George H. Zalzal

Epiglottoplasty for the Treatment of Laryngomalacia

Laryngomalacia is the most common congenital laryngeal anomaly. Patients present with different degrees of stridor and feeding problems that usually resolve by 18 months of age. A small number present with severe feeding problems, failure to thrive, stridor with cyanosis, and apnea, which may result in cardiopulmonary disease. These infants require surgical intervention, usually a hyomandibulopexy or tracheotomy. We present a new procedure, epiglottoplasty, that is performed endoscopically and involves excision of redundant mucosa over the lateral edges of the epiglottis, aryepiglottic folds, arytenoids, and corniculate cartilages. Ten patients have undergone this procedure with good results. Epiglottoplasty represents an alternative to tracheotomy in severe laryngomalacia. Indications, techniques, postoperative management, and complications are presented.

A Staging System for Assessing Severity of Disease and Response to Therapy in Recurrent Respiratory Papillomatosis

INTRODUCTION Recurrent respiratory papillomatosis (RRP) is a perplexing and frustrating disease for both the families it afflicts and the physicians who care for them. Although RRP is a benign disease of viral etiology (most commonly HPV types 6 and ll), it has potentially morbid consequences owing to its involvement of the airway and the risk of malignant conversion. Treatment of RRP has been mainly surgical over the past half century, relying on operative debulking, although adjuvant medical therapies have been utilized for recalcitrant cases. Among the most frustrating aspects of this disease is the observation that whereas some patients demonstrate limited disease with an infrequent need for intervention, others are confronted with recurrent airway compromise and a repeated need for laser surgery. Although it is considered the most common benign neoplasm of the larynx,l RRP is an orphan disease with an incidence in the United States estimated at between 1500 and 2500 new cases per year.2 Owing to the relative paucity of cases and the complicated nature of their treatment, the

The Effect of Intranasal Fentanyl on the Emergence Characteristics After Sevoflurane Anesthesia in Children Undergoing Surgery for Bilateral Myringotomy Tube Placement

Children undergoing placement of bilateral myringotomy tubes (BMT) often exhibit pain-related behavior (agitation) in the postanesthesia care unit. We compared the emergence and recovery profiles of pediatric patients who received sevoflurane with or without supplementary intranasal fentanyl for BMT surgery. By using a prospective, double-blinded design, 150 children 6 mo to 5 yr of age, scheduled for routine BMT surgery, were anesthetized with sevoflurane (2%–3%) in a 60% N2O/O2 gas mixture. Patients were randomized to receive equal volumes of intranasal saline (Control), 1 &mgr;g/kg fentanyl or 2 &mgr;g/kg fentanyl. A blinded observer evaluated each patient using a previously described 4-point agitation scale and the Steward recovery scale. Response to parental presence was observed after a score of six (full recovery) was achieved on the Steward recovery scale. There were no significant differences among the three groups regarding age, weight, surgeon, duration of anesthesia, or ear condition. Recovery times and emergence characteristic scores were not statistically different. Agitation scores were significantly reduced in the 2-&mgr;g/kg Fentanyl group as compared with the Control group (P = 0.012). Fentanyl 2 &mgr;g/kg is recommended to reduce the incidence of agitation seen in these patients.

Intracranial Complications of Sinusitis in Childhood

Complications of sinusitis in children, such as intracranial abscess formation, are uncommon and are often clinically unremarkable in comparison to similar disease processes in adults. Between 1983 and 1991, 443 children were admitted to Childrens National Medical Center in Washington, DC, for treatment of sinusitis. Fourteen of these children presented with intracranial extension of the infection and abscess formation. A retrospective review of these patients revealed that the risk of developing an intracranial abscess secondary to sinusitis was 3%. The management of these patients included surgical drainage of the infected sinuses and intracranial surgical exploration. Cranialization and exenteration of the frontal sinus proved to be effective single-stage procedures. While not indicated in all patients, these procedures eliminated the sinus as a source of continued or potential infection and obviated the need for a second obliterative procedure. Combined antimicrobial therapy and surgical drainage should be the management protocol.

Rib Cartilage Grafts for the Treatment of Posterior Glottic and Subglottic Stenosis in Children

Posterior glottic and subglottic stenosis from endotracheal intubation in children can be managed endoscopically with varying success. Open surgical treatment offers a better potential for correction with a single procedure in moderate and severe cases. The open method consists of splitting the scar and cricoid cartilage posteriorly to the level of the interarytenoid muscle, then stenting the incised cricoid open with a rib cartilage graft. Use of this method is described, and results in 12 cases are reported. Decannulation was achieved in ten patients. In all patients who were decannulated, good exercise tolerance, freedom from aspiration, and an adequate voice quality were achieved.

Management of pediatric orbital cellulitis in patients with radiographic findings of subperiosteal abscess

Objective: Controversies remain regarding the management of orbital cellulitis (OC). The objective of this study was to examine the outcomes of patients admitted to our institution for orbital cellulitis during a 7-year period. Study Design: Case series with chart review. Setting: Tertiary referral pediatric hospital. Subjects and Methods: Charts of 465 consecutive OC admissions were reviewed for presentation, imaging, medical and surgical treatment, and outcome. Results: Of these patients, 189 were treated in the emergency room and 276 were admitted. CT scan was performed on 240 patients. Subperiosteal abscess (SPA) was noted in 68 patients. Of these, 47 were treated medically and 21 had surgery. Surgical patients were older (8.3 vs 6.2 years, P = 0.039), had larger abscesses (>10 mm, P < 0.001), required a longer admission (10.2 vs 6.6 days, P < 0.001), and had higher temperatures on admission (38.0°C vs 37.3°C, P = 0.03). Conclusion: The majority of small SPAs as diagnosed on CT scans in younger children can be successfully treated medically. Surgery, however, should be considered for a worsening clinical examination. Our findings confirm those of previous reports on this clinical entity.

Changing trends in neonatal subglottic stenosis.

OBJECTIVES To determine whether there are any changes in the incidence and management of neonatal subglottic stenosis (SGS). METHODS A retrospective chart review of 416 infants who were admitted to the neonatal intensive care unit of the Childrens National Medical Center between July 1, 1995, and June 30, 1996, was carried out. The incidence of airway obstruction requiring anterior cricoid split or placement of tracheotomy tube was determined and compared with the incidence studied 10 years ago at the same institution. RESULTS One of 416 neonates required surgical intervention for airway obstruction caused by SGS, for an overall neonatal SGS incidence of 0.24%. When only the neonates who were intubated for 48 hours or longer were considered, the incidence of SGS was 0.49% (1/204). In neonates who were intubated for 48 hours or longer and survived, the incidence of SGS was 0.63% (1/160). This is in comparison with the incidences of 0.65% (3/462), 1.5% (3/195), and 1.9% (3/159), respectively, seen in a study done at the Childrens National Medical Center 10 years ago. Five infants in this current study required placement of a tracheotomy tube for reasons other than SGS. Two infants needed tracheotomy tube placement for micrognathia, and 3 others for central hypotonia, an omphalocele that required multiple surgical procedures, and choanal atresia with a serious heart anomaly, which was a manifestation of CHARGE association. None of these 5 infants had evidence of SGS at rigid endoscopy preceding the tracheotomy tube placement. CONCLUSION The incidence and management of neonatal SGS remain unchanged during this study period when compared with those of 10 years ago. (Otolaryngol Head Neck Surg 2000;122:61–3.)

Coblation Adenotonsillectomy: An Improvement Over Electrocautery Technique?

OBJECTIVES: To compare postoperative complication rates of coblation and electrocautery adenotonsillectomies. STUDY DESIGN: Retrospective chart review. RESULTS: From January 2000 to June 2004, 1997 pediatric patients underwent adenotonsillectomy. 745 coblation, and 1252 electrocautery tonsillectomies were performed. Primary bleed, secondary bleed, and dehydration were seen in 3, 35, and 23 coblation, and 9, 41, and 64 electrocautery tonsillectomies, respectively. Data analysis revealed no significant difference in primary and secondary hemorrhage rate, but a higher dehydration rate in the electrocautery group (P = 0.0423). A total of 602 coblation, 763 curette/cautery, and 632 electrocautery adenoidectomies were performed. Neck pain was seen in 0, 17, and 3 patients, respectively. Data analysis showed a higher incidence of neck pain with the curette/cautery technique compared with coblator and cautery techniques (P = 0.0006 and P = 0.0119, respectively). CONCLUSIONS: Coblation tonsillectomy had similar rates of primary and secondary hemorrhage when compared with electrocautery tonsillectomy but a lower incidence of postoperative dehydration. Coblation adenoidectomy caused less postoperative neck pain than curette/cautery adenoidectomy without significant advantage over cautery adenoidectomy. EBM rating: B-3b

Perioperative Airway Complications following Pharyngeal Flap Palatoplasty

This study was performed to determine the incidence and types of perioperative airway complications after pharyngeal flap palatoplasty. We conducted a retrospective chart review of 88 patients who underwent correction of velopharyngeal insufficiency between April 30, 1983, and April 30, 1997, in a tertiary care hospital. Some degree of airway obstruction developed in 7 patients. One child developed laryngobronchospasm and required immediate endotracheal intubation. He was successfully extubated without sequelae. Another patient developed severe obstructive sleep apnea and required flap revision. A third patient was found asystolic and apneic. She was immediately intubated; however, she subsequently died. Two patients aspirated blood, presumably resulting in pneumonia. They were managed with parenteral antibiotics. Another child developed worsening sleep apnea and required flap revision. One patient developed nasal obstruction that resolved with time. Airway compromise in patients who undergo pharyngeal flap palatoplasty can be a potentially fatal complication. Careful surveillance should be maintained over patients with underlying neurologic, craniofacial, or cardiopulmonary disorders.

A Systematic Review of Supraglottoplasty Outcomes

OBJECTIVES To analyze the available published data on supraglottoplasty, epiglottoplasty, and laryngomalacia and to evaluate the relative risk of supraglottoplasty failure. DESIGN Systematic review with determination of relative risk. MAIN OUTCOME MEASURES A PubMed search was performed with the following inclusion criteria: English language, human subjects, supraglottoplasty, epiglottoplasty, and laryngomalacia. The results of the included studies were summarized and analyzed. Subgroup analysis was then performed. RESULTS Twelve studies were identified, with 8 meeting the inclusion criteria. The overall risk ratio of surgical failure among patients with associated comorbidities compared with those with isolated laryngomalacia was 7.14 (k = 6 studies; 95% CI, 3.73-13.74; P < .001). The risk ratio for persistent or significant aspiration after supraglottoplasty among patients with associated comorbidities compared with those with isolated laryngomalacia was 4.33 (k = 3 studies; 95% CI, 1.25-15.06; P = .02). Insufficient data were available to assess outcome by age at surgery or specific technique used. CONCLUSIONS The relative risk of supraglottoplasty failure is significantly higher among patients with associated medical comorbidities. This aggregate finding should be taken into account when parents are counseled as to the expected surgical outcome of infants with laryngomalacia who are undergoing supraglottoplasty.