Harlan R. Muntz

Utility of conventional radiography in the diagnosis and management of pediatric airway foreign bodies.

Pediatric airway foreign bodies are potentially life-threatening situations. The otolaryngologist is often consulted to aid in the diagnosis and management of these difficult cases. Although radiographic studies are often obtained, the decision for surgical intervention is usually based on a suspicious history and physical examination. Our hypothesis is that radiographic imaging should not alter the decision for surgical intervention. We retrospectively reviewed the cases of pediatric airway foreign bodies managed by the otolaryngology department at St Louis Childrens Hospital between December 1990 and June 1996 with both radiographic imaging and operative intervention. Ninety-three cases of potential aspiration were identified, with a median patient age of 20 months. The most common presenting signs and symptoms were aspiration event (n = 82), wheezing (n = 76), decreased breath sounds (n = 47), cough (n = 39), respiratory distress (n = 17), fever (n = 16), pneumonia (n = 14), and stridor (n = 7). At the time of endoscopy, 73 patients were found to have an airway foreign body. The sensitivity and specificity of the imaging studies in identifying the presence of an airway foreign body in the 93 patients were 73% and 45%, respectively. Our decision for operative intervention was based on the history and physical examination, and was not changed in the presence of a negative radiographic study. The routine use of radiography should not alter the management of airway foreign bodies, providing that there is a well-equipped endoscopic team familiar with airway foreign bodies.

Sleep Disordered Breathing and Obstructive Sleep Apnea in the Cleft Population

Objectives/Hypothesis: Children with cleft deformities have the tendency for multilevel airway obstruction. The incidence of sleep disordered breathing (SDB) in this population has not been well studied. This study attempts to describe the high incidence and the results of intervention.

Comparison of Topical Medication Delivery Systems after Sinus Surgery

Objectives: To compare the distribution patterns of topical medication delivery systems in the sinonasal region and upper respiratory tract after functional endoscopic sinus surgery.

Should All Newborns Who Undergo Patent Ductus Arteriosus Ligation Be Examined for Vocal Fold Mobility

To determine the incidence of left vocal fold paralysis (LVFP) in premature infants who undergo patent ductus arteriosus (PDA) ligation.

Adenoidectomy and otitis media

Adenoid enlargement has traditionally been considered a factor in otitis media; adenoid size, however, does not appear to be correlated with otitis media occurrence. Presence of pathogenic bacteria in the adenoids of children with otitis media has been shown, and adenoidectomy appears to affect the middle ear primarily by removal of the source of infection in the nasopharynx. Three recent randomized, controlled studies showed the efficacy of adenoidectomy in the treatment of chronic secretory otitis media. In one study comparing no treatment, adenoidectomy, and adenotonsillectomy, a significant benefit was seen with adenoidectomy that was not enhanced by tonsillectomy. Another study that compared adenoidectomy, tympanostomy tubes, and a combination of the two showed a significant reduction in effusion time and less surgical retreatment over 2 years in the two adenoidectomy groups. The third study demonstrated the effect of adenoidectomy in children with recurrent chronic otitis media with effusion after failure of tympanostomy tube insertion. All three studies showed that the effect of adenoidectomy was independent of adenoid size. This review discusses current concepts of adenoid physiology and pathology, the major adenoidectomy studies, and indications for the procedure.

Auricular Cartilage Grafts in Laryngotracheal Reconstruction

Introduction of the anterior cricoid split (decompression) and laryngotracheal reconstruction with costal cartilage graft has resulted in the successful management of many cases of subglottic stenosis. However, the procedure does not allow uniform extubation, and laryngotracheal reconstruction with costal cartilage may be too aggressive for neonates. We have explored the use of autogenous auricular cartilage graft in laryngotracheal reconstruction. Its high rate of success and low morbidity have enabled us to expand the indications. We report our experience in 23 patients with auricular cartilage grafts.

Pediatric invasive fungal rhinosinusitis in immunocompromised children with cancer.

OBJECTIVES: 1) To determine the factors that predispose towards invasive fungal rhinosinusitis (FS) in immunocompromised children with cancer, and 2) to propose practice guidelines for management of pediatric FS in immunocompromised patients. METHODS: Retrospective chart review of 9 patients who developed invasive FS compared to 8 patients who did not develop invasive FS during the study period. Presenting signs and symptoms, nasal endoscopic findings, radiographs, laboratory studies, histologic and microscopic samples, and outcomes were compared. RESULTS: Seventeen consecutive pediatric immunocompromised patients with hematologic and lymphoid neoplasms underwent nasal endoscopy and biopsy for possible FS. Nine patients were diagnosed with 10 episodes of FS; 1 patient developed FS with different organisms on 2 separate occasions separated by 6 months; 8 patients were not diagnosed with FS. Eight patients had acute myelogenous leukemia (AML); 6 patients had acute lymphoblastic leukemia (ALL); 1 patient had Burkitts lymphoma, 1 patient had undifferentiated leukemia; and 1 patient had biphenotypic acute leukemia. All patients with FS had an absolute neutrophil count (ANC) 600 or less (range 0-600). All patients with FS had either persistent fevers or sinus symptoms (facial pain, nasal congestion, rhinorrhea). Sinus CT scans were abnormal in all patients with FS and without FS. Two patients with FS had maxillary sinus retention cysts. Operative endoscopic findings were helpful diagnostically when necrosis or ulceration was found. All patients in the non-FS group normalized their ANCs; 2 of the 9 patients in the FS group did not normalize their ANC. These 2 patients died from disseminated FS or from complications due to their immunosuppression. CONCLUSION/SIGNIFICANCE: All patients with FS had either persistent fevers or symptoms localized to the sinuses (facial pain, nasal congestion, or rhinorrhea). Endoscopic examination was helpful when necrosis was detected. We recommend directed biopsies of suspicious lesions, the middle and inferior turbinate, in immunocompromised, neutropenic pediatric patients with cancer who present with either persistent fevers or localizing symptoms to the sinuses. We favor the use of “rush” biopsies over frozen sections because of the better-quality sections and ability to perform appropriate stains.

Pediatric otolaryngology : principles and practice pathways

Over the past years, pediatric otolaryngology has made great advances and is now a well-recognized subspeciality which cares for the needs of children with ear, nose and throat diseases. This outstanding textbook aims to cover all the different aspects of pediatric otolaryngology. There are 60 chapters divided into six sections. The first section deals with the general care of the pediatric patient, including the role of allergy and immunologic dysfunction, the principles of molecular genetics as well as an important chapter on psychological considerations for pediatric otolaryngologists. The other five sections cover the specific disorders of the head and neck in children including their treatment. Within each section, the chapters are organized so that the reader, starting with structure and function and radiologic evaluation, is able to progress through a comprehensive description of congenital malformations, acute and chronic disorders, complications, traumatic injuries and neoplasms of the ear (Section II), the nose, paranasal sinuses and orbit (Section III), the oral cavity, pharynx and esophagus (Section IV), the larynx, trachea and upper airway (Section V) and the neck (Section VI). This book is well organized, concise and easy to read. Apart from the practical guidelines, two types of useful inserts are given in each chapter: ‘special consideration’ and ‘at a glance’. ‘Special consideration’ is a short sentence highlighting a well-recognized concept, while ‘at a glance’ is a list of important points. Both of these inserts may be of great help to the student and the busy practicing physician alike. It is difficult to give credit to all chapters individually, but I will highlight some of those I found particularly helpful. The chapter on molecular genetics as well as that on the dizzy child and the one on sensorineural hearing loss are particularly well written. The introductions (to pediatric otology, pediatric rhinology, disorders of the upper alimentary tract and of the upper airway) are certainly recommended for reading. The sections on traumatic injuries (to the ear and temporal bone, facial trauma, oral cavity and pharynx, larynx, trachea, esophagus and neck) are very clear. The subject of vocal cord paralysis and that on diagnosis and treatment of acute and chronic airway obstruction in children and adolescents are dealt with in a very comprehensive manner. The book is not dogmatic but tries to expose in each chapter the different therapeutic approaches, encouraging the reader to be constantly aware of the needs of each individual child when planning and recommending treatment. Most of the illustrations are excellent, but some suffer owing to the black-and-white reproduction, and a few others, e.g. those in the chapter on structure and function of the temporal bone, are not first class. A review of the six sections reveals that this textbook provides a powerful resource as a reference for pediatric otolaryngologists and general otolaryngologists. It is highly recommended to ENT residents who need to study the aspects of the subspeciality. It has been a pleasure to read this book and I would certainly recommend that all otolaryngology libraries have a copy for reference. Salvatore Iurato, Bari

Multicenter Interrater and Intrarater Reliability in the Endoscopic Evaluation of Velopharyngeal Insufficiency

OBJECTIVE To explore interrater and intrarater reliability (R (inter) and R (intra), respectively) of a standardized scale applied to nasoendoscopic assessment of velopharyngeal (VP) function, across multiple centers. DESIGN Multicenter blinded R (inter) and R (intra) study. SETTING Eight academic tertiary care centers. PARTICIPANTS Sixteen otolaryngologists from 8 centers. MAIN OUTCOME MEASURES Raters estimated lateral pharyngeal and palatal movement on nasoendoscopic tapes from 50 different patients. Raters were asked to (1) estimate gap size during phonation and (2) note the presence of the Passavant ridge, a midline palatal notch on the nasal surface of the soft palate, and aberrant pulsations. Primary outcome measures were R (inter) and R (intra) coefficients for estimated gap size, lateral wall, and palatal movement; kappa coefficients for the Passavant ridge, a midline palatal notch on the nasal soft palate, and aberrant pulsations were also calculated. RESULTS The R (inter) coefficients were 0.63 for estimated gap size, 0.41 for lateral wall movement, and 0.43 for palate movement; corresponding R (intra) coefficients were 0.86, 0.79, and 0.83, respectively. Interrater kappa values for qualitative features were 0.10 for the Passavant ridge; 0.48 for a notch on the nasal surface of the soft palate, 0.56 for aberrant pulsations, and 0.39 for estimation of gap size. CONCLUSIONS In these data, there was good R (intra) and fair R (inter) when using the Golding-Kushner scale for rating VP function based on nasoendoscopy. Estimates of VP gap size demonstrate higher reliability coefficients than total lateral wall, mean palate estimates, and categorical estimate of gap size. The reliability of rating qualitative characteristics (ie, the presence of the Passavant ridge, aberrant pulsations, and notch on the nasal surface of the soft palate) is variable.

Carotid sinus hypersensitivity: a cause of syncope in patients with tumors of the head and neck.

Carotid sinus hypersensitivity secondary to the presence of an underlying head and neck cancer has only recently been discussed in the literature. We present seven cases of carotid sinus hypersensitivity, each with paroxysmal bradycardia and hypotension associated both with and without palpation of the carotid bifucation. A discussion of the anatomy and the etiology of the hypersensitivity is given. Currently available therapeutic modalities are discussed in regard to their efficacy in this study.