James D. Sidman

Distraction Osteogenesis of the Mandible for Airway Obstruction in Children

Objectives Objectives of the study were to determine the effectiveness of distraction osteogenesis of the mandible to relieve airway obstruction in children with tongue‐base airway obstruction and to describe the new surgical techniques developed for use in infants and young children.

Airway interventions in children with Pierre Robin Sequence.

Objective To describe the interventions required for successful airway management in children with Pierre Robin Sequence (PRS). Study Design Case series. Subjects and Methods The records of both a cleft and craniofacial clinic and a pediatric otolaryngology clinic were searched, and all children with PRS were identified. Data concerning feeding interventions, airway interventions, and comorbid conditions were extracted. Results Seventy-four cases of PRS were identified. Thirty eight of the 74 children required airway intervention other than prone positioning. Fourteen of these 38 were managed nonsurgically with nasopharyngeal airway and/or short-term endotracheal intubation, whereas the remaining 24 required surgical intervention. Eighteen of the 24 underwent distraction osteogenesis of the mandible, one underwent tracheostomy, and five underwent tracheostomy followed by eventual distraction. Conclusion In our series, over 50 percent of children with PRS required an airway intervention. These were both nonsurgical and surgical. As otolaryngologists, we must be prepared for the challenges children with PRS may present and the interventions that may be necessary to successfully manage these difficult airways.

Topical ofloxacin versus systemic amoxicillin/clavulanate in purulent otorrhea in children with tympanostomy tubes.

Acute otitis media (AOM) in children with tympanostomy tubes in place typically presents with otorrhea (draining ear). Because therapy is not standardized, various topical and systemic antibiotics of unproven efficacy and safety have been used in this indication. This study compared the safety and efficacy of ofloxacin otic solution, 0.3% (OFLX) with that of Augmentin oral suspension (AUG) in pediatric subjects 1-12 years of age with tympanostomy tubes and acute purulent otorrhea. Subjects were randomized to receive 10d of OFLX, 0.25 ml topically bid, or of AUG, 40 mg/kg per day. Audiometry was performed in subjects > or =4 years of age. Overall cure rate for clinically evaluable subjects was 76% with OFLX (n = 140) and 69% with AUG (n = 146; P = 0.169). Overall eradication rates for OFLX and AUG were similar for Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis and were superior with OFLX for Staphylococcus aureus and Pseudomonas aeruginosa (P<0.05 for both). OFLX had a greater overall pathogen eradication rate (96% vs. 67%; P<0.001). Treatment-related adverse event rates were 31% for AUG and 6% for OFLX (P<0.001). Neither treatment significantly altered hearing acuity. Topical ofloxacin 0.3% otic solution 0.25 ml bid was as effective and better tolerated than systemic therapy with Augmentin oral suspension 40 mg/kg per day in treating AOM in children with tympanostomy tubes.

Resolving Feeding Difficulties With Early Airway Intervention in Pierre Robin Sequence

Objectives/Hypothesis: To observe rates of gastrostomy tube (g‐tube) placement in Pierre Robin Sequence (PRS) and to determine whether relieving airway obstruction solves feeding difficulties.

Mandibular Distraction Osteogenesis in Infants Younger Than 3 Months

OBJECTIVES To examine the long-term outcomes and complications in infants with upper airway obstruction and feeding difficulty who underwent bilateral mandibular distraction osteogenesis (MDO) within the first 3 months of life and to identify any preoperative characteristics that may predict the long-term outcome following early MDO intervention for airway obstruction. METHODS An institutional, retrospective medical chart review was performed. Inclusion criteria were bilateral MDO performed at an age younger than 3 months, with a minimum follow-up of 3 years. A quantitative outcome measures scale was developed, and patients were scored based on long-term postoperative complications as well as airway and feeding goals. Factors such as need for an additional surgical procedure were also considered. RESULTS Nineteen children were identified as having undergone MDO before 3 months of age and having more than 3 years of follow-up data. The mean age at distraction was 4.8 weeks (range, 5 days-12 weeks); the mean length of follow-up was 5.6 years (range, 37-122 months). Of these 19 patients, 14 had isolated Pierre Robin sequence (PRS) and 5 had syndromic PRS. All patients with isolated PRS had a good or intermediate long-term result. Infants with comorbidities such as developmental delay, seizures, or arthrogryposis had the poorest outcomes. CONCLUSIONS Bilateral MDO is a relatively safe and effective means of treating airway obstruction and feeding difficulty in infants with PRS. The effects of this procedure, which carries a relatively low morbidity, persist through early childhood in most patients.

Distraction osteogenesis of the mandible.

Purpose of reviewAirway obstruction and craniofacial deformities resulting from mandibular deficiency are challenging and complex clinical problems. Mandibular distraction osteogenesis is playing a rapidly expanding role in the treatment of these children and has supplanted traditional management techniques in many centers. Several recent studies have reviewed clinical experience, described technical refinements, and addressed issues in patient selection and preoperative workup. Recent findingsThe extension of mandibular distraction osteogenesis to newborns with Pierre Robin sequence or craniofacial syndromes associated with micrognathia and airway obstruction has radically altered treatment protocols at several institutions. Early bilateral mandibular distraction has obviated tracheostomy in most newborns, with low operative morbidity. In addition, early decannulation and resolution of obstruction has occurred when mandibular distraction osteogenesis was applied to selected micrognathic children. Some of these patients were tracheotomized and others presented with severe obstructive symptoms. Studies have described success with external and internal distraction techniques. Recent publications have also demonstrated the surgeon’s ability to mold the regenerate safely, the dynamic characteristics of the consolidation phase, and success with secondary and tertiary distraction. SummaryAfter 15 years of clinical use in children for craniofacial deformities, recent advances in distraction osteogenesis have obviated tracheostomy in most newborns with micrognathia and severe airway obstruction. Applications of this technique to children with airway issues related to micrognathia or retrognathia have been rapidly expanding. In addition, refinements in distraction technique have advanced treatment of nonairway-related mandibular deformities.

Sinus surgery in cystic fibrosis patients: comparison of sinus and lower airway cultures.

OBJECTIVE The aim of this study is to determine whether cross-infection occurs between infections in the sinuses and lower airways in Cystic Fibrosis patients, and to determine whether the infections begin in the sinuses before spreading to the lungs. METHODS Retrospective study of pediatric Cystic Fibrosis patients who underwent simultaneous sinus surgery and bronchial washings. The results of the cultures were reviewed to determine if the same organisms colonized both the sinuses and lower airways. RESULTS Staphylococcus aureus (Staph. Aureus) was found in 40.7% of the sinuses but only 33.3% of the lower airways. One patient had Staph. Aureus in the lower airway but not the sinuses. Pseudomonas, Hemophilus Influenza, and Moraxella showed similar patterns: multiple instances of positive sinus cultures and negative bronchial cultures, but only a small number of cases with positive lower airway cultures and negative sinus cultures. CONCLUSION The data showed that as patients age, they are more likely to have infections in both upper and lower airways, but infections start in the upper airways at a younger age. In many cases, organisms were cultured from sinuses in patients who had negative lower airway cultures. In only a few instances, organisms grew in the lower airways and not the sinuses. In most cases, the bacteria that caused sinus infections at a young age caused the lung infections in older patients. This is the paper to show that bacteria spread from the sinuses to the lungs to cause infections in Cystic Fibrosis patients, and not vice-versa.

Pierre Robin Sequence: Evaluation, Management, Indications for Surgery, and Pitfalls

This article reviews the various treatment methods for airway obstruction and feeding difficulty in infants with Pierre Robin Sequence (PRS), and highlights the benefits and limitations of early mandibular distraction osteogenesis in particular as a way of managing both airway obstruction and feeding difficulty in these children.

Distraction osteogenesis of the mandible for airway obstruction in children: Long-term results

Objective: To determine the long-term results of distraction osteogenesis of the mandible for upper airway obstruction in children with micrognathia. Study Design: Case series with chart review. Setting: Tertiary care childrens hospital. Subjects and Methods: The records of a pediatric otolaryngology practice and tertiary childrens hospital were searched for patients treated with bilateral mandibular distraction osteogenesis for upper airway obstruction. Patients were selected if greater than three years of follow-up data were available. Data were analyzed for airway and feeding outcomes, and long-term surgical complications were identified. Results: Thirty-two patients met study criteria. Of the 11 patients who had tracheotomy prior to distraction, seven were decannulated after the procedure. Seventeen patients needed perioperative gastrostomy. Seven are now able to feed orally. Fifteen patients treated with mandibular distraction were able to avoid gastrostomy tube placement altogether. The complication of open bite deformity was experienced by nine patients (28%). Five of 32 patients (16%) had tooth malformation, tooth loss, or dentigerous cyst formation while an additional three patients (9%) had long-term facial nerve injury. Nineteen patients (59%) were under three months old at the time of their distraction. Only one of these patients (5.2%) required an additional distraction procedure. Conclusion: Long-term follow-up data on patients treated with mandibular distraction for upper airway obstruction show sustained airway improvement. Additionally, micrognathic children treated with distraction have improved outcomes in oral feeding with a relatively low rate of long-term complications. It remains important to follow these patients to monitor the need for secondary reconstructive procedures.

Pediatric tracheal and endobronchial tumors: an institutional experience.

OBJECTIVES To report the pathologic findings in cases involving endotracheal and endobronchial tumors in the pediatric population and to describe the presenting symptoms and treatment modalities for endotracheal and endobronchial tumors. DESIGN Retrospective chart review. SETTING Tertiary care childrens hospital. PATIENTS The study included 14 patients with endotracheal and endobronchial tumors. MAIN OUTCOME MEASURES Patients were selected if bronchoscopy was performed to obtain biopsy specimens from the trachea or bronchus. RESULTS There were 14 cases that met the inclusion criteria between 1993 and 2009. The patients ranged in age from 4 to 18 years. The most common presenting symptom was recurrent pneumonia (n = 6), followed by wheezing or asthma that was unresponsive to treatment (n = 4). Nine lesions (64%) were malignant and 5 (36%) were benign. Of the malignant tumors, 5 (55%) were carcinoid, 3 (33%) were mucoepidermoid carcinoma, and 1 was adenoid cystic carcinoma. There were 1 or 2 cases of each of the following benign to intermediate malignant potential lesions: histoplasmosis nodules, chondroid hamartoma, pulmonary chondroma, and inflammatory myofibroblastic tumor. In 12 cases, definitive treatment included surgical resection. Three of these cases required postoperative chemotherapy and radiotherapy. CONCLUSIONS The results of this series suggest that in the pediatric population tracheal and endobronchial tumors are most likely to be carcinoid tumors or mucoepidermoid carcinomas, both malignant processes. For patients with recurrent pneumonias or chronic wheezing, an occult tumor is a diagnostic consideration that may require additional studies.