J. Paul Moxham

Role of Tonsillectomy in PFAPA Syndrome.

OBJECTIVE To examine the efficacy of tonsillectomy in ameliorating symptoms and preventing recurrence of episodes in children with PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenitis). DESIGN Retrospective case series. SETTING Tertiary care childrens hospital. PATIENTS Patients who presented to a major tertiary teaching hospital in Vancouver, British Columbia, Canada, between 2000 and 2004 with the diagnosis of PFAPA syndrome or for whom the diagnosis was made on their initial consultation. INTERVENTION Tonsillectomy. MAIN OUTCOME MEASURES Resolution of symptoms at 3, 12, and 24 months after tonsillectomy. RESULTS Eight of the 9 patients achieved complete remission within 3 months. In the remaining patient, the frequency of episodes decreased from every 2 weeks to once every 3 to 4 months. This patient eventually had resolution of symptoms at 2 years after tonsillectomy. No complications resulted from the tonsillectomy. CONCLUSION Tonsillectomy is a viable treatment option for patients with PFAPA syndrome.

Foreign body aspiration in infants and toddlers: recent trends in British Columbia.

OBJECTIVES The objectives of this study were to (1) examine recent trends in the demographics and presentation of children with foreign body aspiration at British Columbias Childrens Hospital and (2) develop safety guidelines regarding feeding nuts and other hard, crunchy foods to infants and toddlers. METHODS The methods used were a retrospective chart review and a review of swallowing mechanics in early childhood. RESULTS Between July 1997 and July 2001, 51 children under 3 years of age underwent rigid bronchoscopy for suspected foreign body aspiration. Of these patients, 27 (53%) were 18 months of age or younger. Of these 27 infants and toddlers, 24 (89%) had a witnessed choking event and 22 (81%) had an airway foreign body. Nuts, raw carrots, and popcorn kernels accounted for 14 (64%) of the foreign bodies aspirated by these infants and toddlers. Before 2 years of age, children are poorly equipped to grind and swallow hard, crunchy food because they lack second molars and are still adjusting to the descent of the larynx. CONCLUSIONS Infants and toddlers in British Columbia have been aspirating foreign bodies at an alarmingly high rate. Most cases would have been prevented with better public awareness. Caregivers should be informed that children under 3 years of age should never be fed nuts or other hard, crunchy foods. A public awareness campaign is warranted.

Assessment of Vocal Fold Mobility Before and After Cardiothoracic Surgery in Children

OBJECTIVES To assess the incidence of vocal fold immobility (VFI) after cardiothoracic surgery in children and to determine the factors potentially associated with this outcome. METHODS Flexible laryngoscopy to assess vocal fold mobility was performed before surgery and within 72 hours after extubation in 100 pediatric patients who underwent cardiothoracic procedures. The 2 operating surgeons recorded the surgical technique and their impression of possible injury to the recurrent laryngeal nerve. The presence of laryngeal symptoms, such as stridor, hoarseness, and strength of cry, after extubation was documented. RESULTS Of 100 children included in this study, 8 had VFI after surgery. Univariate analyses showed that these 8 patients were younger and weighed less than the patients with normal vocal fold movement. Monopolar cautery was used in all patients with VFI. On univariate analysis, factors statistically significantly associated with VFI were circulatory arrest and dissection or ligation of the patent ductus arteriosus, left pulmonary artery, right pulmonary artery, or descending aorta. However, multivariate analyses failed to show these associations. CONCLUSIONS The incidence of VFI after cardiothoracic surgery in our population of children was 8.0% (8 of 100). Of several factors found to be potentially associated with VFI on univariate analysis, none were significant on multivariate analysis. This may be a result of the few patients with VFI. A larger multicenter prospective study would be needed to definitively identify factors associated with the outcome of VFI.

Electrosurgical adenoid ablation.

OBJECTIVE The technique of adenoidectomy has undergone many refinements over the years with, most recently, the addition of electrosurgery alone as a viable method for removal of adenoid tissue. Several studies have suggested good efficacy with this method. The objective of this study is to examine the effectiveness of adenoidectomy by electrosurgical ablation by the following measures: reduction of the adenoid size, blood loss, and postoperative complications. DESIGN AND METHODS In this prospective study, we reviewed patients who underwent electrosurgical adenoid ablation for either nasal obstructive symptoms or chronic otitis media with effusion requiring a second or greater set of pressure equalization tubes and adenoidectomy. Preoperative and postoperative videonasopharyngoscopy were performed and evaluated. A grading system for adenoid size for the endoscopic parameters was used. The amount of blood loss and postoperative complications were recorded. RESULTS On preoperative nasopharyngoscopy, 7 of 23 children had a grade II adenoid size, 15 of 23 had grade III adenoid pads, and 1 of 23 had grade IV adenoid size. Postoperative follow-up at 6 to 8 weeks revealed that 19 of 23 children showed no evidence of adenoid tissue. Three of 23 children had only tiny residual tissue that fell into grade I and one had regrowth of tissue to fit into grade III. Eight patients were seen at 6 months postoperatively, four of whom were followed up to 12 months postoperatively; all showed no evidence of regrowth of adenoid tissue. Average blood loss for the procedure was 2.6 cc. No postoperative complications (postoperative bleed, dehydration requiring hospitalization, infection, velopharyngeal insufficiency) were encountered. CONCLUSIONS Electrosurgical adenoid ablation is a safe method with minimal intraoperative blood loss and postoperative complications. Follow-up at 6 to 8 weeks and up to 1 year postoperatively suggests that it is an effective method in removing adenoid tissue and alleviating nasal obstruction.

The Reliability of Clinical Tonsil Size Grading in Children

IMPORTANCE Because tonsillar enlargement can have substantial ill health effects in children, reliable monitoring and documentation of tonsil size is necessary in clinical settings. Tonsil grading scales potentially allow clinicians to precisely record and communicate changes in tonsil size, but their reliability in a clinical setting has not been studied. OBJECTIVE To assess the interobserver and intraobserver reliability of the Brodsky and Friedman tonsil size grading scales and a novel 3-grade scale. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study between June 2012 and August 2013 at a tertiary pediatric otolaryngology outpatient clinic at British Columbia Childrens Hospital. We recruited 116 children, aged 3 to 14 years, with no major craniofacial abnormalities. For each child, 2 separate tonsil assessments (with at least a 5-minute interval in between) were conducted by 4 independent observers: 2 staff pediatric otolaryngologists, 1 otolaryngology trainee (fellow or resident), and 1 medical student. Each observer assessed and graded tonsil sizes using 3 different scales. MAIN OUTCOMES AND MEASURES Interobserver and intraobserver reliabilities were assessed by deriving the intraclass correlation coefficients (ICCs) and Pearson correlation coefficients, respectively. To discount for any asymmetric scores, all data analysis was conducted on the left tonsil measurement only. RESULTS Mean interobserver reliability was highest for the Brodsky grading scale (ICC, 0.721; Cronbach α, 0.911), followed by the Friedman grading scale (ICC, 0.647; Cronbach α, 0.879) and the 3-grade scale (ICC, 0.599; Cronbach α, 0.857). The mean intraobserver reliabilities for the Brodsky, Friedman, and modified 3-grade scales were 0.954, 0.932, and 0.927, respectively. CONCLUSIONS AND RELEVANCE The Brodsky grading scale offered the highest interobserver and intraobserver reliability when compared with the Friedman and novel 3-grade scales. The results of this study would support the uniform use of the Brodsky scale for future clinical and research work.

Broken glass mercury thermometer: A difficult airway foreign body

CASE REPORT A 6-year-old Asian girl with a mild upper respiratory tract infection had her temperature taken by her mother using an older glass mercury thermometer. The child suddenly screamed and bit the thermometer roughly in the middle as the mother was inserting it into her mouth. She then inhaled a fragment and had an abrupt choking and coughing spell with an episode of cyanosis that lasted for a few seconds. The mother brought the child to her community hospital, where the child was assessed and transferred to British Columbia’s Children’s Hospital after a radiograph suggested that the object was in the left lung. On arrival in the emergency department she was found to be in mild distress, afebrile, and slightly tachypneic. Chest auscultation revealed audible wheezing in the upper lobe of the left lung and no breath sounds in the lower lobe. The radiograph that was taken at the peripheral hospital was reviewed (Fig 1) and found to show a 5-cm segment of the thermometer in the distal left main stem bronchus. Pediatric otolaryngology then reviewed the patient. An attempt was made to obtain a duplicate of the thermometer but none was readily available. Pediatric anesthesia was contacted, and after a review, the patient was taken to the operating room for a rigid bronchoscopy to attempt removal of the foreign body. Under general anesthesia with the patient breathing spontaneously, a 4.0 rigid bronchoscope was inserted under a laryngoscope blade and the tracheobronchial tree was examined. The cords were slightly edematous and erythematous, but the trachea was otherwise normal and the right main stem and more distal bronchi on the right were all unremarkable. On entering the left main stem bronchus, several small ( 1to 2-mm) fragments of glass were encountered and removed using optical grasping forceps. Once removed, some thick secretions were suctioned and then the fractured From the Division of Paediatric Otolaryngology–Head and Neck Surgery, British Columbia’s Children’s Hospital, University of British Columbia. Reprint requests: J. Paul Moxham, MD, FRCSC, Paediatric Otolaryngology Clinic, British Columbia’s Children’s Hospital, 4480 Oak St, Vancouver, British Columbia, Canada V6H 3V4; e-mail, jpmoxham@hotmail.com. Otolaryngol Head Neck Surg 2002;127:339-41 Copyright

Oncostatin‐M Enhances Osteoinduction in a Rabbit Critical Calvarial Defect Model

Introduction: Oncostatin‐M (OSM) is a member of the interleukin‐6 family of cytokines with controversial roles in bone homeostasis. Evidence supports a role in bone regulation, but the balance between healing promotion and acceleration of bone destruction is unclear. It is also uncertain as to whether these varied responses may be dose dependent or related to interactions with other growth factors within the bone microenvironment.

Casting a look at pediatric plastic bronchitis

OBJECTIVES To review clinical presentations and management strategies for children with plastic bronchitis. METHODS Retrospective chart review. RESULTS Seven patients required rigid bronchoscopy to remove bronchial casts over a 17-year study period. Mean age at presentation was 60 months. Mean follow-up was 53 months. Co-morbidities included: congenital heart disease (n=3), chronic pulmonary disorders (n=2) and sickle cell disease (n=1). 4 patients required multiple bronchoscopies for recurrent casts. Adjunctive topical therapies were administered in all 7 patients, without complication. Rigid bronchoscopy for cast removal was performed in 2 patients who were on extra-corporal membrane oxygenation (ECMO), using special precautions to safeguard the ECMO catheters. CONCLUSIONS Bronchial casts in children may present acutely or sub-acutely. Recurrent casts are unusual; however, in combination with severe cardiac disease may lead to mortality. Adjunctive topical therapies are still under investigation. Special safeguards for ECMO catheters are imperative. This case series complements and adds to the International Plastic Bronchitis Registry.

Cat Scratch Disease Presenting as Acute Mastoiditis

OBJECTIVE To present the first published case of Cat Scratch Disease presenting as acute mastoiditis and review the relevant literature to discuss the Otolaryngologic manifestations of this disease and its treatment. DESIGN A case report and literature review of the Otolaryngologic manifestations of Cat Scratch Disease. METHODS A case report of a clinical scenario followed by a standard literature review. PubMed, EMBASE, and Cochrane database were used to find articles related to the Otolaryngologic manifestations of Cat Scratch Disease. RESULTS A 6 year-old female presented to the Otolaryngologist with the typical appearance of acute mastoiditis. CT Scan confirmed breakdown of the osseous septae of the mastoid and mastoidectomy was undertaken. Granulation tissue and infected lymph nodes adjacent to the mastoid cortex were positive for Cat Scratch Disease. The patient was treated expectantly and recovered uneventfully. CONCLUSION This is the first literature report of Cat Scratch Disease presenting as an acute mastoiditis.

Transforming growth factor-β1 shows an incremental osteoinductive dose-response relationship†

To determine if there is a dose–response curve for TGF‐β1 in a rabbit calvarial defect model.