Haytham Kubba

Endoscopy in the assessment of children with nasal obstruction.

Nasal obstruction is common in children, and is often attributed to adenoid enlargement. This prospective study was performed to determine whether routine nasal endoscopy is of value for children undergoing surgery for nasal obstruction. Forty-eight children aged two to nine years undergoing adenoidectomy, and six normal controls, were examined under general anaesthesia with a 4 mm rigid endoscope. A video of the endoscopy was subsequently assessed independently by an observer blinded to the original findings and the presence of nasal symptoms. The endoscopist and independent assessor were in agreement regarding 86 per cent of the findings. Three quarters of the children had abnormalities on endoscopy in addition to enlarged adenoids, and in 23 per cent these were potentially of major clinical significance (unsuspected foreign body, gross septal deviation, gross hypertrophy of the turbinates). Endoscopy produced no post-operative complications and was possible in children as young as two years of age, without decongestants. Nasal endoscopy is a safe, objective and useful means of identifying potentially significant abnormalities in children with nasal obstruction.

Paediatric obstructive sleep apnoea

#### Summary points Habitual snoring occurs in 12% of children in the United Kingdom.1 Two large cross sectional studies from the UK and Italy found that the prevalence of obstructive sleep apnoea in children was 0.7% to 1.8%.1 2 A recent, well designed cross sectional study of 700 children in the United States found that the prevalence of primary snoring was 15.5% and of sleep apnoea 1.2%.3 Delayed diagnosis of obstructive sleep apnoea can lead to neurobehavioural consequences and even serious cardiorespiratory morbidity.4 History and examination alone are insufficient to distinguish reliably those with sleep apnoea from those who simply snore.5 Paediatric obstructive sleep apnoea has completely different clinical features and requires different management strategies from adult obstructive sleep apnoea. In this review we provide an overview of the diagnosis and management of children with obstructive sleep apnoea, from primary to specialist care. The review is based on the best available evidence, which for much of obstructive sleep apnoea comprises longitudinal or cohort studies. Sleep disordered breathing refers to the whole spectrum of breathing disturbance during sleep, from primary snoring through to obstructive apnoea. Obstructive sleep apnoea is defined as a disorder of breathing during sleep that is characterised by prolonged partial upper airway obstruction and/or intermittent complete obstruction that adversely affects ventilation during sleep and disrupts normal sleep patterns.6 Snoring is noisy breathing caused by turbulent airflow …

The role of fibreoptic laryngoscopy in infants with stridor

Stridor in infants may be potentially serious and would require further investigations in all cases. Laryngomalacia is the most common cause of congenital stridor. This is a self-limiting condition with a good prognosis but other causes of stridor should be excluded to enable the surgeon to plan further intervention if needed. Traditionally microlaryngoscopy and bronchoscopy under a general anaesthetic is performed to evaluate the airway. We have investigated the use of the flexible fibreoptic laryngoscope under local anaesthetics in infants with inspiratory stridor. The procedure was performed in the day surgery unit on a non-fasting, non-sedated child. A retrospective analysis of procedures performed between January 1998 and August 1999 was carried out. Of the 43 patients studied, laryngomalacia was diagnosed in 35, vocal cord palsies in six and two infants had a normal larynx. There were no complications during the procedure and only one child required further intervention. The results showed that the combination of fibreoptic laryngoscopy under local anaesthetic with follow-up is a safe, effective and cost effective method of assessing stridor in this group of patients.

Management of dysphonia in children

BACKGROUND Dysphonia is common in children, but practice varies considerably regarding what, if any, investigations are performed and how the condition is managed. Although childhood dysphonia is mostly due to non-serious causes such as voice misuse, very serious pathology such as papillomatosis or malignancy needs occasionally to be excluded, and treatable congenital anomalies such as webs and cysts can be missed. Voice clinics and voice therapy services are now well established in most adult health services in the developed world, but equivalent services for children are less common, at least in the UK. METHODS We retrospectively reviewed the records of all children presenting to our large childrens hospital with a primary complaint of dysphonia between January 2001 and October 2007, in order to determine their management, investigations and final diagnosis. RESULTS We identified 142 children. Case records were found for 137 (97 per cent). Eight-three children were male (61 per cent) and 54 female (39 per cent). Ages ranged from two months to 15 years (median 5.3 years). In 10 children (7 per cent), hoarseness was congenital, presenting as a hoarse, weak cry at birth. In 15 children (11 per cent), onset of hoarseness was related to a specific surgical procedure. The larynx was visualised by mirror alone in 23 children (17 per cent), by awake fibre-optic laryngoscopy in 27 (20 per cent) and by microlaryngoscopy-bronchoscopy under anaesthesia in 42 (31 per cent). Forty children (29 per cent) did not undergo laryngeal visualisation at any time and were diagnosed based on history alone. A further five (4 per cent) were scheduled for direct laryngoscopy but this was not performed due to resolution of symptoms. Voice abuse accounted for 62 (45 per cent) of all diagnoses. CONCLUSIONS Childhood dysphonia accounts for a large number of referrals. There is considerable variation in how these children are managed. A more structured approach to diagnosis and investigation would be beneficial, perhaps within the setting of a dedicated paediatric voice clinic.

Atypical mycobacterial infection of the head and neck in children: a 5-year retrospective review.

OBJECTIVE: We review the management of 31 cases of atypical mycobacterial lymphadenitis presenting to a tertiary referral pediatric otolaryngology department between February 2002 and February 2007. STUDY DESIGN: Retrospective case review. SUBJECTS AND METHODS: Cases were identified by using the hospitals correspondence and pathology databases. Demographic and clinical information was collected. Descriptive and nonparametric inferential statistics (SPSS; SPSS Inc, Chicago, IL) were calculated. RESULTS: Four patients were treated conservatively with triple-therapy antibiotics. Twenty-seven underwent surgical excision plus 3 months of clarithromycin postoperatively. Thirteen percent developed nodal recurrence; this appeared to be unrelated to the operation performed (χ8 2 = 5.8, P = 0.69) or the management modality used (P = 0.35). Patients with previous surgery were more likely to have recurrent infection (χ2 2 = 9.3, P = 0.01). CONCLUSIONS: In our experience, nodal excision plus postoperative clarithromycin remains the best treatment option for most children, although those with limited disease may benefit from combination antibiotic therapy. Previous incision and drainage leads to high recurrence rates after later excision and therefore, heightened awareness of these infections is essential to ensure appropriate early management.

Tonsillectomy for biopsy in children with unilateral tonsillar enlargement

OBJECTIVE Unilateral tonsillar enlargement (UTE) may be a sign of underlying malignancy and tonsillectomy is often recommended for histology. The limited evidence available suggests that the incidence of malignancy in children with UTE is very low, and that in many cases, the apparent enlargement is due to asymmetry of the mucosa of the tonsillar pillars. The purpose of this study was to evaluate the necessity of tonsillectomy as a routine practice for every case of UTE. METHODS We attempted to identify every child (age < 16 years) undergoing tonsillectomy in our unit from January 1991 to January 2000 where the indication for surgery was UTE. Patients were excluded if the primary indication for surgery was anything other than UTE. The case notes and pathology records were reviewed. RESULTS Exactly 47 children were identified, aged between 4 and 15 years of age (mean 9.5 years), of whom 29 (62%) were girls. In all cases, the tonsillar asymmetry was noted by the otolaryngologist, but had not been noted by the patient or parents, or commented on by the referring General Practitioner. Eighteen of the children (38%) had no history of sore throats. No malignancies were encountered. When the tonsils were measured by the pathologist after excision, the actual degree of asymmetry in size ranged from 0 to 25 mm. In seven cases (15%), the clinically larger tonsil was actually the smaller of the two when examined by the pathologist. In 17 cases (36%) there was no difference in size at all. CONCLUSIONS We conclude that apparent UTE is often spurious, and that many unnecessary tonsillectomies are performed when UTE is taken as an indication for surgery in the absence of any other suspicious features. Tonsillectomy carries risks and clinical observation may be prudent where clinical suspicion is low.

'A parent's kiss': evaluating an unusual method for removing nasal foreign bodies in children

Nasal foreign bodies are a common problem in children. Various techniques have been described for removing the offending articles. Positive pressure techniques have long been described, and have many potential advantages, but are not yet in widespread use. The aim of this study was to evaluate the efficacy, safety and acceptability of a technique of mouth-to-mouth blowing. Of 19 children with intranasal foreign bodies, the technique was successful in 15 (79 per cent). The procedure caused little or no distress to the child, and no complications were encountered. All parents found the technique acceptable. This technique for nasal foreign body removal is, as far as we are aware, the first to be subjected to any prospective evaluation of effectiveness. We suggest that it should be used as the first line management for removing nasal foreign bodies in young children.

The external rhinoplasty approach for congenital nasal lesions in children

OBJECTIVE Congenital lesions of the nose can be challenging to excise. While some lesions carry infection risks, in most cases surgery is primarily performed for cosmesis. Some lesions may extend up to the skull base and this can occasionally be missed on MRI scans. Surgical access has to allow complete excision in all circumstances, but access must be balanced against cosmetic results. We present our experience of the external rhinoplasty approach which allows wide access with little visible scarring. METHODS Retrospective chart review of all cases performed between November 2003 and October 2009. RESULTS 15 children underwent excisional surgery using the external rhinoplasty approach. They were aged 1-5 years at the time of surgery, and 12 were male. Pathology comprised congenital midline nasal dermoid cysts in 13 (of which 4 extended intracranially), extranasal glioma in 1 and non-resolving haemangioma in 1. The surgical approach provided adequate visualisation in all cases. The children with intracranial dermoids had resection and repair of the dura as part of their procedure. No post-operative CSF leaks occurred. One child with nasal dermoid had a small cyst recurrence in the skin of the nasal tip requiring further surgery but no deep recurrences occurred. Follow up ranges from 3 months to 6 years. Children with widened nasal bones before surgery have all shown rapid bony remodelling after surgery. CONCLUSIONS The external rhinoplasty approach offers excellent access in young children, even for intracranial lesions.

Tonsillectomy A Cost-Effective Option for Childhood Sore Throat? Further Analysis of a Randomized Controlled Trial

Objective. To compare the estimated cost-effectiveness of childhood (adeno)tonsillectomy vs medical therapy for recurrent sore throats from the intention-to-treat (ITT) analysis of a randomized controlled trial (RCT) with that modeled on the recorded timing of surgical interventions as observed in all participants irrespective of their original group allocation. Study Design. A pragmatic RCT (trial) with a parallel nonrandomized patient preference group (cohort) of (adeno)tonsillectomy vs medical therapy. Setting. Five secondary care UK otolaryngology departments. Subjects and Methods. Eligible children, aged 4 to 15 years, were enrolled to the trial (268) or cohort (461) groups. Outcomes included sore throat diaries, quality of life, and general practice consultations. The RCT protocol ITT analysis was compared with an as-treated analysis incorporating the cohort group, modeled to reflect the timing of tonsillectomy and the differential switch rates among the original groups. Results. >In the RCT ITT analysis, tonsillectomy saved 3.5 sore throats, whereas the as-treated model suggested an average reduction of more than 8 sore throats in 2 years for surgery within 10 weeks of consultation, falling to only 3.5 twelve months later due to the spontaneous improvement in the medical therapy group. Conclusion. In eligible UK school-age children, tonsillectomy can save up to 8 sore throats at a reasonable cost, if performed promptly. Further prospective data collection, accounting for baseline and per-trial preferences and choice, is urgently needed.OBJECTIVE To compare the estimated cost-effectiveness of childhood (adeno)tonsillectomy vs medical therapy for recurrent sore throats from the intention-to-treat (ITT) analysis of a randomized controlled trial (RCT) with that modeled on the recorded timing of surgical interventions as observed in all participants irrespective of their original group allocation. STUDY DESIGN A pragmatic RCT (trial) with a parallel nonrandomized patient preference group (cohort) of (adeno)tonsillectomy vs medical therapy. SETTING Five secondary care UK otolaryngology departments. SUBJECTS AND METHODS Eligible children, aged 4 to 15 years, were enrolled to the trial (268) or cohort (461) groups. Outcomes included sore throat diaries, quality of life, and general practice consultations. The RCT protocol ITT analysis was compared with an as-treated analysis incorporating the cohort group, modeled to reflect the timing of tonsillectomy and the differential switch rates among the original groups. RESULTS In the RCT ITT analysis, tonsillectomy saved 3.5 sore throats, whereas the as-treated model suggested an average reduction of more than 8 sore throats in 2 years for surgery within 10 weeks of consultation, falling to only 3.5 twelve months later due to the spontaneous improvement in the medical therapy group. CONCLUSION In eligible UK school-age children, tonsillectomy can save up to 8 sore throats at a reasonable cost, if performed promptly. Further prospective data collection, accounting for baseline and per-trial preferences and choice, is urgently needed.

The prevalence of ear, nose and throat disorders in preschool children with Down's syndrome in Glasgow.

Guidelines suggest that all children with Downs syndrome have hearing testing on a regular basis. Since 2004, the ear, nose and throat (ENT), audiology and education services have conducted a joint clinic for annual ENT health and hearing surveillance of all preschool children with Downs syndrome in Greater Glasgow. The aim of this study is to report the prevalence of ENT problems in this well-defined birth cohort, and the proportion of children for whom ENT surgery is required. A prospective database has been kept since 2004, detailing the ENT health status of every child attending the community-based surveillance clinic. Between September 2004 and September 2008, 87 preschool (aged 9 months to 6 years) children with Downs syndrome were sent appointments for the clinic. Of these, 48 (55%) were female and 39 were male. Data were available for 79 (91%). Over the course of the study, 37% were listed for surgery at some point, either adenotonsillectomy for obstructive symptoms or grommet insertion for otitis media with effusion (OME). The prevalence of OME was 93% at age 1, falling to 68% by age 5. None had significant sensorineural hearing impairment. Obstructive symptoms were also common, with 79% of children having either currently symptomatic upper airways obstruction or a history of adenotonsillectomy by age 5. One child had laryngomalacia and two had symptomatic congenital subglottic stenosis. The prevalence of ENT problems in these children is high. Surgical intervention is frequently required. We advocate a proactive approach of regular ENT and audiology surveillance leading to early intervention, with the aim of maximizing health and educational achievement in the long term.