Duncan S. Postma

Endoscopy of the airway in infants and children

We believe that many of our readers will appreciate having some familiarity with the procedures described in this manuscript. For those who have had difficulty in deciding whether the need for diagnosis justifies the risk of a procedure, this perspective will shed new light on the problem. It is appropriate to warn our readers that complete unanimity on several points is not yet evident. For example, the indications for flexible bronchoscopy, by whom the procedure should be done, and even more specific technical aspects are questions not completely resolved. However, this article is not an effort to instruct anyone in how to do the procedure. Rather, it is an effort to acquaint our readers with progress in the field. With that in mind, we are confident that the remaining questions will be answered on the basis of the training, experience, and, ultimately, the good judgment of all the physicians involved.

Part I. DNA Flow Cytometry as a Prognostic Indicator in Head and Neck Cancer

The prognostic significance of deoxyribonucleic acid (DNA) flow cytometry has been investigated for many solid tumors, but few data have been accumulated for squamous cell carcinomas of the head and neck. To our knowledge, we report the largest number of patients (69) with head and neck primary carcinomas to be studied by DNA flow cytometry. In the first part of this study, we reviewed 109 consecutive patients with laryngeal or hypopharyngeal primary carcinomas which were treated at North Carolina Memorial Hospital during the period of 1981 to 1984. The final analysis comprised 139 DNA histograms (mean coefficient of variation: 8.02) on paraffin-embedded specimens from 48 patients. Of the 48 patients with primary carcinomas, 24 had glottic, 18 had supraglottic, and 6 had carcinomas from the piriform sinus. Patients had follow-up for a minimum of 12 months, with a mean follow-up period of 23 months. Twenty-three of the 48 primary carcinomas (48%) were clearly aneuploid, and the remaining 52% were tetraploid (22%) or diploid (30%). We have concluded that patients with clearly aneuploid primary carcinomas had significantly better prognoses than those with diploid tumors (p = 0.008). High DNA amounts (greater than 40% of cells beyond the diploid peak, DNA G1GO) also correlated with a favorable prognosis when compared with low DNA amounts (p <0.01), and this remained significant when the clinical outcome was adjusted for staging of the primary site (T), nodal status, and stage of disease. Ploidy was the most significant prognostic variable for the laryngeal group of patients. In the second part of the study, twenty-one patients with oral cavity squamous cell carcinomas were studied in a similar fashion as the group with laryngeal carcinomas. In this group, a low DNA amount, with 40% as the cutoff point, was associated with a favorable prognosis (p = 0.024), and this remained significant while controlling for I, nodal status, and stage of disease. Numbers were too small to permit evaluation of the impact of ploidy in this group, but there was a slight trend toward aneuploidy and tetraploidy, correlating with a poor treatment outcome (p = 0.228). DNA amount was the most significant prognostic variable for the group of patients with oral cavity carcinomas. We conclude that DNA flow cytometry may be a powerful prognostic indicator in malignant conditions of the head and neck. The implications of these data for the management of head and neck cancer are discussed.

Significance of ploidy in laryngeal cancer

We studied 48 patients with laryngeal or hypopharyngeal primary tumors with DNA flow cytometry. Twenty-four of the tumors were glottic, 18 were supraglottic, and 6 were from the pyriform sinus. Patients were followed for a minimum of 12 months, with a mean follow-up of 23 months. Twenty-three of the 48 primary tumors (48 percent) were clearly aneuploid, 22 percent were tetraploid, and 30 percent were diploid. We concluded that patients with aneuploid primary tumors, high DNA levels, or both have a significantly better prognosis than those with diploid tumors, and this remained statistically significant when clinical outcome was adjusted for tumor status, stage, and nodal status.

The case for an outpatient "approach" for all pediatric tonsillectomies and/or adenoidectomies: a 4-year review of 1419 cases at a community hospital.

OBJECTIVE: We sought to document the safety and efficacy of approaching all pediatric tonsillectomies and/or adenoidectomies (T/A) as outpatient procedures. STUDY DESIGN AND SETTING: We conducted a 4-year retrospective study of 1419 pediatric patients undergoing T/A at an outpatient center with procedures performed by a single group of surgeons. RESULTS: None of the 593 patients undergoing an adenoidectomy and only 5 (0.6%) of those having a tonsillectomy had significant bleeding postoperatively. There were no readmissions for airway problems. Children younger than age 3 were most likely to have complications and to be held for overnight observations. CONCLUSIONS: Most children can be safely discharged after T/A. The higher incidence of perioperative complications in children who are younger than 3 years of age paralleled their higher rate of overnight observation. SIGNIFICANCE: Children less than 3 years of age require more careful observation, especially after tonsillectomy and more likely will need to be observed overnight than older children.

Severe hospitalized croup: Treatment trends and prognosis†‡

We have reviewed 43 cases of severe croup admitted from 1977 to 1981 at North Carolina Memorial Hospital. All patients were treated with mist, 23 (54%) of 43 were treated with racemic epinephrine, but only 7 (16%) of 43 were treated with steroids. None of the 5 patients who required intubation received steroids. Nine (36%) of 25 patients available for at least 6 months of follow‐up had subsequent clinical diagnoses of asthma.

Management of Plexiform Neurofibroma of the Larynx

We report the ninth case of plexiform neurofibroma of the larynx, which occurred in a 2-year-old with multiple café au lait spots and obstructive sleep apnea. In discussing this clinical problem, we have attempted to make the following points. 1) A patients having more than six café au lait spots of greater than 1.5-cm diameter is diagnostic of von Recklinghausens disease. 2) It is much more difficult to completely excise plexiform neurofibroma than nonplexiform neurofibroma. 3) The association of juvenile xanthogranuloma with von Recklinghausens disease may be a risk factor for the later development of leukemia.

Metastasizing Pleomorphic Adenoma with Myoepithelial Cell Predominance

The biological behavior of pleomorphic adenomas (mixed tumors) of salivary gland origin is complex. Tumors with benign histologic features may exhibit recurrence and locally aggressive behavior especially after incomplete excision. A small percentage of pleomorphic adenomas have obvious malignant components in epithelial or in both epithelial and mesenchymal components and can metastasize. There are also rare case reports which appear to document typical pleomorphic adenomas of salivary gland with histologically identical visceral and lymph node metastases. Recently myoepithelial cell proliferation has been identified as a possible predictor of aggressive clinical behavior in otherwise histologically benign pleomorphic adenomas. We report such a parotid gland lesion with local recurrence and retroperitoneal spread. DNA-flow cytometry of cells from the paraffin-embedded primary and metastasis showed similar aneuploid populations. Aneuploidy appeared to reflect the malignant potential of this particular pleomorphic adenoma and suggests that DNA-flow cytometry of salivary gland tumors may yield important prognostic information.

Presentation and management of postcricoid hemangiomata in infancy

Phillips and Ruh (1912)1 were the first to describe a congenital hemangioma of the larynx. Sweetser2 subsequently classified laryngeal hemangiomata into infantile and adult types and noted differences in incidence, location, and symptoms. According to Sweetser, the infantile form is less common, is almost always subglottic, and presents with stridor which may be intermittent. The adult form is somewhat more common, is generally supraglottic, and often presents with hoarseness or dysphagia.

Characterization of cough associated with angiotensin-converting enzyme inhibitors.

Chronic cough is a side effect of the angiotensin-converting enzyme (ACE) inhibitor class of antihypertensives. The cough is thought to be a result of inhibition of the enzymes that break down some of the mediators of inflammation, such as the bradykinins and tachykinins. We report 20 patients with chronic cough caused by ACE inhibitors and some of the characteristics of the cough. The cough is typically dry, nonproductive, and worse at night. Interference with sleep is common and was severe in three patients. Women outnumbered men in this series: urinary stress incontinence developed in five, rectal and vaginal prolapse developed in one. Three patients felt they were incapacitated by the cough. Most had been on multiple medications; only oxycodone was reported to be effective in controlling the cough, and four patients thought they were addicted to that. All coughs resolved with withdrawal of the ACE inhibitor. Chronic cough is common among individuals taking ACE inhibitors. It may be severe and associated with complications. The incidence and potential severity is understated in drug information sources, and patients and physicians often fail to recognize cough as a drug side effect.

Effects of Dexamethasone and Oxymetazoline on “Postintubation Croup”: A ferret model

Several studies recommend the use of steroids and racemic epinephrine for treatment of postintubation croup. Few controlled clinical or laboratory studies, however, support their effectiveness, and many questions remain about their use. The present study was undertaken to develop a reproducible animal model for postintubation croup and to perform initial controlled studies of the effects of dexamethasone (4 mg/kg) and the long-acting vasoconstrictor oxymetazoline (0.01 solution). An animal model for intubation trauma was developed with ten 10-week-old ferrets. Two models were created to reflect the spectrum of trauma—from simple mucosal contusion to mucosal ulceration. The first was to surgically strip mucosa in a circumferential manner at the level of the cricoid ring; the second was intubation trauma to the glottic and subglottic regions by use of a circular brush. Neither dexamethasone nor oxymetazoline had any statistically significant effect on subglottic edema in the mucosal stripping model. In the brush intubation model, oxymetazoline decreased subglottic edema at 2, 4, and 8 hours (P < 0.05), while dexamethasone and combination therapy decreased edema at 2,4, 8, and 24 hours (P < 0.05). At 24 hours, combination therapy was demonstrated to be the most effective in reducing subglottic edema. Oxymetazoline was as effective as dexamethasone and combination therapy at 2, 4, and 8 hours (P < 0.05). In this preliminary study, we have established the potential usefulness of the brush intubation model for the study of this disorder. This model was shown to have a reproducible and reversible lesion. The mucosal stripping model was not shown to have reversible lesion and—while further study needs to be performed—may only be useful as a model for very severe cases of this disorder. These initial studies also demonstrated high-dose dexamethasone and oxymetazoline to be effective in treatment of subglottic edema secondary to mucosal trauma. They also indicate that combination therapy is a more effective treatment than either agent alone.