David J. Beste

Pediatric External Auditory Canal Foreign Bodies: A Review of 698 Cases:

OBJECTIVE: The study goal was to determine the relationships between patient management factors and patient outcomes in pediatric patients with external auditory canal foreign bodies. STUDY DESIGN AND SETTING: Retrospective analysis was conducted of 698 consecutive cases of pediatric external auditory canal foreign bodies (n = 605 patients) who presented to a tertiary care pediatric referral center during a 6-year period. RESULTS: Emergency physicians frequently removed foreign bodies under direct visualization while otolaryngologists primarily used otomicroscopy. Both of these methods had high success rates overall (77% and 86%), but attempts under direct visualization had lower success rates with removing spherical objects, objects touching the tympanic membrane, and objects in the canal for more than 24 hours. Failed removal attempts resulted in higher complication rates. CONCLUSION: Certain foreign body and patient characteristics are associated with poor outcomes with removal attempts made under direct visualization. These cases should be referred directly to otolaryngologists for otomicroscopic removal.

Pierre Robin Sequence: Secondary Respiratory Difficulties and Intrinsic Feeding Abnormalities

Objective: There is considerable variation in opinion regarding the optimal management of patients with Pierre Robin sequence (PRS). No single method of airway intervention or feeding strategy is universally appropriate and effective. This study was performed to examine methods used for airway and feeding management and to identify specific problems encountered.

Mediastinitis associated with foreign body erosion of the esophagus in children

OBJECTIVE Timely and experienced intervention for esophageal foreign bodies generally allows for removal with minimal morbidity. However, esophageal foreign bodies present a risk for esophageal perforation and subsequent mediastinitis, especially if the diagnosis of the foreign body is delayed. Although much has been written about the management of esophageal foreign bodies and their complications, little has been mentioned in recent literature about the specific complication of mediastinitis. This review was performed to examine our experience with this uncommon complication of esophageal foreign bodies. METHODS A retrospective review of the esophageal foreign body database at Childrens Hospital of Wisconsin from 1987 to 1997 was performed to identify patients with esophageal foreign bodies and subsequent mediastinitis. RESULTS Four patients with esophageal perforation with associated mediastinitis secondary to retained esophageal foreign bodies were identified. Three of the four patients were treated with conservative measures consisting of foreign body removal, intravenous antibiotics and discontinuing of oral nutrition. These patients all achieved resolution of their mediastinitis and esophageal perforation with subsequent return to normal diets and no significant morbidity. One patient, with vascular erosion, required aggressive, invasive therapy. CONCLUSION From review of this limited number of patients, in the absence of major vascular erosion, conservative methods of treating children with foreign body esophageal perforation and subsequent mediastinitis appears to be effective.

Gastroesophageal reflux complicating choanal atresia repair

Four infants with bilateral congenital choanal atresia (CCA) underwent transpalatal (3) or transnasal (1) repairs. Postoperatively all four infants experienced gastroesophageal reflux (GER) with intermittent nasal reflux. GER was documented by GER radionuclide scanning in one patient and by dual nasopharyngeal and esophageal pH probe studies in the remaining three patients. The infants with documented GER required prolonged stenting and dilations for choanal restenosis and granulations. The literature emphasizes the importance of the technical repair for prevention of these complications; GER can be a significant complicating factor.

Recovery of vocal fold immobility following isolated patent ductus arteriosus ligation

OBJECTIVE Identify laryngoscopic and functional outcomes of infants with vocal fold immobility (VFI) following patent ductus arteriosus (PDA) ligation and identify predictors of recovery. METHODS Retrospective review of patients with VFI following PDA ligation from 2001 to 2012 at a single institution. Inclusion criteria were: (1) PDA ligation as only cardiac surgical procedure; (2) left VFI documented by laryngoscopy; (3) minimum follow up 120 days, with at least 2 laryngoscopies performed. Resolution of VFI was determined at follow-up laryngoscopy. Univariate logistic regression models were used to identify variables associated with VFI recovery. RESULTS 66 subjects were included with median follow up of 3.0 (± 2.1) years. The mean gestational age was 24.5 ± 1.4 weeks, mean birth weight 673 ± 167 g, and mean age at procedure was 18.6 ± 14.3 days. Patients presented with respiratory symptoms (39%), dysphonia (78%) and dysphagia (55%). Resolution of VFI was observed in 2/66 (3%) patients. Recovery was documented at 20 days and 11 months respectively. Respiratory symptoms, dysphagia, and dysphonia persisted at last follow up in 11%, 47%, and 20% of patients. CONCLUSIONS VFI associated with ligation of the ductus arteriosus has a low rate of recovery. Clinical symptoms frequently persist, and as such regular follow-up by otolaryngologists to mitigate morbidity is indicated.

Laryngeal involvement in toxic epidermal necrolysis.

Toxic epidermal necrolysis (TEN) represents the most severe form of Stevens-Johnson syndrome (SJS), a mucocutaneous reaction most frequently related to medication use. Mucosal involvement of the oral cavity is a diagnostic criterion of SJS, and involvement of the tracheobronchial mucosa has also been well-documented. To our knowledge, epiglottitis associated with TEN has been reported only once previously. I We report a case of an 8-year-old boy in whom epiglottitis in progression from SJS to TEN developed; we also provide a brief discussion of this clinical entity.

Clinical characteristics of aero-digestive foreign bodies in neurologically impaired children

OBJECTIVE To determine if children with neurological impairment are at additional risk for foreign body aspiration or impaction and if they present with a different clinical course than normal children. DESIGN Retrospective cohort study. SETTING Tertiary care childrens hospital. PATIENTS AND OTHER PARTICIPANTS A retrospective chart review of 328 consecutive procedures for aero-digestive foreign body removal over a 6 year period was performed. Of these patients 52 (15.9%) were identified with neurological impairment. RESULTS Compared with the non-impaired children, those with neurological impairment were older, diagnosed later, hospitalized longer and had a higher incidence of complications. CONCLUSION A greater index of suspicion is needed to timely treat aero-digestive foreign bodies in children with neurological impairment. These children may not be receiving the necessary attention when presenting with non-specific symptoms.

Interleukin-1 receptor antagonist as an adjunct in the treatment of Haemophilus influenzae otitis media in the chinchilla.

Objectives This purpose of this study was to investigate the effect of blockade of the inflammatory cytokine pathway on experimentally induced otitis media in the chinchilla model.

Otitis media in infants aged 0-8 weeks: Frequency of associated serious bacterial disease

OBJECTIVE To determine the frequency of serious bacterial infection in well appearing infants aged 0-8 weeks with isolated otitis media (OM). METHODS Infants with confirmed OM underwent tympanocentesis with middle ear fluid (MEF) culture and complete sepsis evaluation. Enrolled infants were admitted to the hospital for parenteral antibiotics until blood, urine, and CSF cultures were negative for 48 hours. RESULTS Forty non-toxic appearing infants were enrolled between January 1994 and April 1995, of whom 15 (38%) had a documented rectal temperature > or =38 degrees C. Bacterial pathogens were isolated from MEF cultures in 25 (62.5%) infants. All afebrile infants had negative blood, urine, and cerebrospinal fluid cultures (upper limit (UL) 95% CI 0.11). Only two febrile infants had positive cultures from sites other than the MEF (UL 95% CI 0.36). CONCLUSION In our study population, previously healthy, non-toxic appearing afebrile infants aged 2-8 weeks and having isolated OM infrequently have an associated serious bacterial infection, suggesting that outpatient treatment with oral antibiotics and close follow-up may be an option. Further studies with large numbers of infants are necessary to confirm this conclusion.

Massive blood loss during tonsillectomy in a child with congenital venous malformation

Tonsillectomy and adenoidectomy have become frequently performed outpatient procedures and are generally considered to have a low morbidity profile. Postoperative haemorrhage remains a rare but important complication, while intraoperative uncontrollable bleeding is extremely uncommon. A child with congenital vascular malformation of the lip and oropharynx undergoing tonsillectomy experienced massive blood loss, subsequent resuscitation and significant perioperative morbidity including a prolonged intensive care unit stay. Preoperative/preanaesthetic nasopharyngoscopic exam and magnetic resonance imaging did not reveal vascular prominence of the tonsils. Preoperative consideration of angiography or magnetic resonance angiography may be prudent to avoid this potentially fatal complication.