Jeffrey D. Carron

Pediatric tracheotomies: changing indications and outcomes.

Objective/Hypothesis To study the outcomes and complications associated with pediatric tracheotomy, as well as the changing trend in indications and outcomes since 1970.

Spontaneous tracheal rupture caused by vomiting

OBJECTIVES To present a pediatric case of spontaneous tracheal rupture caused solely by vomiting and to discuss its diagnosis and management. STUDY DESIGN Case presentation and literature review. RESULTS A 14-year-old girl with a new diagnosis of type 1 diabetes mellitus presented with respiratory distress. History was significant only for 4 days of violent vomiting, and she was diagnosed with diabetic ketoacidosis. Examination revealed tachypnea and considerable subcutaneous air overlying the upper chest and neck; chest x-ray showed pneumomediastinum. A swallow study showed no evidence of an esophageal tear. Computed tomography of the chest showed a posterior tracheal tear 4.5 cm distal to the cricoid cartilage. The patients ketoacidosis was controlled, and supplemental oxygen was administered temporarily to promote absorption of the extravasated air. Serial chest x-rays showed complete resolution within 5 days and intubation was not required. CONCLUSIONS To our knowledge, this is the first reported pediatric case of tracheal rupture secondary to vomiting. Previous reports of spontaneous tracheal rupture have been related to paroxysmal coughing. In similar cases of subcutaneous emphysema and pneumomediastinum after retching, an esophageal rupture should be ruled out. Conservative management was successful in this case.

Fetal rhabdomyoma of the posterior cervical triangle.

Rhabdomyoma is an uncommon benign tumor, with the majority arising from cardiac muscle. Seventy to 90% of extracardiac rhabdomyomas are found in the head and neck region, usually within the upper aerodigestive tract. The case of a 7-month-old boy with an enlarging posterior triangle neck mass found to be fetal rhabdomyoma is presented. This location is quite rare for benign rhabdomyoma, with previous literature search showing overwhelming predilection for the upper aerodigestive tract.

Van den Ende-Gupta syndrome: laryngeal abnormalities in two siblings.

In 1992, van den Ende et al. first reported an autosomal recessive multiple congenital anomaly syndrome characterized by blepharophimosis, arachnodactyly, and congenital contractures in a Brazilian girl born to consanguineous parents. Since then, nine total patients have been reported with van den Ende–Gupta syndrome (VDEGS), and the syndromes phenotype has been found to also include additional dysmorphic facial features, palatal abnormalities, and slender skeletal features. We present two African‐American sisters born to nonconsanguineous parents who have been diagnosed with VDEGS. Both sisters developed stridor and were found to have an unusual malformation characterized by large, globular cuneiform cartilages, shortened aryepiglottic folds, a tightly coiled epiglottis, and laryngomalacia. Both patients underwent supraglottoplasty with a successful outcome. A review of the literature reveals that airway problems have been reported in a previous patient. However, no specific airway anomaly has been reported. We suggest that all patients with VDEGS and stridor undergo direct laryngoscopy with consideration for surgical correction.

Endoscopic Resection of an Aggressive Juvenile Ossifying Fibroma

A two-year old boy with left sided proptosis, epiphora, and nasal congestion progressively worsening for 6 months underwent CT/MR imaging and intranasal biopsy, which revealed juvenile aggressive ossifying fibroma. Preoperative imaging revealed a large tumor obliterating the left maxillary sinus, extending into the sphenoid sinus, abutting the cribriform plate, and causing proptosis secondary to orbital compression. Endoscopic Resection of an Aggressive Juvenile Ossifying Fibroma Kimberly A Donnellan MD and Jeffrey D Carron MD, FACS

Pediatric rhinosinusitis: is it a surgical disease?

Sinusitis is a common disease in children. Acute, uncomplicated rhinosinusitis following viral upper respiratory infection usually resolves without antibiotic therapy, with a minority of cases persisting as chronic rhinosinusitis. In children with chronic rhinosinusitis refractory to medical therapy or with overlying medical illness such as cystic fibrosis or ciliary dysmotility, endoscopic sinus surgery has become a mainstay of treatment. Other modalities, including sinus aspiration and irrigation, adenoidectomy, and reflux treatment, may be used in selected patients in lieu of endoscopic sinus surgery. The generally favorable course of chronic rhinosinusitis with medical management makes endoscopic sinus surgery unnecessary for the majority of patients with this disease.

Focal parotid necrosis in systemic lupus erythematosus: Case report and review of the literature

Systemic lupus erythematosus (SLE) is a disease that may affect a number of organ systems, particularly the joints, skin, kidneys, heart, lungs, and immune system. Salivary gland involvement is usually associated with Sjögrens syndrome, in which lymphocytic acinar infiltrates predominate histologically. We present the case of a 29-year-old woman with SLE who developed bilateral parotid enlargement with a unilateral focus of parotid necrosis that was consistent with a cystic mass on computerized tomography. A biopsy of this lesion was histologically similar to a cervical lymph node biopsy in the same patient, with both specimens showing loss of architecture and foci of necrosis consisting of nuclear dust, histiocytes, and scattered plasma cells without formation of granulomata or presence of multinucleated giant cells; these findings are classic for SLE lymphadenopathy. We believe this to be the first reported case of focal necrosis in the parotid gland directly associated with SLE.

The use of cephalometric landmarks with 3-dimensional volumetric computer modeling to position an auricular implant surgical template: a clinical report

The number of tools available to make a correctly positioned surgical guide for auricular implant placement is rapidly expanding as advances in 3-dimensional computer modeling continue. While the correct orientation of a missing auricle previously relied solely on soft tissue topography, computer modeling software now allows for navigational viewing of hard tissue and cephalometric landmarks. This clinical report describes a technique to establish the orientation of an auricular surgical guide incorporating the use of fundamental cephalometry. Cephalometry as a treatment planning tool has been limited to orthodontics and maxillofacial surgery. This article describes its use in a patient with a missing ear.

Case presentation of soft tissue parapharyngeal chondroma in a pediatric patient

Soft tissue chondromas are uncommon benign tumors found mostly in the hands and feet and rarely reported in the pediatric population. In this case presentation we describe a 10 year old boy who had an MRI for facial paralysis due to Ramsey Hunt Syndrome, which incidentally revealed a parapharyngeal mass. He underwent transoral resection of the mass without complication, and histopathology confirmed the diagnosis of soft tissue chondroma. This case is unique due to the unusual location of the tumor and its presentation in a child.

Endoscopic management of a massive nasal osteoma presenting as an orbital abscess.

1. Case presentation A 13-year-old female with a 1-week history of sinusitis and a 3-day history of right-sided proptosis and diplopia from limited extraocular muscle movement was evaluated in our pediatric emergency department. The patient also had complaints of prior nasal obstruction for several years and had undergone 2 prior adenoidectomies for these complaints. No history of craniofacial trauma was elicited. Computed tomographic scan of the orbit revealed a large abscess involving the superior medial aspect of the orbit, displacing the globe laterally. Also noted was a large, dense, homogenous bony mass essentially involving the entire right nasal cavity, including the ethmoid and maxillary sinuses (Fig. 1). Magnetic resonance imaging showed no intracranial extension. A diagnosis of nasal osteoma with secondary orbital abscess was made, and the patient was taken to the operating room for biopsy of the mass and drainage of the orbital abscess. An external approach was necessary due to the intranasal obstruction from the tumor. The drainage was uncomplicated, and the patient was treated with intravenous ceftriaxone and changed to oral clindamycin. The ophthalmologic service was consulted before discharge, and the patients vision was within normal limits. Her proptosis persisted after drainage of the abscess, but intraocular pressures were normal. The pathologic results were consistent with an osteoma of the nasal cavity. The patient was therefore scheduled for image-guided endoscopic removal of this mass as well as right medial orbital wall decompression 4 weeks later. At the time of surgery, she was noted to have a massive osteoma of the right nasal cavity, which appeared to originate from the middle turbinate. It was involving the entire nasal cavity, approximating the anterior skull base along its entire length. It also abutted the face of the sphenoid, as well as the lamina papyracea, with thinning and lateral bowing of the lamina papyracea, causing residual mild to moderate proptosis. The mass also involved the entire right maxillary antrum. It was excised endoscopically with the use of a 0° nasal endoscope and various-sized otologic cutting and diamond burs. The mass was “cored out” in an inferior to superior direction and removed in a piecemeal fashion via delivery through the right nostril and nasopharynx. At the end of the procedure, total ethmoidectomy and sphenoidotomy were performed in the standard fashion because they had been significantly distorted by the expansion of this mass. Right medial orbital wall decompression was also accomplished by removal of the lamina papyracea to help reverse her proptosis. The procedure was tolerated well with minimal blood loss. A sinus computed tomographic scan at 6 months postoperatively illustrated resolution of her proptosis with no evidence of recurrence (Fig. 1). The patient was subsequently noted to have developed right-sided synechiae and polypoid changes for which she underwent resection at 13 months postoperatively.