Ian N. Jacobs

Use of intranasal fentanyl in children undergoing myringotomy and tube placement during halothane and sevoflurane anesthesia.

BackgroundMany children are restless, disoriented, and inconsolable immediately after bilateral myringotomy and tympanosotomy tube placement (BMT). Rapid emergence from sevoflurane anesthesia and postoperative pain may increase emergence agitation. The authors first determined serum fentanyl concentrations in a two-phase study of intranasal fentanyl. The second phase was a prospective, placebo-controlled, double-blind study to determine the efficacy of intranasal fentanyl in reducing emergence agitation after sevoflurane or halothane anesthesia. MethodsIn phase 1, 26 children with American Society of Anesthesiologists (ASA) physical status I or II who were scheduled for BMT received intranasal fentanyl, 2 &mgr;g/kg, during a standardized anesthetic. Serum fentanyl concentrations in blood samples drawn at emergence and at postanesthesia care unit (PACU) discharge were determined by radioimmunoassay. In phase 2, 265 children with ASA physical status I or II were randomized to receive sevoflurane or halothane anesthesia along with either intranasal fentanyl (2 &mgr;g/kg) or saline. Postoperative agitation, Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) scores, and satisfaction of PACU nurses and parents with the anesthetic technique were evaluated. ResultsIn phase 1, the mean fentanyl concentrations at 10 ± 4 min (mean ± SD) and 34 ± 9 min after administering intranasal fentanyl were 0.80 ± 0.28 and 0.64 ± 0.25 ng/ml, respectively. In phase 2, the incidence of severe agitation, highest CHEOPS scores, and heart rate in the PACU were decreased with intranasal fentanyl. There were no differences between sevoflurane and halothane in these measures and in times to hospital discharge. The incidence of postoperative vomiting, hypoxemia, and slow respiratory rates were not increased with fentanyl. ConclusionsSerum fentanyl concentrations after intranasal administration exceed the minimum effective steady state concentration for analgesia in adults. The use of intranasal fentanyl during halothane or sevoflurane anesthesia for BMT is associated with diminished postoperative agitation without an increase in vomiting, hypoxemia, or discharge times.

Clinical consensus statement: tracheostomy care.

Objective This clinical consensus statement (CCS) aims to improve care for pediatric and adult patients with a tracheostomy tube. Approaches to tracheostomy care are currently inconsistent among clinicians and between different institutions. The goal is to reduce variations in practice when managing patients with a tracheostomy to minimize complications. Methods A formal literature search was conducted to identify evidence gaps and refine the scope of this consensus statement. The modified Delphi method was used to refine expert opinion and facilitate a consensus position. Panel members were asked to complete 2 scale-based surveys addressing different aspects of pediatric and adult tracheostomy care. Each survey was followed by a conference call during which results were presented and statements discussed. Results The panel achieved consensus on 77 statements; another 39 were dropped because of lack of consensus. Consensus was reached on statements that address initial tracheostomy tube change, management of emergencies and complications, prerequisites for decannulation, management of tube cuffs and communication devices, and specific patient and caregiver education needs. Conclusion The consensus panel agreed on statements that address the continuum of care, from initial tube management to complications in children and adults with a tracheostomy. The panel also highlighted areas where consensus could not be reached and where more research is needed. This consensus statement should be used by physicians, nurses, and other stakeholders caring for patients with a tracheostomy.

Percutaneous sclerotherapy in neonatal and infant head and neck lymphatic malformations: a single center experience

PURPOSE To evaluate the clinical outcomes of percutaneous sclerotherapy for congenital head and neck lymphatic malformations in our institution. MATERIALS AND METHODS Over a 7-year period, 17 children (10 M, 7 F) mean age 5.8 months (5 days to 13 months) underwent 49 sclerotherapy procedures for congenital head and neck malformations. The imaging and clinical records were reviewed for each patient. Ten of 17 had macrocystic disease; 7 of 17 had microcystic disease. Imaging response was categorized by volume reductions of 0% to 25%, 25% to 50%, 50% to 75%, or 75% to 100%. A concentration of 10 mg/mL doxycycline was used routinely via catheter in 3 instillations with a dose range of 50 to 500 mg per session as per our standard protocol in 17 of 17 patients. In more recent patients, systemic doxycycline levels were obtained after instillations. Additional treatments included direct injection doxycycline (10/17), instillation of absolute ethanol (7/17) or sodium tetradecyl sulfate (4/17), or a combination of these methods. RESULTS Imaging improvement of ≥ 76% was noted in 11 of 17. Of these, 8 of 11 had macrocystic disease. Four of 17 had 51% to 75% resolution, of which 3/4 were mixed. Two of 17 children had 25% to 50% resolution with a mixed lesion. Seven of 49 peri-procedural complications: hemolytic anemia in 2 infants, hypoglycemic and metabolic acidosis in 3 neonates aged 7 to 10 days, transient hypotension during absolute alcohol instillation in 1 neonate, and self-limiting skin excoriation secondary to peri-catheter leakage of doxycycline in one neonate. Neonates prone to these systemic complications had doxycycline doses of greater than 250 mg and resulted in serum levels of >5 μg/mL but as high as 21 μg/mL. Delayed neural complications occurred in 7 of 49 procedures, Horners syndromes in 4 of 49 procedures, transient left lip weakness in 1 of 49 procedures, right facial nerve palsy in 1 of 49 procedures, and transient left hemidiaphragm paralysis in 1/49 procedures. CONCLUSION Our experience with catheter directed doxycycline sclerotherapy provides excellent results for large macrocystic head and neck lymphatic malformations. Microcystic and mixed lesions continue to provide a therapeutic challenge.

Pediatric button battery injuries: 2013 task force update

Over the last 10 years, there has been a dramatic rise in the incidence of severe injuries involving children who ingest button batteries. Injury can occur rapidly and children can be asymptomatic or demonstrate non-specific symptoms until catastrophic injuries develop over a period of hours or days. Smaller size ingested button batteries will often pass without clinical sequellae; however, batteries 20mm and larger can more easily lodge in the esophagus causing significant damage. In some cases, the battery can erode into the aorta resulting in massive hemorrhage and death. To mitigate against the continued rise in life-threatening injuries, a national Button Battery Task Force was assembled to pursue a multi-faceted approach to injury prevention. This task force includes representatives from medicine, public health, industry, poison control, and government. A recent expert panel discussion at the 2013 American Broncho-Esophagological Association (ABEA) Meeting provided an update on the activities of the task force and is highlighted in this paper.

Use of Helium–Oxygen Mixtures to Relieve Upper Airway Obstruction in a Pediatric Population†

Objectives Helium as a component of inspired gas decreases turbulent flow and airway resistance. Helium–oxygen mixtures have been used since the 1930s in the management of patients with upper airway obstruction. The objective of this study was to evaluate the efficacy of helium–oxygen mixtures in relieving upper airway obstruction in a pediatric population.

Multimodality Education for Airway Endoscopy Skill Development

Objectives: Airway endoscopy is a difficult skill to master. A unique practicum was designed to help otolaryngology residents develop endoscopy skills. The learning modalities included lectures, an animal laboratory, high-fidelity manikins, virtual bronchoscopy simulation, and standardized patients. This study compares the relative subjective value of these learning modalities for skill development and realism. Methods: Participants used a Likert scale (1 = disagree to 5 = agree) and open responses to anonymously rate the efficacy of 5 learning modalities for teaching airway management, endoscopy skills, and clinical leadership and for providing a realistic experience. Results: The results in 2007 were uniformly positive, with mean scores for every category and modality greater than 4 for developing cognitive, psychomotor, and affective skills; managing normal and abnormal conditions; preventing and managing complications; improving endoscopy skills; understanding team process; and experiencing overall and manual “feel” realism. In 2008, the participants were encouraged to more critically evaluate the course. The ratings demonstrated statistically significant differences between the mean scores for 4 of the 9 evaluation categories in 2007 and all 9 categories in 2008. Conclusions: Specific learning modalities (eg, lecture, animal laboratory, high-fidelity manikin, virtual bronchoscopy, standardized patient) were perceived to have different values for teaching airway management, developing endoscopy skills, teaching clinical leadership, and providing a realistic experience. We propose that these learning modalities can be used in a complementary manner.

Laryngeal Electromyography in the Management of Vocal Cord Mobility Problems in Children

Objectives To evaluate the efficacy and clinical usefulness of laryngeal electromyography (EMG) in the evaluation and management of vocal cord mobility problems in children; and to determine the ability of laryngeal EMG to differentiate vocal fold fixation versus paralysis.

Chromosomal and cardiovascular anomalies associated with congenital laryngeal web

OBJECTIVE The purpose of this study was to estimate the frequency of chromosomal and cardiovascular anomalies associated with a congenital laryngeal web. METHODS We reviewed our experience with 25 patients who underwent intervention for a symptomatic congenital laryngeal web between 1988 and 2000, in order to investigate the frequency of associated chromosomal and cardiovascular anomalies. Twelve patients underwent cytogenetic evaluation, including seven that were tested for a chromosome 22q11 deletion by fluorescence in situ hybridization. RESULTS Chromosomal abnormalities were detected in seven of the 12 patients in whom cytogenetic evaluation was performed (28% of the entire cohort), including a chromosome 22q11 deletion in six and trisomy 21 in one. Associated cardiovascular anomalies were diagnosed in nine of the 25 patients, most commonly aortic arch anomalies. Of the patients with cardiovascular anomalies, 55% also had chromosomal alterations, and 71% of patients with chromosomal alterations also had a cardiovascular defect, of which four had the triad of a congenital laryngeal web, a chromosome 22q11 deletion, and congenital cardiovascular anomalies. CONCLUSIONS Chromosomal and cardiovascular anomalies are common in patients with a congenital laryngeal web. A chromosome 22q11 deletion was particularly common, as were the cardiovascular anomalies associated with the chromosome 22q11 deletion syndrome. Accordingly, patients with a congenital laryngeal web should undergo genetic screening, including evaluation for a chromosome 22q11 deletion, and a thorough cardiovascular evaluation, including imaging of the aortic arch. Particular attention should be paid to identifying patients with the triad of a congenital laryngeal web, a chromosome 22q11 deletion, and cardiovascular anomalies, particularly a vascular ring.

Graft healing in laryngotracheal reconstruction : An experimental rabbit model

The actual sequence of events in graft healing in laryngotracheal reconstruction (LTR) is not well understood. To investigate sequential changes in graft healing, we submitted 21 rabbits to LTR with an anterior auricular cartilage graft. They were immediately extubated after surgery, and no stent was used. Rabbits were painlessly sacrificed at 7 different time periods (0, 1, 2, 3, 4, 6, and 10 weeks after surgery). Cross sections of the larynx and graft were cut and stained with hematoxylin-eosin and trichrome. Epithelialization progressed very rapidly and was complete by 21 days. During the 10 weeks, there was a progressive necrosis and resorption of the original graft cartilage. However, neochondrification progressed very rapidly and resulted in excellent structural support of the graft in the airway. Problems, such as infection and granulation tissue formation, were relatively minor and infrequent.

Evolving treatments in the management of laryngotracheal hemangiomas: Will propranolol supplant steroids and surgery?

There has been a dramatic evolution in the treatment of laryngotracheal hemangiomas during the past decade and recent accounts and case reports of propranolol treatment have been encouraging. The purpose of the study is to determine the clinical course and outcomes of treating laryngotracheal hemangiomas at The Childrens Hospital of Philadelphia in the last 8 years with the various modalities. We review with contemporary surgical techniques, including propranolol, and determine the results, limitations and complications. The study was a retrospective review of all patients referred to the Otolaryngology service at The Childrens Hospital of Philadelphia with symptomatic laryngotracheal hemangiomas between January 2002 and December 2010. The study consisted of 30 infants, ranging in age from 1 to 18 months at time of diagnosis. Surgical interventions included open surgical excision, laser surgery, microdebrider excision and/or propranolol therapy. The main outcome measures include improvement in symptoms, decannulation, number of required treatments and airway size. All but two patients underwent an initial trial of steroids. Thirteen patients underwent open surgical excision, 9 requiring cartilage grafts and 12 were done in a single stage. Twelve surgical patients remained asymptomatic. One patient with diffuse mediastinal disease experiencing postoperative airway symptoms despite a normal appearing airway improved on propranolol. Two patients underwent at least 2 laser ablations, 4 responded to systemic steroids alone, and 1 had microdebrider resection. In the last 14 months, 12 patients have had propranolol therapy at a dose of 2mg/kg divided every 8h. Eight patients improved clinically within 1 week of initiating treatment. Four patients failed to respond to propranolol therapy; 1 patient subsequently underwent open excision and the other continued with a tracheostomy for 18 months and finally was decannulated. A third patient had a partial response, but remains relatively asymptomatic. A fourth patient has had no response at all. There were no major complications from propranolol; minor complications included diarrhea and decreased appetite. This study gives an overview of the evolution of hemangioma treatment at our institution over the last 8 years. Surgical excision remains an effective treatment for subglottic hemangiomas. Carefully administered, propranolol may demonstrate efficacy as a first-line agent in most cases avoiding surgery, tracheostomy, prolonged steroids, or as treatment of diffuse and unresectable disease. However, some lesions may be resistant to propranolol and require surgery or long-term steroids.