David N. Madgy

The incidence of gastroesophageal reflux in recurrent croup.

The incidence of gastroesophageal reflux in recurrent croup was evaluated by a retrospective analysis of patients at the Childrens Hospital of Michigan from 1986 to 1991. Sixty-six patients required hospitalization for recurrent croup during this 6-year period. Of the patients evaluated, 47% with recurrent croup had an additional diagnosis established of gastroesophageal reflux. In patients with three or more hospitalizations for croup, there was a 63% association with gastroesophageal reflux. Compared to all patients with recurrent croup, the patients with gastroesophageal reflux tended to be younger and had a shorter interval between episodes of croup. A prospective series of six cases of recurrent croup was seen in consultation. The diagnostic procedures involving lipid-laden macrophage quantitation, endoscopy, and gastroesophageal reflux scintiscans were utilized to establish the diagnosis of gastroesophageal reflux with tracheal aspiration. The results of these studies and the follow-up is discussed.

Pediatric tracheotomy: A review of technique

It is well documented that the morbidity, mortality, and complication rates for pediatric tracheotomy are significantly higher than for adult tracheotomy. IF4 With trends toward performing pediatric tracheotomies in an increasingly premature population with less emergent indications, it is essential that techniques be reviewed for any factors that may reduce complications. At Children’s Hospital of Michigan, the same tracheotomy technique has been used since 1985. The technique and experience with 141 patients are reviewed.

Why does Adenotonsillectomy Not Correct Enuresis in All Children with Sleep Disordered Breathing

PURPOSE We analyzed the outcome of nocturnal enuresis after adenotonsillectomy in children with sleep disordered breathing. We also evaluated differences in demographic, clinical, laboratory and polysomnography parameters between responders and nonresponders after adenotonsillectomy. MATERIALS AND METHODS We prospectively evaluated children 5 to 18 years old diagnosed with sleep disordered breathing (snoring or obstructive sleep apnea syndrome) on polysomnography and monosymptomatic primary nocturnal enuresis requiring adenotonsillectomy to release upper airway obstruction. Plasma antidiuretic hormone and brain natriuretic peptide were measured preoperatively and 1 month postoperatively. RESULTS Sleep studies were done in 46 children and 32 also underwent blood testing preoperatively and postoperatively. Mean ± SD patient age was 8.79 ± 2.41 years and the mean number of wet nights weekly was 6.39 ± 1.26. Polysomnography revealed obstructive sleep apnea syndrome in 71.7% of patients and snoring in 28.3%. After adenotonsillectomy 43.5% of patients became dry. Preoperative polysomnography findings indicated that responders, who were dry, had significantly more arousals and obstructive apnea episodes but fewer awakenings than nonresponders, who were wet. Significant increases in plasma antidiuretic hormone and significant decreases in plasma brain natriuretic peptide were seen in all children with no difference between responders and nonresponders. No difference between the groups was noted in age, gender, race, body mass index, constipation, preoperative number of wet nights weekly or type of sleep disordered breathing. CONCLUSIONS Nocturnal enuresis resolved after adenotonsillectomy in almost half of the children with sleep disordered breathing. Those who became dry had more frequent arousal episodes caused by apnea events than those who remained wet.

Esophagoscopy for removal of foreign bodies in the pediatric population.

A retrospective chart review of children who had rigid esophagoscopy for potential foreign body ingestion from 1998 to 2001 was conducted at Childrens Hospital of Michigan Detroit. All pediatric patients less than 11 years of age who presented with suspected foreign body ingestion in a hospital setting over a 4-year period were retrospectively studied. Patient characteristics noted included age, sex and clinical presentation. Pre-operative radiographic findings, esophagoscopy findings, clinical presentations and types of foreign bodies were recorded. A history compatible with foreign body ingestion dictates diagnostic endoscopy with or without radiographic confirmation, and an acceptable rate of performing esophagoscopy without finding a foreign body was found to be 6.2%.

An analysis of the inferior based tracheal flap for pediatric tracheotomy.

In the past, various tracheotomy incisions have been used at the Childrens Hospital of Michigan with the occurrence of complications related to accidental decannulation and immediate recannulation. Since that time the inferior based tracheal cartilage flap has been used to minimize early complications. A retrospective study of 126 pediatric tracheotomies performed at the Childrens Hospital of Michigan from June 1986 to January 1991 was reviewed. Only tracheotomies performed by a staff otolaryngologist utilizing the inferior based tracheal cartilage flaps were reviewed. This study includes patients with a 6 month to 5 year follow up. The early complication rate was 4%, while the late was 50%. Stomal granulation tissue was comparatively increased in this series of patients but did not hinder decannulation. We consider the use of the inferior based tracheal cartilage flap in the pediatric population a safe and effective technique without increasing the morbidity of long-term tracheotomy.

A simple surgical technique using the plasma hook for correcting acquired nasopharyngeal stenosis.

INTRODUCTION Obstructive sleep apnea related to postsurgical scarring does not usually respond to continuous positive airway pressure therapies. In cases with mild scarring, some success has been observed with triamcinolone acetonide injections, but essentially, the only curative treatments for acquired nasopharyngeal stenosis (NPS) are surgical. All of these procedures are highly individualized and can be complex to perform; they are also associated with a significant recurrence rate. We propose a new, simple surgical approach for treating acquired NPS using the plasma radiofrequency-based (coblation) Plasma Hook (ArthroCare Corp., Sunnyvale, CA). Similar devices have been used successfully in otolaryngology for adenotonsillectomy, soft palate reduction, and inferior turbinate reduction. All three of our patients had severe NPS, demonstrating a classic clinical history consistent with problematic obstructive symptoms, including chronic mouth breathing, excessively loud snoring, and apneic episodes.

Pediatric tracheotomy discharge teaching: a comprehensive checklist format

Discharge planning for a child undergoing a tracheotomy is a complex process. In 1989, a multidisciplinary team at Childrens Hospital of Michigan developed specific discharge criteria in a checklist format to address all facets of home care for these patients. We present and discuss the checklist. A survey of user satisfaction with the checklist demonstrated that 80% of parents and care-givers felt well-prepared by this format at the time their child was discharged from the hospital with a new tracheotomy. We conclude that the protocol allows for comprehensive and efficient discharge teaching of parents and care-givers for children with new tracheotomies.

Adenotonsillectomy Normalizes Hormones and Urinary Electrolytes in Children With Nocturnal Enuresis and Sleep-Disordered Breathing.

OBJECTIVE To assess (1) plasma levels of antidiuretic hormone (ADH) and brain natriuretic peptide (BNP) and urinary levels of electrolytes in children with sleep disordered breathing (SDB), with or without nocturnal enuresis (NE), and (2) the effect of adenotonsillectomy (T&A) on urinary electrolytes and the secretion of ADH and BNP in children with NE and SDB. We previously reported post-T&A improvements in plasma levels of BNP and ADH in children with SDB and NE. However, the differences in plasma concentration of these hormones in SDB children with and without NE, and their relationships with urinary electrolytes, have not yet been addressed. METHODS This prospective study compared concentrations of urinary electrolytes and plasma ADH and BNP in (1) children with SDB and NE (study group) and an age- and sex-matched control group of children with SDB without NE, and (2) the study group before and 1-month after T&A. RESULTS Compared with the control group (n = 31), the study group (n = 37) exhibited significantly lower ADH (P = .04) and higher BNP (P = .009) plasma levels. The differences in urinary electrolytes were not significant. Post-T&A, the study group showed significantly decreased BNP (P = .018), urinary sodium-to-creatinine ratio (P = .02), and urinary calcium-to-creatinine ratio (P = .007) compared with the pre-T&A values. Post-T&A changes in urinary calcium were significantly correlated with changes in sodium excretion (P = .002) and in plasma levels of BNP (P <.001). CONCLUSION The presence of NE is associated with altered ADH and BNP levels in children with SDB. T&A led to normalization of ADH and BNP, probably through a calcium- and sodium-dependent mechanism.

Adenotonsillectomy improves quality of life in children with sleep-disordered breathing regardless of nocturnal enuresis outcome

BACKGROUND Nocturnal enuresis (NE) and sleep-disordered breathing (SDB) have both been associated with impaired health-related quality of life (HRQoL). The following were investigated: (1) whether tonsillectomy and/or adenoidectomy (T&A) significantly affect the HRQoL in children with NE and SDB, and 2) differences in HRQoL between children with NE persistence versus resolution post-T&A. METHODS This was a prospective study comparing the HRQoL of children with SDB and NE (study group) pre- and 4 weeks post-T&A, and the HRQoL of children with SDB without NE (control group) (independent t-tests). HRQol was assessed using the Obstructive Sleep Apnea Quality of Life 18 questionnaire (OSAS-18), a validated measure containing five subscales that combine to create a total score. Individual items were scored on a Likert-type scale ranging from 1 (none of the time) to 7 (all of the time). Symptoms of SDB were evaluated using the validated Pediatric Sleep Questionnaire (PSQ). Mixed ANOVA was conducted to evaluate changes in the measures between the wet and dry children post-T&A. Pre- and post-T&A change scores were calculated for both the PSQ and the OSAS-18. RESULTS There were 30 children in the study group (18 male, mean age 9.07 years, SD 2.19), and 30 age-matched controls (16 male). There were no statistically significant differences between the two groups in regards to OSAS-18 total, PSQ total, BMI, diagnosis of snoring or OSAS on sleep study, or race. Overall, OSAS-18 and PSQ scores significantly improved in all children post-surgery (p < 0.001; p < 0.001, respectively), with no significant differences between dry and wet children post-T&A. The correlation between the pre- and post-T&A change scores on the OSAS-18 and PSQ was significant (r(29) = 0.58, p = 0.001), suggesting that a reduction in SDB symptoms post T&A is related to improved HRQoL. CONCLUSIONS T&A significantly improved HRQoL in all children with SDB and NE, regardless of NE outcomes. These findings support recommendations for T&A in children with SDB with or without NE.

FloSeal with Adenotonsillectomy to Prevent Adverse Outcomes

Objective: The aim of study was to compare the postoperative complications associated with adenotonsillectomy with or without the application of FloSeal at the completion of the procedure in 2 similar groups. Method: This retrospective study was performed at a tertiary care pediatric hospital between January 2007 and December 2008, for OSA and chronic tonsillitis in patients between 1 and 18 years old. Eight hundred patients underwent adenotonsillectomy in an identical manner, with half reciving FloSeal intraoperatively. Outcomes measured were: hemorrhage, return to OR, and dehydration. Results: Age ranged from 1 to 18 years. Male gender was found to have a slight predominance without statistical significance (χ2 = 0.01, P = .93). Preoperative diagnosis was more commonly OSA (79.9%) compared to chronic tonsillitis (20.1%). Primary bleed rate was found to occur in 2 subjects (0.3%); 1 FloSeal and 1 No FloSeal subject (χ2 = 0.004, P = .95). Secondary bleeding was seen in 18 subjects (2.5%); 11 FloSeal and 7 No FloSeal (χ2 = 1.32, P = .25). Dehydration was seen in 51 subjects (7.1%); 24 FloSeal and 27 No FloSeal (χ2 = 0.01, P = .92). The need for return to OR was seen in 7 subjects (1%); 5 FloSeal and 2 No FloSeal (χ2 = 1.59, P = .21). Conclusion: In our experience, the application of FloSeal hemostatic matrix after monopolar adenotonsillectomy demonstrates no additional reduction in postoerative complications encountered in the pediatric population.