheostomy alone. Intralesional steroid injection or laser therapy together with intubation was associated with avoidance of a tracheostomy in 66% of cases. Single-stage open surgical excision in two cases resulted in successful resolution of the SGH and discharge after a mean follow up period of 3 months. CONCLUSIONS Despite the more widespread use of steroids and other treatment modalities, the requirement for tracheostomy has remained unchanged over the last 20 years. The use of laser therapy does not appear to confer any additional therapeutic benefit over and above tracheostomy alone in bringing about resolution of SGHs. Systemic steroids may reduce the size of the haemangioma but are associated with multiple adverse effects. The decision to use the above techniques must, therefore, be made in the light of these observations. Our early experience of single-stage excision suggests that this technique represents an exciting and promising surgical alternative, and its more widespread adoption may be the only way of further improving the outcome of patients with SGHs.

Tuberculous mastoiditis: when is surgery indicated?

Mycobacterium tuberculosis is a rare cause of mastoiditis, but diagnosis is often delayed, with potentially serious results. We present the case of a 7-year-old child who failed to improve even once the diagnosis was made and appropriate medical treatment initiated. At mastoidectomy, a bony sequestrum was found which had not been evident on CT scanning. We review the diagnosis and management of this condition and suggest that failure to respond to drug therapy even in the absence of demonstrable complications be added to the list of indications for surgical intervention.

Peri-operative complications after adenotonsillectomy in a UK pediatric tertiary referral centre.

OBJECTIVES Adenoidectomy and/or tonsillectomy are commonly performed in tertiary pediatric hospitals for the management of obstructive sleep apnea, often in children with significant comorbidities. This study examines the peri-operative course of a large series of complex patients undergoing such surgery at a major pediatric centre, reporting particularly cases of respiratory compromise requiring intensive care admission, both electively and unplanned. METHODS This study was conducted by the pediatric ENT department at Great Ormond Street Hospital. All children undergoing adenoidectomy and/or tonsillectomy from July 2003 to December 2010 were included in this study. This involved a retrospective review of the case notes and hospital databases, with particular emphasis on those children requiring admission to the pediatric intensive care unit. RESULTS A total of 1735 consecutive admissions for adenoidectomy and/or tonsillectomy (1627 individual patients aged 4-197 months, median 46 months) were included between 2003 and 2010 (998 adenotonsillectomies, 182 tonsillectomies and 555 adenoidectomies). In this group, 999/1627 patients (61.4%) had a diagnosis of sleep disordered breathing or sleep apnea, including 258 who had polysomnography. 407/1627 (25.0%) had no specific comorbidities which were felt likely to influence their surgical outcome. Established high risk factors included age less than 24 months (292), Down syndrome (99), neuromuscular problems (314), craniofacial abnormalities (94), storage diseases (23), morbid obesity (20), cardiovascular disease (133), respiratory disease (261), hemoglobinopathy (76) and coagulophathy (34). 300/1735 admissions were day cases and 1082/1735 were observed for one night. 353/1735 required more than one night in hospital (294 for two to three nights). 7/1735 had primary hemorrhage necessitating return to the operating room, all after tonsillectomy. 41/1735 (38 with major comorbidities) required peri-operative intensive care admission, mostly for respiratory support. Of these, 7 were admitted pre-operatively to intensive care, and 17 were planned post-operative transfers. Only 17/1735 required unanticipated post-operative admission to intensive care. Odds ratio analysis suggested a significantly higher chance of PICU admission in children with particular comorbidities (Down Syndrome, cardiac disease, obesity, cerebral palsy, craniofacial anomalies, mucopolysaccharidoses and hemoglobinopathy) when compared to children without comorbidities. Adenotonsillectomy was associated with a higher risk of PICU admission than adenoidectomy alone, but patient age less than 24 months was not associated with significantly higher rates of PICU admission. There were no peri-operative mortalities in this cohort. CONCLUSIONS The peri-operative course was largely uneventful for the majority of children undergoing surgery during this period, particularly given the high prevalence of sleep apnea and other risk factors in this cohort. Major complications were uncommon, with 2.4% of these selected, typically high risk cases requiring peri-operative intensive care admission. Importantly, only 1% of all admissions required unanticipated transfer to intensive care. This has informed changes in peri-operative management in this unit, with implications for other pediatric tertiary referral centres.