Jacqueline E. Jones

Current trends in pediatric tracheotomy

A retrospective analysis was performed on 103 pediatric patients, less than 5 years of age, undergoing tracheotomy at New York Hospital between 1980 and 1990. Charts were reviewed with respect to primary diagnosis, indication for tracheotomy, duration of the tracheotomy, complication rate and mortality rate. Approximately 62% of the tracheotomies were performed in patients less than 12 months of age, with the most common indication being an acquired or congenital airway abnormality. The number of patients receiving tracheotomies for neurological disorders, however, increased more than threefold over the course of this review. Approximately one-third of the patients experienced immediate, early or delayed complications. There was a significant correlation between the complication rate and weight at the time of the tracheotomy as well as the degree of prematurity of the child. Over one half of the infants under 2000 g suffered complications. A mortality rate of 2.9% was noted in our study with mucous plugging of the tracheotomy being the most common etiology of death.

Surgical Management of Congenital Saccular Cysts of the Larynx

Congenital saccular cysts of the larynx are unusual lesions that commonly present with respiratory obstruction in infants and children. The saccular cyst may result from an atresia of the laryngeal saccule orifice or may represent the retention of mucus in the collecting ducts of submucosal glands located around the ventricle. Traditionally, the treatment of the lesions has been endoscopic unroofing or marsupialization. Frequently, this modality requires multiple procedures as well as concomitant tracheotomy. There also have been reports of acquired subglottic stenosis. We have found that removal of the recurrent saccular cyst can be achieved relatively safely and effectively via a lateral cervical approach to the thyrohyoid membrane. We review our experience with four patients with congenital saccular cysts and detail the evaluation and surgical management of these lesions.

Complications of Adenotonsillectomy in Patients Younger Than 3 Years

OBJECTIVE To evaluate the complication rate for adenotonsillectomy in children younger than 3 years, without a diagnosis of severe obstructive sleep apnea, to assess the necessity for postoperative inpatient admission. DESIGN Retrospective medical record review (January 1, 2003, through October 31, 2009). SETTING Tertiary care academic medical center. PATIENTS Retrospective medical record review of 105 patients younger than 3 years who underwent adenotonsillectomy performed by a single surgeon. Nineteen patients were excluded from our review because of incomplete medical records or severe underlying disease, leaving a total of 86 patients with medical records available for inclusion in our study. Patient medical records were deidentified and reviewed for age, sex, indications for surgery, intraoperative and perioperative interventions, and postoperative complications. One child with a diagnosis of severe obstructive sleep apnea was excluded from the study. MAIN OUTCOME MEASURES Complications, including bleeding, dehydration requiring admission, and airway intervention, during the intraoperative or perioperative period were recorded. RESULTS The mean age of the study population was approximately 27.5 months (range, 13-35 months), with most children (76.5%) between 23 and 31 months of age. Among the patients whose records were reviewed, 80 (93.0%) did not experience any intraoperative or postoperative complications. Dehydration was the most common complication and was the cause of all documented readmissions (4.7%) in our patients who ranged in age from 14 to 30 months. Two patients had other complications, reactive airway disease (n=1) and postoperative fever (n=1), which were identified and treated in the postanesthesia care unit, resulting in same-day discharge. No airway complications were noted in our study. CONCLUSIONS Our study reveals a low complication rate in children younger than 3 years. The recommendations for mandatory admission for children younger than 3 years should be reexamined. Criteria for inpatient admission for children younger than 3 years should be based on preoperative and postoperative clinical evaluation of the patient and an evaluation of the family resources for adequately caring for young children at home in the postoperative period. These recommendations apply only to otherwise healthy children (American Society of Anesthesiologists classifications I and II) without a diagnosis of severe obstructive sleep apnea syndrome.

Congenital Bony Nasal Cavity Deformities

Although the most common form of nasal obstruction in neonates is soft tissue edema, congenital bony nasal deformities are being recognized as an important cause of newborn airway obstruction. In addition to the well described choanal atresia, CT imaging of the newborn in respiratory distress reveals two other forms of bony nasal cavity deformities: nasal pyriform aperture stenosis and nasal cavity stenosis. All of the three types of bony nasal cavity deformities have characteristic anatomical features, are associated with distinctive congenital anomalies, and are postulated to have differing embryological causes. Five patients with congenital bony nasal cavity deformities are presented. These cases illustrate the clinical and radiological presentation of varied types of congenital nasal cavity obstruction as well as the criteria used to guide clinical management.

Large intraosseous arteriovenous malformation of the maxilla - a case report with review of literature.

Large intraosseous arteriovenous malformations (AVM) of the maxilla are rare lesions, which are probably hamartomas. We report a case of an 8-year-old child who presented with exsanguinating hemorrhage after an attempted dental biopsy. The management of dental intraosseous AVMs includes transarterial embolization and direct intralesional injection of liquid acrylic (NBCA). This approach avoids mutilating surgery and its sequelae in children. We present this case for its rarity and the intralesional use of acrylic glue in its management.

Duration-Related Efficacy of Postoperative Antibiotics Following Pediatric Tonsillectomy: A Prospective, Randomized, Placebo-Controlled Trial

OBJECTIVE To determine whether a 3-day course of postoperative antibiotics is as effective as a 7-day course in reducing pain and reducing time to resumption of a normal diet and level of activity following pediatric tonsillectomy. DESIGN A prospective, randomized, placebo-controlled trial. SETTING Academic medical center. PATIENTS Forty-nine patients were enrolled in the study. Preoperative demographic information was obtained. INTERVENTIONS Tonsillectomy with or without adenoidectomy was performed by the senior author (J.J.) using electrocautery. Patients were randomized to receive either a 3- or 7-day course of amoxicillin. MAIN OUTCOME MEASURES Parents were asked to record the following information: analgesic use for the first 7 postoperative days, postoperative days the child initiated his or her usual diet and level of activity, and medical treatment for oral hemorrhage or dehydration. RESULTS Of the 49 patients, 26 were randomized to receive 7 days of postoperative antibiotics (group A) and 23 to receive 3 days of antibiotics, followed by 4 days of placebo (group B). Results were obtained for 47 of the enrolled patients (96%). No statistically significant difference was noted between the 2 groups with regard to postoperative pain or time to resumption of a normal diet and level of activity. CONCLUSION A 3-day course of antibiotics following pediatric tonsillectomy is as effective as a 7-day course with regard to postoperative analgesic use and resumption of normal diet and level of activity. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00662987.

Role of Bronchoalveolar Lavage in Hospitalized Pediatric Patients

Bronchoalveolar lavage (BAL) has been shown to be a rapid, relatively safe, and relatively noninvasive diagnostic procedure. Theoretically, BAL can be performed on all children hospitalized for pneumonia resistant to oral antibiotics, though practically and economically, this is not feasible. A 1-year retrospective review was conducted to define a cost-effective role for BAL in the management of hospitalized children with resistant pneumonia. The data revealed identification of at least one pathogen in 87% of sputum samples and in 95% of BAL specimens. Sputum samples provided the same information as the more invasive BAL technique in 60% of patients who had both sputum and BAL obtained for culture. Recommendations are made for the use of BAL as a diagnostic tool in the hospitalized child with resistant pneumonia.