David S. Leonard

Cautery-assisted palatal stiffening operation for the treatment of obstructive sleep apnea syndrome

Cautery-assisted palatal stiffening operation (CAPSO) is a recently developed single office-based procedure performed with local anesthesia for the treatment of palatal snoring. A midline strip of soft palate mucosa is removed, and the wound is allowed to heal by secondary intention. The flaccid palate is stiffened, and palatal snoring ceases. This prospective study evaluated the ability of CAPSO to treat obstructive sleep apnea syndrome (OSAS). Twenty-five consecutive patients with OSAS underwent CAPSO. Responders were defined as patients who had a reduction in apnea-hypopnea index (AHI) of 50% or more and an AHI of 10 or less after surgery. By these strict criteria, 40% of patients were considered to have responded to CAPSO. Mean AHI improved from 25.1 ± 12.9 to 16.6 ± 15.0 (P = 0.010). The Epworth Sleepiness Scale, a subjective measure of daytime sleepiness, improved from 12.7 ± 5.6 to 8.8 ± 4.6 (P < 0.001). These results indicate that CAPSO is as effective as other palatal surgeries in the management of OSAS.

Prospective trial of the ultrasonic dissector in thyroid surgery.

Use of the ultrasonic dissector in thyroid surgery is becoming more prevalent, with reduced operative time and incision size reported. We assessed the value of the harmonic scalpel in routine thyroid lobectomy.

Neonatal respiratory distress secondary to bilateral intranasal dacryocystocoeles

Obstruction of the nasolacrimal duct is a common congenital abnormality reported in up to 84% of neonatal patients [J. Yohendran, A.C. Wignall, E.J. Beckenham, Bilateral congenital dacryocystocoeles with concurrent intranasal mucocoeles causing respiratory distress in a neonate, Asian J. Surg. 29 (2) (2006) 109-111; M.J. Cunningham, J.J. Woog, Endonasal endoscopic dacryocystorhinostomy in children, Arch. Otolaryngol. Head Neck Surg. 124 (1998) 328-333; D. Guery, E.L. Kendig, Congenital impotency of the nasolacrimal duct, Arch. Ophthalmol. 97 (1979) 1656-1658]. Rarely, obstruction results in the development of an intranasal lacrimal duct cyst, or dacryocystocoele, which arises inferolateral to the inferior turbinate [H.R. Jin, S.O. Shin, Endoscopic marsupialisation of bilateral lacrimal sac mucoceles with nasolacrimal duct cysts, Auris Nasus Larynx 26 (1999) 441-445]. These lesions can cause nasal obstruction and, when bilateral, significant respiratory compromise. We present the case of a 3-day-old infant with bilateral intranasal lacrimal duct cysts causing nasal obstruction and intermittent respiratory compromise. The diagnosis was suspected on clinical examination and confirmed on MRI. The patient was successfully managed by bilateral endoscopic marsupialisation and probing of the nasolacrimal ducts. We also present a review of the literature surrounding investigation and management of intranasal lacrimal duct cysts.

The effect of gastric decompression on postoperative nausea and emesis in pediatric, tonsillectomy patients.

Nausea and vomiting is a common and distressing event following surgery [1], and can significantly impact on the postoperative course following adenotonsillectomy or tonsillectomy. Postoperative emesis may lengthen hospital stay, and can potentially cause electrolyte imbalance, aspiration of gastric contents or bleeding [2–5]. In addition to the effect on individual patients, protracted postoperative recoveries for elective pediatric patients have financial implications for the health service. The physiology of the reflex pathways involved in nausea and vomiting is complex and incompletely understood [6,11]. The afferent and efferent pathways involved in the initiation of vomiting are linked to an area in the medulla oblongata, known as the vomiting centre. In addition to afferent stimuli from the cerebral cortex and the chemoreceptor trigger zone (located in the area postrema), the vomiting centre also responds to afferents from the viscera such as gastric irritation or stasis causing distension. Therefore, anti-emetic drugs consist of many neurotransmitter antagonists and may act in the periphery, the CNS or both sites. This includes drugs acting at muscarinic, dopamine D2, 5-HT3, neurokinin NK1 and histamine H1 receptors [11]. Indeed recent advances in the understanding of the pathophysiological states induced by any surgical intervention have revealed that a multimodality approach is essential to the modern prophylactic

Membranous band of a first branchial cleft anomaly

Athree-year-old girl presented with fever and a slowly enlarging left neck mass over a period of one week. Physical examination revealed a 3 3 cm, erythematous, tender, and fluctuant mass inferior to the mandibular ramus (Fig A1A; available online at: www.otojournal.org). Laboratory studies showed a leukocytosis of 21,700. Owing to concerns for imminent spontaneous rupture, the abscess was managed surgically. Preoperative CT imaging demonstrated a tubular, rim-enhancing fluid collection originating at the inferior border of the external auditory canal (EAC) and extending inferiorly over the parotid gland and into the submandibular space (Fig A1B; available online at: www.otojournal.org). Otomicroscopy prior to the incision and drainage revealed a membranous band between the left tympanic membrane (TM) and the EAC floor (Fig 1), confirming the diagnosis of a first branchial cleft anomaly. Institutional review board approval is not required by our institution for this submission.

A convenient, practical adapter for bronchotracheoscopy through a tracheostomy tube in a ventilator-dependent patient

Pediatric intensivists caring for patients with tracheostomies will frequently request an otolaryngology evaluation for any patient with new-onset bleeding from the tracheostomy site. Fiberoptic visualization of the bronchotracheal tree to assess for a source of bleeding is a required aspect of this evaluation. However, in the pediatric intensive care unit (PICU) setting, many patients have poor pulmonary function, often because of extreme prematurity and consequent bronchopulmonary dysplasia, and require high ventilator settings to maintain adequate oxygenation. These patients cannot tolerate more than a few moments without ventilatory support. The adverse cardiopulmonary effects of disrupting delivery of ventilatory support to ventilator-dependent patients have been well documented in the critical care literature in studies investigating the consequences related to heart and lung function of disconnecting intubated neonates from ventilator support for pulmonary toilet, and performing bronchoscopy in intubated adult patients and lung models. Accordingly, intensivists must weigh the benefits and drawbacks of all interventions involving ventilator disruption. Historically intensivists have benefited from the use of “elbow” attachments to the external end of an endotracheal or tracheostomy tube to minimize the loss of ventilator pressures during bronchoscopy. These adapters provide the endoscopist with a third port containing a one-way valve that permits bronchoscope passage while maintaining a high level of ventilatory support. The much smaller caliber of the nasopharyngoscope (NPS), however, has precluded otolaryngologists from effectively using these attachments and has correspondingly limited the time allowed for bronchotracheoscopy in critically ill children. In these instances, the hurried examination frequently consists of a “quick look” at the airway with the NPS through the tracheostomy tube while the patient is completely disconnected from the ventilator. The endoscopy must oftentimes rapidly end as the patient’s oxygen saturation and cardiopulmonary status begins to decline. Alternative means of revising the “elbow” adapters used for bronchoscopy have unfortunately enjoyed limited success. In an effort to provide otolaryngologists with better tools for thorough examinations of the bronchotracheal tree in tracheostomy patients requiring high ventilator settings, we have begun modifying the Ballard Trach Care Elbow (Kimberly-Clark, Roswell, GA), a disposable piece of respiratory care equipment readily available in most PICUs. Our modification of these tracheostomy care elbows creates an analogous version of the elbows used for bronchoscopy with a much smaller third port opening. Accordingly, these adapters are ideal for use with the NPS.

Laryngotracheobronchitis complicated by spontaneous pneumomediastinum.

Spontaneous pneumomediastinum (SPM) is an unusual clinical entity that most frequently follows episodes of increased intrathoracic pressures. While typically a benign condition, potentially fatal complications of SPM must be considered and ruled out with each case. We aim to present the first case of croup-associated SPM in the otolaryngology literature and to discuss clinical, diagnostic and management principles. Days following the diagnosis of viral croup, a 7-year-old asthmatic girl presented with unstable vital signs and severe SPM. The patient was urgently taken to the operating room for an endoscopic airway evaluation, which revealed only a mild bacterial croup superinfection. Conservative treatment with inpatient monitoring and antibiotic therapy successfully resolved the episode. SPM should be immediately considered in the differential diagnosis of any patient presenting with cervical emphysema, especially in association with asthma, cough or strenuous activity. Following exclusion of other causes of SPM, conservative and supportive therapies are the mainstays of SPM management.