Hans Hoeve

Paediatric laryngotracheal stenosis: a consensus paper from three European centres

Abstract. Surgical reconstruction of paediatric laryngotracheal stenosis (LTS) has only been developed over the last 30 years, but during that period great advances have been made, and the operation is now very much tailored to the needs of the individual patient. Closed (endoscopic) techniques have a very limited place in the correction of LTS. Of the open surgical techniques, laryngotracheal reconstruction (LTR) with cartilage grafting can precisely correct grade II and mild grade III stenosis with minimal morbidity and high decannulation rates. Partial cricotracheal resection (PCTR) can deliver high success rates for more severe stenoses, but it is a more complex procedure. Because LTR is more straightforward, it tends to be preferred for grade II and mild grade III stenosis. For a suitably experienced surgeon, PCTR is the preferred option for grade IV and severe grade III stenosis, especially where there is a clear margin between the stenosis and the vocal cords. The best chance for the patient lies in the first operation: this means that the surgeon managing the problem must be fully trained in paediatric airway endoscopy and laryngotracheal surgery, since inappropriate initial management of LTS may lead to permanent intractable sequelae.

Bile acids identified in middle ear effusions of children with otitis media with effusion

Several studies have shown the presence of pepsin in the middle ear effusions of children with otitis media with effusion (OME). When gastric reflux is the cause, other noxious reflux products might be present. We therefore investigated the presence of bile acids in the middle ear effusions of children with OME.

Sinusitis: hidden source of sepsis in postoperative pediatric intensive care patients.

Paranasal sinusitis is reported as a complication of prolonged nasal intubation and the source of sepsis in adult intensive care patients. In surgical neonates with congenital malformations, prolonged intubation with a nasotracheal (NT) or NG tube is often necessary, but sinusitis with complicating sepsis is seldom reported. Sinus x-rays may confirm the diagnosis; in infancy, prolonged nasal intubation delays the pneumatization of the sinuses and the mastoids, resulting in additional diagnostic problems. In a 1-yr period, we saw three patients with multiple septic episodes in which the source of sepsis was undetectable. Despite the absence of clinical symptoms and radiologic evidence of sinusitis or mastoiditis, surgical drainage revealed pus and led to the disappearance of septic episodes and ear, nose, and throat problems. There is an association between prolonged NT and NG intubation, and sinusitis or mastoiditis as an unrecognized source of sepsis in young infants. Absence of radiologic evidence of sinusitis or mastoiditis causes pitfalls in diagnosis and is related to delayed pneumatization of the sinuses and the mastoid in prolonged nasal intubation in young infants.

The prevalence of tracheal bronchus in pediatric patients undergoing rigid bronchoscopy.

Background:Tracheal bronchus (TB) is defined as an abnormal bronchus that originates directly from the lateral wall of the trachea above the carina and goes towards the upper lobe territory of the lung. We analyzed rigid endoscopies of the trachea in children to determine the incidence and characteristics of TB. Methods:In total, 1021 rigid endoscopies of the trachea recorded from children aged 0 to 6 years were analyzed. Endoscopic examination was performed from supraglottic region to carina using a 0-degree Hopkins rod-lens telescope. Patients with a TB were identified and the site of origin of the TB and its level above the carina was noted. Data of the identified patients was reviewed for the presence of preoperative airway findings such as stridor, upper lobe pneumonia and wheezing or atelectasis, other congenital anomalies, and intraoperative complications. Results:TB was detected in 11 (1.06%) of 1021 upper airway endoscopic examinations. All originated from the right lateral wall of the trachea. Six children had retained secretions in the TB, and 3 children had perioperative airway problems unrelated to the TB. One child showed right main stem bronchus narrowing as seen at the true carina, in the presence of a TB. All the children with TB exhibited at least 1 additional congenital anomaly at birth besides TB. Conclusions:TB is a relatively common congenital endoscopic lower airway anomaly in childhood, which is itself rarely symptomatic, but almost always coexists with other congenital anomalies.

Airway management and fiberoptic tracheal intubation via the laryngeal mask in a child with Marshall-Smith syndrome.

clamshell surgical incision was performed which provided a good access for both surgery and for arterial and venous cannulation should emergency cardiac bypass be necessary. This type of incision also allows bilateral simultaneous lung decompression. CLE emphysema may produce an acute shift of the mediastinum with loss of cardiac output and subsequent death. There have been several descriptions of the anesthetic management of patients with unilateral congenital emphysema (4,5), to our knowledge, this is the first description of the anesthetic management of a child undergoing surgery for bilateral CLE. Our concerns in anesthetising this patient were that initiation of positive pressure ventilation would cause hyperinflation of the emphysematous lobes and compromise oxygenation, venous return and cardiac output. We therefore used an inhalational induction and maintained spontaneous ventilation with sevoflurane in 100% oxygen and only instituted positive pressure ventilation after femoral and arterial line access was obtained. This allowed us to minimize the duration of positive pressure ventilation prior to surgical incision and reduce the potential for hyperinflation of the emphysematous lobes. We feel our method facilitated safe induction of anesthesia and establishment of invasive monitoring, avoided the potential for cardio respiratory compromise and allowed the surgery for a single stage excision of bilateral CLE via a clamshell incision to proceed without complications. Francesca Iodice Fraser Harban Isabeau Walker Department of Anaesthetics, Great Ormond Street Hospital, Great Ormond Street, London WC 1N 3JH (email: francesca_iodice@yahoo.it)

Prevalence and characteristics of tracheal cobblestoning in children

Tracheal follicular pattern or so‐called tracheal cobblestoning is a poorly described entity in the literature and is depicted as a nodular or lumpy appearance of the tracheal wall mucosa suggesting tracheal irritation from factors like gastro‐esophageal reflux (GERD) or pulmonary infection. The aim of the present study was to investigate the prevalence and characteristics of tracheal cobblestones in a large pediatric population.

Endoscopic airway findings in children with or without prior endotracheal intubation

Airway alterations found after endotracheal intubation are usually associated with mechanical trauma from the tube. However, no studies are available concerning alterations in airways that have never been intubated before. It was the aim of the study to compare endoscopic findings in the larynx and trachea of children who had undergone prior endotracheal intubation with findings in children who had not been intubated before.

Malformation and stenosis of the cricoid cartilage in association with Larsen's syndrome

Three patients with the typical features of Larsens syndrome are described. All three developed severe respiratory symptoms caused by a congenital subglottic stenosis. Tracheotomy and treatment of the stenosis by means of laryngotracheoplasty resulted in complete collapse of the cricoid cartilage and the proximal tracheal skeleton. Lack of rigidity of the laryngeal and tracheal cartilages in patients with Larsens syndrome could well be responsible for this failure. Surgical treatment consisted of resection of the stenotic and collapsed areas and end‐to‐end anastomosis. This therapy was eventually successful in all three patients.

Paediatric otorhinolaryngology in the Netherlands

In the Netherlands, with a population of 16 million, there are three full time paediatric otorhinolaryngologists. They dedicate their working hours exclusively to infants and children, treating virtually all types of ORL pathology, with a main focus on severe and rare diseases, in the only two university children’s hospitals. Two are practising in the Sophia Children’s Hospital, Erasmus MC in Rotterdam, and one in the Wilhelmina Children’s Hospital, University MC, Utrecht. In the other six university ORL departments, the otorhinolaryngology care for infants and children is organized in a different way. Ear surgery in children is performed by an otologist, nose surgery by a rhinologist, and airway surgery by a laryngologist or head and neck surgeon, who also treat adult patients. The third children’s hospital, the Juliana Children’s Hospital in The Hague, not part of a university hospital, employs otorhinolaryngologists who treat adult patients in another hospital. The majority of otorhinolaryngologists in the Netherlands see children together with adults in their practice.