Donald B. Hawkins

Caustic ingestion: Controversies in management. A review of 214 cases

Two hundred fourteen patients admitted with a history of caustic ingestion are reviewed. Sixty‐five had mucosal penetrating burns. Children five years of age and under accounted for 39% of admissions, but only 8% of burns requiring treatment. Adults accounted for 48% of admissions and 81% of burns requiring treatment. Complications associated with mucosal penetrating burns occurred in 31 patients; all but one were due to lye or acids. A three year prospective study evaluating methylprednisolone in the management of caustic burns is reported. This included 24 patients with mucosal penetrating burns due to lye or acids. The results of this study, and this review as a whole, indicate that methylprednisolone is beneficial in moderately severe burns due to lye, but is not indicated for severe burns from liquid lye, or for acid burns.

Hyaline membrane disease of the neonate prolonged intubation in management: effects on the larynx.

Hyaline membrane disease, an illness of premature neonates, is associated with 20–30% of all neonatal deaths and 50–70% of premature deaths in the United States. Often related to perinatal hypoxia, its basic pathophysiology consists of surfactant deficiency with diffuse atelectasis, and pulmonary hypoperfusion.

Tracheotomy in infants and young children: The changing perspective 1970–1985

One hundred fifty‐three children 3 years of age or younger who had tracheotomies performed during the past 15 years are reviewed. During this time, short‐term endotracheal intubation for airway obstruction from acute infections and long‐term intubation for patients on ventilators have replaced early tracheotomy for these conditions. The number of tracheotomies decreased during each of three 5‐year periods, from 73 to 55 to 25, respectively. Improvements in medical management resulted in prolonged survival of children with multiple abnormalities and resulted in more prolonged tracheotomies. Early complications occurred in 12% of patients and late complications occurred in 26%. In spite of changes in the indications, basic fundamentals of pediatric tracheotomy management remain unchanged.

Acute mastoiditis in children: a review of 54 cases.

Fifty‐four children with acute mastoiditis were managed at the Los Angeles County‐University of Southern California Medical Center from 1972 through 1982. Our criteria for the diagnosis of acute mastoiditis are acute or subacute otitis media, postauricular swelling and erythema, protrusion of the auricle, and clouding of mastoid air cells on radiographs. Thirty‐one (57%) recovered with conservative therapy consisting of early myringotomy and intravenous antibiotic, usually ampicillin. Twenty‐three patients were managed surgically. The indication for surgery in each case was the clinical diagnosis of subperiosteal abscess; mastoid radiographs played no part in the decision to operate. Two of the 23 patients managed surgically had only incision and drainage of abscess; simple mastoidectomy was performed on 20 and radical mastoidectomy on one. Etiologic bacteria were cultured in 21 instances. S. pyogenes was cultured in 9, S. pneumoniae was cultured in 6, H. nfluenzae in 1, enterococci in 1, anaerobes in 2, and M. tuberculosis in 2.

Removal of Blunt Foreign Bodies from the Esophagus

Historically, removal of blunt foreign bodies from the esophagus by esophagoscopy under general anesthesia has been considered to be relatively safe and effective. In recent years, alternative techniques of blind removal with balloon catheters or bougies have been advocated. This paper reports 246 esophagoscopies performed over a 19-year period to remove blunt esophageal foreign bodies. Eighty-one percent of the foreign bodies were coins and 74% were in children under 3 years of age. There were no deaths, no perforations, and no instances of mediastinitis. The only complications encountered were those due to esophageal erosion and/or respiratory problems secondary to longstanding foreign bodies. In the authors opinion, esophagoscopy is the best method for removal of all esophageal foreign bodies. There simply does not seem to be a need for alternative methods involving blind removal.

Tracheostomy in infants and young children

Seventy‐three tracheostomies performed in children three years of age and under in a 52‐month period are discussed. Thirty‐six were under one year of age. Forty‐one were performed for upper airway obstruction, 23 for ventilation or suction, and nine for a combination of upper airway obstruction and lower bronchopulmonary disease.

Basilar skull fractures in children

In this paper we are reporting a retrospective study of patients under 18 years of age managed at the Los Angeles County/University of Southern California Medical Center from January 1979 through December 1987 with the diagnosis of basilar skull fracture. Sixty-two patients with basilar skull fractures were admitted during that 7 1/2 year period. The most common etiology was pedestrain versus vehicle accidents (42%), followed by falls (27%), vehicle accidents (23%), and being hit by an object (8%). The most common physical findings were hemotympanum (58%) and bleeding in the ear canals (47%). Thirty-four percent of the patients complained of hearing loss. Cerebrospinal fluid otorrhea was noted in 16 patients (26%), while only 1 patient had cerebrospinal fluid rhinorrhea. Facial nerve paralysis was present in 8 patients (13%). Vestibular symptoms were rare. Sixty-three percent of the patients had the diagnosis confirmed by radiography. The clinical presentation, complications, management and outcome of basilar skull fractures in the pediatric population are discussed.

Flexible Laryngoscopy in Neonates, Infants, and Young Children

Flexible laryngoscopy was performed 453 times on 264 patients 4 years of age or younger. Sixty-five percent were under 6 months of age. Stridor was the indication for laryngoscopy in 60% of the patients. Problems secondary to intubation and poor voice each were indications in 12%. The most common finding was laryngomalacia, followed by laryngeal edema, normal larynges, and vocal cord paralysis or paresis. Subglottic stenosis was diagnosed in 17 patients. Flexible laryngoscopy is a relatively noninvasive, safe, and effective technique for examining the larynx of infants and young children.

Orbital Involvement in Acute Sinusitis Lessons from 24 Childhood Patients

The possibility of acute bacterial sinusitis should be considered in any child with sudden swelling about the orbit. Management is determined by the stage of the disease as well as by the sinus predominantly involved. Extraocular movements and proptosis are the best guidelines for therapy. When there is no proptosis and extraocular mobility is normal, conservative therapy with intravenous antibiotics and nasal deconges tants is usually effective. When ocular mobility is impaired or proptosis develops, intranasal or external surgical drainage are usually required. Of 24 patients summarized in this paper, the ethmoid was the predominantly involved sinus in 12, the frontal in 7, the maxillary in 5. Only 4 of the 12 with predominant ethmoiditis required surgery. Of the 5 with predominant maxillary sinusitis, 2 required surgery. All 7 were pre dominant frontal involvement needed surgical drainage.

Corticosteroids in airway management.

Adrenal corticosteroids exert a strong suppressive influence on the basic inflammatory response that leads to tissue swelling. The corticosteroid effect is nonspecific. In upper airway obstruction caused by edema from infection, allergy, or trauma, corticosteroids will exert some degree of suppressive effect. The steroid effect is local and directly proportional to the concentration of steroids in the inflamed tissue. In upper airway obstruction steroids should be delivered to the inflamed tissue in high concentration with the least delay. Dexamethasone and methylprednisolone produce high blood levels within 15 to 30 minutes of intramuscular injection. Recommended initial doses for acute airway obstruction are dexamethasone, 1.0 to 1.5 mg/kg, or methylprednisolone, 5 to 7 mg/kg. The risk of harm from steroid therapy of 24 hours or less is negligible.