David S. Parsons

Mucociliary Clearance and Buffered Hypertonic Saline Solution

Nasal irrigations have been used for centuries without any scientific data to determine efficacy. For 10 years, the senior author has used buffered hypertonic saline nasal irrigation for patients with acute/chronic sinusitis and for those having undergone sinus surgery. A simple study was undertaken using volunteers without any significant sinonasal disease. Patients served as their own control using a saccharin clearance test before any nasal irrigation was used. Patients then used one of two solutions to irrigate their nose‐buffered normal saline or buffered hypertonic saline‐and were then retested. On a separate day, the control test was repeated, followed by irrigation with the alternate solution and a second saccharin clearance test. The outcome showed buffered hypertonic saline nasal irrigation to improve mucociliary transit times of saccharin, while buffered normal saline had no such effect.

Functional endoscopic surgery in children: a retrospective analysis of results.

The impact of chronic sinusitis on children has become more apparent as the awareness of the disease has increased. Consequently, the knowledge of its effect in the pediatric patient has expanded dramatically. Functional endoscopic sinus surgery (FESS) has become the primary surgical modality for treatment of this illness in children who have not responded to optimal medical management. A retrospective study was conducted in patients from 7 months to 17 years of age who were treated with FESS for chronic sinusitis refractory to medical therapy. Using a comprehensive parental questionnaire and a review of the medical charts, results were analyzed from these post‐FESS children. Parents of the children were interviewed with a mean follow‐up time of 21.8 months postoperatively. Factors discussed included chronic nasal obstruction, purulent nasal discharge, postnasal drip, chronic cough, halitosis, headaches, behavioral problems, allergies, and asthma symptoms. This preliminary investigation suggests that FESS is effective in treating medically recalcitrant severe chronic sinusitis in children.

Functional Endoscopic Sinus Surgical Outcomes for Contact Point Headaches

Headaches secondary to sinonasal anatomic abnormalities continue to remain a difficult entity to diagnose and to manage. This retrospective study analyzed the outcome of care for 34 patients who presented with headaches as one of their primary sinonasal complaints and were subsequently found to have contact points between the nasal septum and one or more turbinates on nasal endoscopy and/or computed tomography scan. Following functional endoscopic sinus surgery to relieve the contact points, these patients were interviewed regarding preoperative and postoperative intensity and frequency of the headaches and the overall response of the chronic sinusitis and headaches to surgery, after a mean follow‐up period of 13.9 months. After surgery, reduction in intensity and frequency of headaches was experienced in 91% and 85% of the patients, respectively. This investigation demonstrates that surgical management of contact point headaches can make a significant impact on the headache symptomatology in children and adults.

The results of functional endoscopic sinus (FES) surgery on the symptoms of patients with cystic fibrosis

The relationship between cystic fibrosis (CF) and sinus disease has been appreciated since at least 1959. Unfortunately the standard methods used to treat sinus disease have been very unrewarding in the CF patients. We evaluated the long-term results achieved on 17 patients with CF that underwent FES surgery between July 1988 and January 1991. This group consisted of 16 pediatric and 1 adult patients with previously diagnosed CF, documented chronic sinus disease and nasal polyposis that had failed long-term maximal medical management. The patients, or their parents, were contacted and asked to rate the severity and frequency of their symptoms associated with chronic sinus disease, pre- and postoperatively. The specific symptoms evaluated were nasal obstruction, nasal discharge, postnasal drip, halitosis and cough. In addition, we attempted to measure the number of hospitalizations and the presence and frequency of headaches. We were able to show that, while there was no change in the relative health of patients as measured by the number of hospitalizations, there was a significant improvement in the quality of life. There was a marked decline in the frequency of nasal obstruction, nasal discharge and postnasal drip and a high level of patient satisfaction with the procedure. No changes were seen in the frequency or nature of the cough, halitosis or headache.

Type I Posterior Laryngeal Clefts

Posterior laryngeal clefts (PLCs) are described in the literature as rare laryngeal abnormalities. The authors believe type I clefts are much more common than previously reported. In two busy pediatric tertiary care centers, such clefts are the second most common congenital laryngeal finding at rigid endoscopy, second only to laryngomalacia. PLCs frequently present with symptomatology that can be attributed to other common disease processes and are often undiagnosed unless the surgeon maintains a high index of suspicion and specifically examines the posterior glottis by palpation during microlaryngoscopy. This report presents a series of 41 patients with type I PLCs, reviews their subtle and often confusing presenting signs and symptoms, and describes a simple yet reliable method of diagnosis.

Tracheal reconstruction with polytetrafluoroethylene graft in dogs

Use of prosthetic materials for long-segment tracheal reconstruction has been limited owing to infection, graft migration, ingrowth of fibrous tissue, and stenosis. Polytetrafluoroethylene (PTFE) is flexible and porous, and it may resist infection more than previously used materials. We evaluated PTFE for use in long-segment tracheal reconstruction. A 5-cm segment of trachea was resected in 9 dogs and replaced with a 20-mm reinforced PTFE graft using 4-0 Vicryl sutures. In 2 control dogs, one tracheal arch was resected and a primary anastomosis was performed. The animals were followed up with weekly bronchoscopy and endoscopic photography. Euthanasia was performed at 16 weeks or when signs of respiratory distress developed. At postmorten examination, the anastomoses were examined grossly and with light and scanning electron microscopy. In all 9 dogs that underwent tracheal replacement with PTFE, granulation tissue developed at the anastomoses resulting in airway obstruction after 3 to 8 weeks. No epithelial growth occurred over the graft between the anastomoses. The control animals did well. We conclude that granulation tissue formation at the anastomosis and the lack of respiratory epithelial ingrowth across the graft makes PTFE unsuitable for long-segment tracheal reconstruction.

A treatment for primary ciliary dyskinesia : efficacy of functional endoscopic sinus surgery

Primary ciliary dyskinesia (PCD) is an inherited disorder manifested in children as chronic otomastoiditis, recurrent pneumonia, and chronic sinusitis. The failure of the ciliary beat pattern to effectively function in the respiratory tract produces stasis of secretions with secondary inflammation, edema, and infection. The authors report three young children with PCD who presented with variable severities of symptoms. Each had the aforementioned respiratory tract problems. The child with the most severe symptomatology was treated with a variety of medical options, including long‐term gamma globulin injections, but hospitalizations persisted twice per month because of severe sinopulmonary illness. All three of the children underwent functional endoscopic sinus surgery (FESS). In addition, two children received pressure equalization (PE) tubes. One child required a revision procedure. Their surgical outcomes are discussed. Follow‐up of FESS in three children with this disorder shows a marked improvement in symptomatology with a decreased incidence of hospitalization and a somewhat decreased need for medical therapy.

Botryomycosis: improved therapy for a difficult infection

Botryomycosis is a chronic bacterial granulomatous disease often involving the skin and subcutaneous tissue. Head and neck involvement is rare. Botryomycosis presents with clinical and histological features similar to actinomycosis or mycetoma, but the causative organism is usually Staphylococcus aureus. Microscopically the organisms appear to be encapsulated in granules, which are thought to protect them from the effects of standard courses of antibiotics. Botryomycosis usually requires surgical intervention for cure. Major debilitating surgery has been required for most patients, because the infection has been unresponsive to seemingly appropriate medical therapy. We present an 8-month-old male with periorbital botryomycosis. Surgical specimens for diagnosis were obtained, but complete resection would have created debilitating functional and cosmetic defects. The lesion failed to respond to nafcillin alone or combination therapy with hyperbaric oxygen, but showed slow, steady improvement with long-term clindamycin. The patient has been disease free for more than 4 years, with minimal scarring and no functional impairment. Prolonged medical therapy for botryomycosis may be a viable alternative to the traditionally recommended surgical resection, thereby reducing cosmetic and functional morbidity.

Delayed diagnosis of a laryngotracheoesophageal cleft

Laryngotracheoesophageal (LTE) clefts are rare anomalies of the airway. Surgical correction has been performed in all cases reported in the literature for clefts diagnosed during life. Posterior laryngeal clefts (PLC) are defined as minor (type I) to severe (type IV), with types III and IV being further described as LTE clefts. Type I clefts have been observed with an increased frequency of up to 6% of all pediatric direct laryngoscopies performed at a tertiary pediatric referral hospital. These can be managed medically and seldom require surgical correction. A case is presented of a boy whose initial diagnosis of LTE cleft (PLC type III) was made at age 7 years. His presenting complaints were chronic airway symptoms without airway distress. He developed only two episodes of pneumonia. Surgical correction was not performed. This young athlete has been followed for more than 6 years without significant problems. This appears to be the only case found in the literature of the successful management of a LTE cleft that has not required surgical correction. Photographic documentation and suggestions on endoscopic diagnosis are presented.

Unique Case Presentations of Acute Epiglottic Swelling and a Protocol for Acute Airway Compromise

Acute epiglottitis is a well‐described life‐threatening disease. Since the generalized use of the Haemophilus influenzae type B (HIB) vaccine, presentations of this disorder have decreased dramatically in children. Presentations of this and other acute epiglottic swelling can vary remarkably and may easily be misdiagnosed by physicians who have little or no experience with the acutely obstructed airway. Early suspicion and a proper evaluation is mandatory to prevent a life‐threatening crisis. Six patients are presented with unusual presentations of acute epiglottic swelling from differing etiologies; these include the following: case 1, recurrent epiglottitis; case 2, chronic epiglottitis; case 3, traumatic epiglottitis; case 4, caustic ingestion; and cases 5 and 6, simultaneous infection of family members. Because the incidence of acute epiglottitis is decreasing, it has become rare at most institutions. To help primary care and emergency room physicians, a formal written protocol should be available at medical facilities that might be faced with patients presenting with acute airway obstruction. An “acute airway obstruction protocol” used successfully for the last decade is offered. Use of such a written document might be lifesaving for patients with impending upper airway obstruction. The otolaryngologist is a key member of the recommended multidisciplinary team.