Donald B. Kearns

Fourth branchial pouch sinus: Principles of diagnosis and management

The fourth branchial pouch sinus is a congenital anomaly which most frequently manifests itself by recurrent episodes of neck abscess or acute suppurative thyroiditis. This lesion usually becomes symptomatic before the age of 10 years and is more common than has previously been suspected. It has been found on the left side in 93% of the 28 cases reported in the English literature. Barium swallow during periods of quiescence and nasopharyngoscopy have frequently been successful in identifying the presence of these embryological remnants. Definitive therapy consists of total excision of the sinus tract, which can be facilitated by direct endoscopic placement of a Fogarty® catheter into the sinus lumen before surgical exploration. The embryological basis for the occurrence of these sinuses is discussed.

Pediatric airway manifestations of gastroesophageal reflux

Gastroesophageal reflux (GER) in children may be classified as physiologic or pathologic, depending on its degree and consequences. There are many head and neck complications of GER in pediatric patients, but most numerous are the airway manifestations, including stridor, recurrent croup, exacerbation of subglottic stenosis, laryngeal irritation with or without laryngospasm, chronic cough, and obstructive apnea. Diagnosis may be difficult unless there is a high index of suspicion for GER and awareness of the concept of “silent” GER. We present the common pediatric airway manifestations of GER, illustrated by case reports, and provide a paradigm to assist in the diagnosis and management of children with airway compromise associated with GER.

Imaging and surgical approach of nasal dermoids

OBJECTIVE Determine the most accurate and cost effective radiographic evaluation for nasal dermoids. Determine the best surgical approach for excision of nasal dermoids. DESIGN Retrospective chart review. SETTING Division of Pediatric Otolaryngology, Childrens Hospital and Health Center, San Diego, California. PARTICIPANTS All patients with nasal dermoids evaluated and treated from 1990 to 2000. INTERVENTION Preoperative radiographic evaluation and surgical excision. OUTCOME MEASURES Accuracy of CT and MRI correlated with surgical findings and results. RESULTS Ten patients were identified with the diagnosis of nasal dermoid. The age at diagnosis ranged from 0 to 24 months, with a mean of 3 months. Six children presented with masses located at the glabella, three patients presented with masses located at the nasal dorsum and one presented with a mass at the nasal tip. Six children underwent a computed tomogram with contrast of the head. Seven children underwent a MRI study of the head. Three children underwent an initial CT followed by MRI. Twenty percent of children were found to have intracranial extension. CT scan accurately diagnosed intracranial extension in one case, was indeterminate in a second case and falsely positive in a third case. MRI correctly diagnosed intracranial extension in two cases and had no false positive or false negative results. No children were found to have associated intracranial anomalies. In the early years of the review, a simple excision was made over the mass with blunt and sharp dissection for removal. (An external rhinoplasty incision is now used with better exposure and improved cosmetic results.) In cases with intracranial communication, a combined approach of external rhinoplasty and craniotomy was used. CONCLUSIONS MRI alone is the most cost effective and accurate means of evaluating nasal dermoids and is essential for preoperative planning. The surgical approach of choice is external rhinoplasty for both cosmetic reasons and exposure of nasal dermoids with and without intracranial extension.

Surgical therapy of obstructive sleep apnea in children with severe mental insufficiency

Obstructive sleep apnea is the underlying cause of a variety of pediatric maladies, including pulmonary hypertension and failure to thrive. In children, unlike adults, obstruction secondary to lymphoid hyperplasia is often encountered; adenotonsillectomy restores airway patency. Patients who fail this procedure, such as children with cerebral palsy and associated muscular hypotonia, may face tracheotomies. We report on 10 pediatric patients with severe mental insufficiency and obstructive sleep apnea in whom palatal hypotonicity and lack of adenotonsillar hypertrophy was identified. Uvulopalatopharyngoplasty was performed in conjunction with adenotonsillectomy to enlarge the diameter of the nasopharyngeal inlet with successful resolution of the obstructive symptoms in eight patients. The remaining two children required more surgery. This procedure is presented as a possible alternative to tracheotomy in selected patients.

An atypical presentation of Kawasaki disease resembling a retropharyngeal abscess

Kawasaki disease is an acute systemic inflammatory disease, which occurs in children less than 10 years of age. The etiology of the disorder is unknown. Diagnosis is based upon clinicians recognition of a symptom pattern that includes high fevers, oral cavity changes, polymorphous rash, conjunctival injection, and cervical adenopathy. Most feared are the cardiac manifestations of Kawasaki syndrome, which result in an overall mortality rate of 2% in patients. Because of the common presenting symptoms, the otolaryngologist often plays a central role in early diagnosis of the disorder. The following case report describes a patient with Kawasaki disease whose initial presentation mimicked a retropharyngeal abscess. A literature review details the common and atypical early signs and symptoms of Kawasaki disease.

Cervicofacial mycobacterial adenitis in children: Endemic to san diego?†

Nontuberculous mycobacteria (NTM) are an important cause of cervicofacial lymphadenitis in children. A dramatic increase has been seen in confirmed cases of NTM lymphadenitis in San Diego in the past few years. This report encompasses a span of 2 years 9 months, during which 22 children had confirmed NTM infection and another 14 had necrotizing granulomatous lymphadenitis in whom the specific diagnosis of NTM could not be made. This apparent increase in the prevalence of NTM as compared to previous reports in the literature suggests a possible endemic risk for NTM in the San Diego area. These cases are reviewed and our diagnostic and surgical approach to possible NTM infection is described. We also discuss possible explanations for the increasing occurrence of NTM in the San Diego area.

Chondroid hamartoma presenting as a neonatal nasal mass

We present a case of a 3-month-old female with a right nasal mass. Upon evaluation with computed tomography, magnetic resonance imaging and angiography, a large right intranasal mass extending through the cribiform plate, displacing the dura, was noted. The patient underwent a combined midfacial degloving and bifrontal craniotomy for complete resection of the tumor mass. Pathologic evaluation demonstrated a mesenchymal tumor with spindle and stellate cells from which islands of immature cartilage emerged. The spectrum of histologic features closely resembled a mesenchymal chondroid hamartoma typically located in the chest wall. It is the first reported case of a chondroid hamartoma of the head and neck in the literature to date. We examine the characteristics and treatment of this unusual tumor.

Work environment discomfort and injury: an ergonomic survey study of the American Society of Pediatric Otolaryngology members☆☆☆

BACKGROUND Workplace-related musculoskeletal pain has been studied in various occupations, but it is rarely reported in the surgical literature. OBJECTIVE The aim of this study was to examine work-related discomfort and injury among pediatric otolaryngologists and to assess their knowledge of workplace ergonomic principles. METHODS We surveyed current North American members of the American Society of Pediatric Otolaryngology. Our main outcomes were whether the physician had ever experienced discomfort or physical symptoms that they attributed to their surgical practice. RESULTS Response rate of 43.7% was attained, and 62.0% of respondents reported experiencing pain or discomfort that they attributed to their surgical practice. Women were significantly more likely to report experiencing pain or discomfort that they associated with their surgical practice (P = .033). There were no significant differences found among length of time in practice, academic vs community setting, or number of surgeries completed by the surgeon. Some of the surgeons (31.0%) were aware of ergonomic principles, and of those who were aware, 83.9% had implemented ergonomic principles into their surgical practice. CONCLUSION Almost two thirds of surgeons who responded to the survey reported experiencing pain or discomfort that they attributed to their surgical practice. Only a minority of respondents were aware of ergonomic principles. These findings may confirm that most physicians believe that their physical health is affected by their operative environment. Increased knowledge of surgical ergonomics may lead to strategies that improve workplace health and safety.

Adenotonsillectomy in the very young patient: cost analysis of two methods of postoperative care

Postoperative management of the patient younger than 36 months undergoing adenotonsillectomy has been the subject of many debates. Concerns for early postoperative complications such as airway obstruction, emesis, dehydration, and hemorrhage have led many physicians to consider overnight hospitalization following adenotonsillectomy in very young children. Trends in health care management have had increasing focus on cost effective means of treating patients to limit unnecessary expenditure on the part of the patient, physician, and hospital facility. The purpose of this retrospective review was to analyze two methods of early postoperative management in children less than 36 months old undergoing adenotonsillectomy at the Childrens Hospital, San Diego from 1992 to 1997. Three hundred and seven cases were reviewed. Same-day discharge was compared with overnight inpatient observation based on the cost analysis of these two methods of postoperative care. Postoperative care was based on length of stay in the recovery room and as an inpatient. Expense of postoperative care was based on cost calculation for the recovery room and overnight hospitalization. Of the 307 patients, 194 went home the day of surgery and 113 were observed overnight in the hospital. Average hospital cost was higher in the outpatient group than in the inpatient group (P < 0.001). This difference reflects longer recovery room stay (350 min) in the outpatient group compared to the inpatient group (108 min) (P < 0.001). Outpatient adenotonsillectomy in the patient under 36 months may be safe; however, prolonged recovery room stays may actually make outpatient surgery less cost-effective than overnight admission. Recovery room costs are significantly higher per unit time than costs of inpatient hospitalization. Further investigation of cost-effective outpatient observation units may improve cost containment in the outpatient surgical setting.

Candida laryngotracheitis : a complication of combined steroid and antibiotic usage in croup

The use of corticosteroids to reduce the morbidity associated with laryngotracheobronchitis (croup) has been a controversial issue for many years. Recent literature, however, does support a decreased morbidity and increased clinical response when short-term steroids are used. As a prophylactic measure against bacterial superinfection, antibiotics are commonly utilized in the treatment of croup. We present the case of an otherwise healthy infant with severe croup who was hospitalized and treated with both steroids and antibiotics. A relapse in her symptoms led to the diagnosis of candida laryngotracheitis. We recommend close monitoring of patients with croup treated aggressively with steroids and antibiotics. Steroid use should be limited to 24 h with antibiotics reserved for patients with signs of bacterial infection.