Jean-Michel Triglia

Severe laryngomalacia: surgical indications and results in 115 patients.

Between 1987 and 1993, 115 children were operated on for severe forms of laryngomalacia in two pediatric ear, nose, and throat (ENT) departments. The criteria used to determine the severity of the illness were selected following short hospitalization periods during which the children received both pediatric and ENT checkups. Based on clinical manifestations and/or the results of pH monitoring gastroesophageal reflux was found to be present in 68% of the children in the study. Detailed analysis and endoscopy were used to differentiate the symptoms that were related to laryngomalacia from those that were caused by other conditions, including mixed‐breathing, swallowing, and sucking difficulties.

Fourth branchial pouch anomalies: A study of six cases and review of the literature

A retrospective study in the ENT departments of the Timone Childrens Hospital in Marseille and the Armand Trousseau Hospital in Paris and a review of the literature was performed in order to update knowledge about fourth branchial pouch anomalies. Over the 12-year period studied, a total of six children were treated: three boys and three girls. The lesions were located on the left side in all cases and infection was the most common manifestation. Clinical presentation ranged from suppurative thyroiditis in most cases to stridor in a few newborns. The most useful diagnostic examinations are CT-scan of the neck and endoscopy of the pyriform sinus. The authors emphasize the need for complete surgical resection including the cyst and fistulous tract down to the pyriform sinus.

Nasal and sinus polyposis in children

Nasal and sinus polyposis in the pediatric population is uncommon and its etiology is unclear. In this 11‐year retrospective study, the authors describe the etiologic features and evaluate the effectiveness of endoscopic sinus surgery in 46 children. Patients were divided into three groups according to whether nasal and sinus polyposis was isolated (n = 14), or associated with either asthma (n = 5) or cystic fibrosis (n = 27). An allergy was present in 10% of patients with isolated polyposis, 80% of patients with polyposis associated with asthma, and 22% of patients with polyposis associated with cystic fibrosis. The indications for surgery were disabling symptoms, especially chronic nasal obstruction, rhinorrhea, and mouth breathing, and failure to respond to medical treatment. No surgical complications were encountered. Most patients reported improvement in quality of life with reduction of nasal obstruction in 83% of cases and rhinorrhea in 61%. Minor asymptomatic recurrence (i.e., a few micropolyps localized on the roof of the ethmoid cavity) was observed in 24% of the cases in this series, and major recurrence with the same functional symptoms as before surgery in 12%. However, recurrences were higher in patients with cystic fibrosis, because minor recurrence with no clinical manifestation was observed in 32% of these cases and major recurrence in 16%. Endoscopic sinus surgery must be decided in collaboration with the pediatric and pulmonary physicians, and must be performed skillfully. With a mean follow‐up of 3.7 years, results in this series are encouraging.

Primary cricotracheal resection in children: indications, technique and outcome

OBJECTIVE Treatment of subglottic stenosis has benefited greatly from development of grafting techniques such as larygontracheoplasty. Meanwhile, cricotracheal resection of the stenotic area and a major part of the cricoid cartilage have been shown to give excellent results in adults. PATIENTS AND METHODS From June 1993 to June 2000, we performed cricotracheal resection, as the primary surgical procedure, for acquired (n=13), congenital (n=2) or mixed (n=l) subglottic stenosis in 16 pediatric patients comprising seven boys and nine girls. At the time of surgery, the mean weight was 16 kg and the mean age was 5 years. Degree of stenosis was classified as grade II in one case, grade III in 12, and grade IV in three. Eight patients underwent two-stage procedures with postoperative tracheostomy. A rolled reinforced silastic stent was placed for a mean period of 20 days and the tracheostomy tube was removed within a mean period of 44 days after stent removal. Eight patients underwent single-stage procedures. The Portex endotracheal tube was used for a mean period of 4 days. RESULTS All patients underwent regular clinical and endoscopic postoperative examination. Mean follow-up was 38 months. No interference with laryngotracheal growth has been noted in any case, including the five with follow-ups longer than 5 years. CONCLUSIONS The indications for laryngotracheoplasty and cricotracheal resection in children with subglottic stenosis are still unclear. Decisions must be made on a case-by-case basis. In this article the authors discuss decisional factors in terms of clinical findings, surgical techniques, potential complications, and outcome.

Primary pediatric neuroblastic tumors of the neck

Neuroblastic tumors are the third most common cause of solid tumors in early childhood. Cervical tumors account for only 5% of cases. In this report, we describe a series of four pediatric neuroblastic tumors of the neck. The histological diagnosis was ganglioneuroblastoma in three cases and neuroblastoma in one case. Presenting signs were solitary cervical mass in two cases and respiratory distress in association with Claude-Bernard Horners syndrome in two cases. Mean age at presentation was 15 months. Cervical computed tomography scan and/or magnetic resonance imaging depicted calcifications within the tumor in 50% of cases and allowed accurate assessment of extension. Increased urine catecholamine levels were observed only in the patient with neuroblastoma. Scintigraphy with [131]iodine-methyliodobenzylguanidine demonstrated selective uptake by the tumor in two cases. Amplification of N-myc oncogene, a documented unfavorable prognostic sign, was not found in any case. Surgical treatment was performed in all patients. Neoadjuvant chemotherapy was performed in one case. All patients underwent regular surveillance. No evidence of recurrence has been observed with a mean follow-up period of 7 years.

Management of subglottic stenosis in infancy and childhood.

Abstract During the 12-year period between June 1987 and June 1999, 141 children underwent curative treatment for subglottic laryngeal stenosis at La Timone Children’s Hospital in Marseille, France. Ninety-six children (68%) were under the age of 5 years; 106 (75%) presented with acquired stenosis and 93 had narrowing involving over 70% of the subglottic lumen. Endoscopic laser surgery was performed in 25 cases and open surgery in 116. Open surgical techniques included laryngotracheoplasty with autologous cartilage interposition in 83 cases, laryngotracheal split in 22, and cricotracheal resection in 11. After decannulation, 132 children (94%) were able to breathe normally through the upper airway. Perspectives for development of new techniques and improvement of conventional methods are discussed.

Arytenoidopexy for bilateral vocal fold paralysis in young children

The purpose of this retrospective study was to describe and evaluate the results of arytenoidopexy performed by the external laterocervical approach in 15 consecutive children presenting bilateral vocal fold paralysis causing life-threatening airway compromise. Mean age at the time of surgery was 20 months and mean follow-up was 42 months. At the end of follow-up all patients were in good health and did not need special care for breathing. No abduction movement has been observed on the opposite vocal fold since arytenoidopexy. One failure subsequently required arytenoidectomy. The findings of this study suggest that arytenoidopexy is an effective surgical treatment for life-threatening bilateral vocal fold paralysis in young children.

Laser cordotomy for the treatment of bilateral vocal cord paralysis in infants

OBJECTIVE Vocal cord paralysis is the second cause of neonatal stridor. Several surgical treatments are proposed in order to avoid tracheotomy or to decanulate patients. Laser posterior partial cordotomy is supposed to be a minimal invasive procedure. The purpose of the study is to share our experience in management of laryngeal paralysis with this technique in infants and appreciate its role in avoiding tracheotomy in infants. DESIGN Retrospective study. PATIENTS The charts of 0-2-year-old patients treated for vocal cord paralysis from 1996 to 2007 are reviewed. Eleven infants with bilateral laryngeal paralysis in adduction presented severe dyspnoea. Tracheotomy was performed in four out of them, proposed in five others. One infant out of 11 underwent long-term intubation, and one presented with progressive dyspnoea. RESULTS The laser posterior partial cordotomy allowed the decanulation after one session (n=2) or avoided tracheotomy (n=5), one patient had significant improvement of his respiratory function. Two patients needed a second session of laser cordotomy and were decanulated. The functional results for the voice and swallowing qualities were subjectively satisfactory. One patient had pejorative evolution. CONCLUSION Posterior partial cordotomy is an effective, minimal invasive technique which can be proposed to avoid tracheotomy in infants with bilateral adduction vocal cord paralysis. No functional sequelae were observed.

Intralaryngeal manifestation of thyroglossal duct cyst

Laryngeal expression of a thyglossal duct cyst is extremely rare, only 10 cases were reported up to this time. All the cases were located either in the hyoid bone or in the supraglottal region. Moreover, all of them were reported in adults. This is the first case of thyroglossal duct cyst in a young child presenting as a pure noninflamed subglottal cyst. A 2-year-old boy was referred to our ENT consultation with laryngeal dyspnea. These respiratory troubles appeared progressively for 1 month after a common cold. The patient had an inspiratory dyspnea, could eat well, and had normal throat, ears, and nose. A little mass was noted on palpation of the larynx between the thyroid cartilage and the cricoid ring. The boy’s parents said that this “little pea” was always noted but its size never increased nor decreased. The flexible laryngoscopy performed during the initial consultation showed vocal cords and supraglottis free of anomaly. The subglottal region could not be seen well, but it seems that a mass was obstructing its lumen. An endoscopy with the patient under general anesthesia was then performed during the following days. An anterior and depressible mucosa-lined subglottal mass was found obstructing more than 80% of the lumen (Fig 1). The mucosa that covered the mass had a regular aspect and was free of hyperhemia. Because there was an extralaryngeal component noted during the physical examination, it was decided to perform a CT-scan. A typical cystic well-delimited lesion was visualized through the cricothyroid membrane (Fig 2). A surgical removal with an external approach was decided on and performed. The cricoid ring was heavily eroded by the cyst that could be separated from the subglottal mucosa that was not breached. It was noted during the dissection that the cyst had a tract leading superiorly to the body of the hyoid bone. The mass was then removed with the central part of the hyoid bone and a complete Sistrunk procedure was performed. The histologic features were consistent with a benign thyroglossal duct cyst. A new endoscopy was performed 6 weeks later and showed a normal airway.

Management of Pediatric Laryngotracheal Stenosis

In the past 6 years, 40 children underwent surgery for laryngotracheal stenosis; 32 by the external approach and 8 by endoscopic CO2 laser. Twenty-seven children (67%) were less than 5 years old at the time of treatment and 80% of the stenoses (n = 32) corresponded to an etiology that is secondary to endotracheal intubation and/or tracheotomy. By grading the stenoses according to the amount of narrowing of the lumen, the authors emphasize the interest of conservative treatment (endoscopic for grade I [less than 70%, n = 8], and treatment by external surgical methods for grade II [70% to 90%, n = 13], grade III [90% to 99%, n = 14], and grade IV [total obstruction, n = 5]). At this time, the most commonly used technique is laryngotracheoplasty with costal cartilage interposition. In this series, 88% of the patients were successfully decannulated. As for the treatment of stenosis in infants, the authors describe their recent experience of laryngotracheofissure in 7 patients as an alternative to either tracheotomy in cases of difficult extubation or laryngotracheoplasty when the child is underweight.