Gabriel Kuhl

Association Between Length of Intubation and Subglottic Stenosis in Children

To investigate the role of the length of intubation and other risk factors in the development of laryngeal lesions in children undergoing endotracheal intubation in an intensive care unit and to determine the incidence of subglottic stenosis (SGS).

Laringoplastia com balão em crianças com estenose subglótica em evolução: experiência de um hospital terciário

UNLABELLED Management of subglottic stenosis (SGS) in children is still a challenge to Otorhinolaryngologists. Balloon laryngoplasty (BLP) is an endoscopic procedure, first described in 1984 for the treatment of airway stenosis. It shows promising results and seems to be more effective than other procedures. AIM To present our experience with BLP in children with SGS. MATERIAL AND METHOD Prospective study of children diagnosed with acute subglottic stenosis, i.e., stenosis with granulation tissue. They underwent direct laryngoscopy under general anesthesia and dilatation of the stenotic segment with angioplasty balloon. They were followed up and a second laryngoscopy was performed one week later. RESULTS Eight children were included in this study between June 2009 and October 2010. Four had Grade 3 SGS, three had Grade 2 SGS and one had Grade 1 SGS. By the second examination, two children presented with asymptomatic Grade 1 SGS, while the other six presented with normal airway and remained asymptomatic. CONCLUSION BLP seems to be an effective treatment for acute SGS. We need more studies to refine our knowledge concerning efficacy rates, safety and indications for balloon dilatation.

Desenvolvimento de uma órtese de Dumon modificada para aplicações traqueais: um estudo experimental em cães

OBJECTIVE: To describe the development of a silicone stent and perform in vivo testing for biocompatibility/applicability in the normal canine trachea. METHODS: Four different densities were tested in order to obtain the silicone prototypes. The pressure required for compression considering a contact area of 1 cm2, and a 30% reduction in diameter was calculated for each density. The best density was 70-75 Shore A hardness. Powdered barium sulfate was added to the silicone to make the stent radiopaque and easily identifiable in radiological imaging. This novel stent presents a corrugated external surface with discontinuous and protruding arcs resembling the tracheobronchial rings (for intercalation and fixation in the lumen of the lower airways), a highly polished inner surface and smooth extremities (to prevent friction-related damage). The prototype considered most appropriate in terms of rigidity and flexibility was bronchoscopically implanted in normal canine tracheas. After eight weeks, the animals were euthanized, and the tracheas were removed for anatomopathological analysis. RESULTS: There were no postimplantation complications, and none had to be removed. After eight weeks, the devices were found to be well-positioned. Histopathology revealed a well-preserved epithelial basal membrane, foci of denuded epithelium, mild submucosal inflammatory infiltrate with scattered granulation tissue, vascular neoformation, and no microorganisms. CONCLUSIONS: The stent developed proved resistant to mechanical stress, biocompatible in the canine trachea and well-preserved at the study endpoint.

Nasal paraganglioma: a case report

Paragangliomas are tumors of the autonomic nervous system, arising from paraganglionic tissue. Paragangliomas of the head and neck region are very rare. In the head and neck, the most common sites of origin of this neoplasm are the carotid body, the jugular bulb and the vagal body. Paragangliomas of the nose and paranasal sinuses are very uncommon. The authors referred one case of nasal paraganglioma in a 45-year-old male patient, who was submitted to surgical excision, and included clinical findings, diagnostic criteria, treatment, prognosis and literature review. The importance of reporting this case refers to the rare incidence of paragangliomas in the nasal cavity and paranasal sinuses.

Incidence and endoscopic characteristics of acute laryngeal lesions in children undergoing endotracheal intubation

INTRODUCTION Acute laryngeal lesions after intubation appear to be precursors of chronic lesions. OBJECTIVE To describe the incidence and type of acute laryngeal lesions after extubation in a pediatric intensive care unit (PICU). METHODS A cohort study involving children from birth to <5 years, submitted to intubation for more than 24h in the PICU of an university hospital. In the first eight hours after extubation, a flexible fiberoptic laryngoscopy (FFL) was performed at the bedside. Those with moderate to severe abnormalities underwent a second examination seven to ten days later. RESULTS 177 patients were included, with a median age of 2.46 months. The mean intubation time was 8.19 days. Seventy-three (41.2%) patients had moderate or severe alterations at the FFL, with the remaining showing only minor alterations or normal results. During follow-up, 16 children from the group with moderate to severe lesions developed subglottic stenosis. One patient from the normal FFL group had subglottic stenosis, resulting in an incidence of 9.6% of chronic lesions. CONCLUSION Most children in the study developed mild acute laryngeal lesions caused by endotracheal intubation, which improved in a few days after extubation.

Post-intubation acute laryngeal injuries in infants and children: A new classification system.

OBJECTIVE To compare the Classification of Acute Laryngeal Injuries (CALI) with other classifications to determine which of these offers the greatest sensitivity and specificity in predicting the development of subglottic stenosis. METHODS All children intubated for the first time in the pediatric intensive care unit were included and subjected to flexible fiber-optic laryngoscopy (FFL) within 8 h of extubation. Their injuries were categorized using the CALI, as well as adapted classifications from Lindholm, Colice and Benjamin. The children were followed up to determine who developed subglottic stenosis. RESULTS This study included 194 children, with a median age of 2.67 months. The sensitivity and specificity of the CALI were 90% and 73%, respectively. The CALI showed greater specificity than the adapted classifications from Colice and Benjamin (p < 0.001 for both), and greater sensitivity than the adapted classification from Lindholm (p < 0.001). CONCLUSIONS Based on the CALI, 90% of children who developed subglottic stenosis had moderate to severe injuries on the initial FFL. The CALI includes all injury types described by Benjamin, as well as a proposed severity scale for these lesions, and was predictive of the development of chronic laryngeal injury.

Paraganglioma nasal: relato de caso

Paragangliomas sao neoplasias que surgem a partir do tecido paraganglionico do sistema nervoso autonomo. Os paragangliomas da cabeca e pescoco sao bastante raros. Os tipos mais frequentemente encontrados sao o carotideo, o jugulo-timpânico e o vagal. Paragangliomas do nariz e dos seios paranasais sao muito infrequentes. Os autores descrevem um caso de paraganglioma nasal em um paciente do sexo masculino, com 45 anos de idade, que foi submetido a exerese da lesao, e relatam os achados clinicos, criterios diagnosticos, tratamento, prognostico e revisao da literatura. Consideramos importante o relato deste caso em vista da raridade da localizacao nasal dos paragangliomas.

Accuracy of clinical swallowing evaluation for diagnosis of dysphagia in children with laryngomalacia or glossoptosis

To investigate the accuracy of clinical evaluation of swallowing in a sample of children with laryngomalacia or glossoptosis and describe the prevalence of dysphagia in each of these diseases, as well as characterize the swallow response to speech and language therapy interventions.

Association between congenital nasolacrimal duct cyst and bilateral choanal atresia

1 MD Federal University of Rio Grande do Sul UFRGS (1991); ENT Residency at Hospital de Clinicas de Porto Alegre (1992-1993), MSc (1997) and PhD (2000) in Medicine: Medical Sciences UFRGS. Fellowship at the Pediatric ENT Division at the Massachusetts Eye & Ear Infirmary, Harvard Medical School, Boston, USA (1997-1998) (Adjunct Professor IV Of the Federal University of Health Sciences Porto Alegre, Professor at the Graduate Program in Medical Sciences UFRGS, Director of the Pediatric ENT Division at Hospital da Crianca Santo Antonio do Complexo Hospitalar Santa Casa de Porto Alegre; Scientific director of the Associacao Gaucha de Otorrinolaringologia; Chairman of the ENT committee of the Pediatric Otorhinolaryngology Socity of RS and member of the Management Core of the ENT Department of the Brazial Association of Pediatrics; Board Member at the Brazilian Association of Otorhinolaryngology and Neck and Facial Surgery, in the International Relations and Teaching, Residency and Training Departments. 2 MD University of Coimbra (1973), MD Universidade de Caxias do Sul (1977) Medical Residency at the Hospital de Clinicas de Porto Alegre (1979) . Assistant Professor III Federal University of Rio Grande do Sul; Other Founding Partner of the Brazilian Association of Laryngology and Voice and aide at the Society of Otorhinolaryngology of Rio Grande do Sul. 3 MD Pontificia Universidade Catolica do Rio Grande do Sul (1994); MD Universidade Federal do Rio Grande do Sul (2000) and Medical Residency at the Hospital de Clinicas de Porto Alegre (2004) (Effective Member of the Brazilian Association of Otorhinolaryngology and Special Graduate Student at the Hospital de Clinicas de Porto Alegre. Experienced in Medicine, with enphasis in Otorhinolaryngology). 4 MD Universidade Federal de Pelotas (2006). Resident Physician at Santa Casa de Misericordia de Porto Alegre. 5 MDUniversidade Federal de Ciencias da Saude de Porto Alegre (2009). Paper submitted to the BJORL-SGP (Publishing Management System – Brazilian Journal of Otorhinolaryngology) on October 04, 2009; and accepted on October 01, 2010. cod. 6692 cAsE REPORT Braz J Otorhinolaryngol. 2011;77(2):267. BJORL

Undersedation is a risk factor for the development of subglottic stenosis in intubated children

OBJECTIVE To analyze the level of sedation in intubated children as a risk factor for the development of subglottic stenosis. METHODS All patients between 30 days and 5 years of age who required endotracheal intubation in the pediatric intensive care unit between 2013 and 2014 were included in this prospective study. They were monitored daily and COMFORT-B scores were obtained. Flexible fiber-optic laryngoscopy was performed within eight hours of extubation, and repeated seven to ten days later if the first examination showed moderate to severe laryngeal injuries. If these lesions persisted and/or if the child developed symptoms in the follow-up period, microlaryngoscopy under general anesthesia was performed to evaluate for subglottic stenosis. RESULTS The study included 36 children. Incidence of subglottic stenosis was 11.1%. Children with subglottic stenosis had a higher percentage of COMFORT-B scores between 23 and 30 (undersedated) than those who did not develop subglottic stenosis (15.8% vs. 3.65%, p=0.004). CONCLUSION Children who developed subglottic stenosis were less sedated than children who did not develop subglottic stenosis.