Jeffrey P. Ludemann

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.

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.

Intranasal Topical Local Anesthetic and Decongestant for Flexible Nasendoscopy in Children: A Randomized, Double-blind, Placebo-Controlled Trial

IMPORTANCE To our knowledge, the present study is the first double-blind, randomized, placebo-controlled trial in children to compare nasal preparation sprays administered before flexible nasendoscopy with placebo. OBJECTIVE To compare the degree of pain experienced by children undergoing flexible nasendoscopy after 1 of 3 intranasal sprays: placebo, decongestant with topical local anesthetic (TLA), or decongestant without TLA. DESIGN, SETTING, AND PARTICIPANTS A randomized placebo-controlled trial with blinding of participants, caregivers, observers, and otolaryngologists was conducted in a tertiary pediatric otolaryngology ambulatory clinic. Participants included a consecutive sample of children aged 3 to 12 years requiring flexible nasendoscopy. Exclusion criteria included concomitant respiratory tract infection, known allergy to a trial agent, or previous flexible nasendoscopy. One hundred fifty-one children were assessed for eligibility; 24 eligible children refused participation and 69 were included and block-randomized. All completed the study, and there were no adverse events. INTERVENTIONS Nasal spray administration of placebo (normal saline); xylometazoline hydrochloride, 0.05% (decongestant); or lidocaine hydrochloride, 1%, with xylometazoline hydrochloride, 0.05% (TLA with decongestant) was performed 10 minutes before flexible nasendoscopy. MAIN OUTCOMES AND MEASURES Primary outcome measure was the child-reported Wong-Baker Faces Pain (WBFP) scale. Secondary outcomes included the caregiver-proxy WBFP scale; the Face, Legs, Activity, Cry, and Consolability (FLACC) scale; and the physician-reported Difficulty of Procedure Visual Analog Scale (DPVAS). RESULTS Twenty-three children were recruited in each of the intervention arms. Baseline characteristics were comparable between groups. The mean child-rated WBFP scale scores were 2.4, 1.8, and 2.2 for the placebo, decongestant, and TLA with decongestant groups, respectively (P = .45). Although the finding was statistically nonsignificant, decongestant had the lowest mean caregiver-proxy WBFP scale score, lowest observer-rated FLACC scale score, and highest physician-rated DPVAS score. Subgroup analysis did not demonstrate any correlation between the outcomes and age or sex. CONCLUSIONS AND RELEVANCE This study revealed no statistically significant difference in the discomfort experienced by children undergoing flexible nasendoscopy after placebo, decongestant, or TLA with decongestant. Decongestant was associated with the least discomfort (on child, caregiver, and observer-rated pain scale scores) and the lowest rating for difficulty of procedure. With these findings, the study suggests that there is no significant benefit of topical decongestant with or without TLA compared with placebo in reducing pain associated with pediatric flexible nasendoscopy. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01351298.

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.

Florid infectious mononucleosis: clinicopathological correlation in acute tonsillectomy.

In patients with infectious mononucleosis (IM), acute tonsillectomy is advocated only in the minority who develop severe airway compromise. In such florid cases, the pathological diagnosis of IM, well known to morphologically simulate that of lymphoma, is particularly challenging. The present case describes a 15-year old male with a clinical course consistent with IM in whom acute tonsillectomy was performed due to progressive airway obstruction. The striking histological findings emphasize the need for close clinicopathological correlation. Recently available ancillary studies are described which both surgeon and pathologist should be familiar with in the differentiation of IM from other lymphoproliferative conditions.

Accuracy of the Weber and Rinne tuning fork tests in evaluation of children with otitis media with effusion.

OBJECTIVE The purpose of this study was to determine the accuracy of the Rinne and Weber tuning fork tests in predicting the degree of hearing loss secondary to otitis media with effusion (OME) in children compared with pure-tone audiometry. DESIGN A blinded prospective study was performed on cases of unilateral and bilateral OME in children between ages 2 and 11 years. SETTING Patients were recruited from the tertiary Pediatric Otolaryngology Clinic at British Columbias Childrens Hospital in Vancouver. METHODS The subjects consisted of 58 children with unilateral or bilateral OME. The Rinne and Weber tests were performed using a 256 Hz and a 512 Hz tuning fork. Pure-tone audiometry was performed to establish the presence and degree of an air-bone gap (ABG). MAIN OUTCOME MEASURES The tuning fork responses were correlated with the ABG to determine their accuracy. RESULTS The Weber test did not show an association between the ABG and the lateralization response using either the 256 Hz (p = .484) or the 512 Hz tuning fork (p = .120). For the Rinne test, an increase in ABG was significantly associated with a higher rate of response air conduction < bone conduction using either the 256 Hz or the 512 Hz fork (p < .04). Age was not associated with outcome for any of the tuning fork tests. CONCLUSIONS The overall accuracy of the Rinne and Weber tuning fork tests in predicting conductive hearing loss associated with OME in children is poor.

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.

Best management of ultra-small tracheobronchial foreign bodies in neonates.

OBJECTIVES To develop (1) a practical and comprehensive algorithm of instruments and techniques available to treat neonates with tracheobronchial foreign bodies, based on the patients subglottic diameter and (2) primary and secondary prevention strategies for neonatal tracheobronchial foreign bodies. METHODS (1) Analysis of the case of a severely premature infant who presented with the incidental radiological finding of a 2cm suction catheter tip, which, over a two week period, had migrated between her main bronchi; the foreign body was removed with a previously unreported combination of instruments: a 3French (F) flexible urological forceps through the side port of a 2.5mm rigid bronchoscope. (2) In vitro testing of typical foreign bodies and readily available endoscopic instruments. RESULTS We have developed a practical and comprehensive algorithm for the treatment of neonates with tracheobronchial foreign bodies, as well as primary and secondary prevention strategies. CONCLUSIONS The treatment algorithm and prevention strategies may reduce morbidity and mortality from neonatal tracheobronchial foreign bodies.

Return to home, school, and sports after electrosurgical adenoidectomy: when is it safe?

OBJECTIVE To determine when it is safe for healthy children to return to home, school, and sports after uncomplicated electrosurgical adenoidectomy (EA). DESIGN (1) A survey of Canadian otolaryngologists (COs) regarding their EA complication rates and their opinions regarding best practice standards for patient care after EA. (2) Informal retrospective analysis of approximately 200 children who have been allowed to resume sports 3 days after uncomplicated EA. RESULTS (1) Thirteen COs responded to the survey. The total estimated EA cases performed were 8617 over 10 years. Four patients were known to have bled mildly; none required reoperation. Eleven of 13 COs supported discharge home 2 hours after uncomplicated EA if other standard discharge criteria were met. Seven of 13 COs supported a return to school the next day if the child had returned to his or her usual state of health; however, 2 COs suggested 7 to 10 days at home. Four of 13 COs supported a return to sports 3 days after uncomplicated EA. (2) None of the 200 children who had been allowed to resume sports 3 days after uncomplicated EA have had any known bleeding. At least 10 toddlers have actually engaged in unplanned strenuous exercise within 4 to 6 hours of EA without adverse effect. CONCLUSIONS Considerable variation exists in Canada in terms of current practice standards regarding return to home, school, and sports after uncomplicated EA. Survey data suggest that, after uncomplicated EA, it is safe for healthy children to return home after 2 hours and to school the next day. Preliminary data suggest that it may be safe for children to resume sports 3 days after uncomplicated EA; however, ideally, this should be studied prospectively, on a large scale.