Juliana Sato

Indicações e complicações de traqueostomia em crianças

UNLABELLED Indications for tracheostomy have changed and its complications are more common in children. AIM To evaluate the indications and complications of tracheostomies performed in children. MATERIALS AND METHODS A retrospective study with review of medical records of patients aged from 1 day to 16 years who underwent tracheostomy at a university hospital during the period of August 2000 to July 2008. We assessed data on age, gender, indications and intra and postoperative complications. RESULTS Fifty-eight children under 16 years of age underwent tracheotomy during the study period. The mean age was 3.7 years. Airway obstruction was the main indication for surgery (n = 40; 69%). The incidence of complications in the postoperative period was 19% (11 patients), the majority happening during the late postoperative period. A further complication observed was cannula clogging. There were no complications related to the procedure during the surgery. CONCLUSION The main indications for tracheostomy in children were airway obstruction and prolonged OTI. The most frequent postoperative complications were cannula obstruction and decannulation. The indications and complications observed were similar to those reported in the literature by other services.

Polisomnographic findings on children with laryngopathies

UNLABELLED Polysomnography is the goldstandard exam for child OSAS. When possible, polysomnography clearly distinguishes between those with isolated primary snoring and patients with sleep apnea (obstructive, central and mixed). The most common cause of OSAS in childhood is adenotonsillar hypertrophy. Laryngomalacia is the most common cause of stridor in childhood, though its physiopathology remains unknown. Among the most prominent theories are immaturity of the cartilaginous framework of the larynx and/or neuromuscular immaturity. OBJECTIVE Our proposal was to describe polysomnographic findings in children with laryngomalacia or other isolated laryngeal alterations, that is, without other alterations in the upper airways. METHODS The sample included 29 children with exclusively laryngeal alterations. All of them underwent an otorhinolaryngological exam, nasofibrolaryngoscopy and polysomnography. Information was recorded concerning age, nasofibrolaryngoscopy and polysomnography. For analysis, the children were divided into two groups: those with laryngomalacia and those with other laryngeal diseases. RESULTS Among the 18 children with a diagnosis of laryngomalacia, 18 had central breathing events, knowing that the majority had showed desaturation of oxihemoglobin and bradycardia. In this same group, 3 children had obstructive events. On the other hand, 11 children with other laryngeal alterations showed no predominance of one type or another of apnea. Of these, 4 had central type breathing events and 2 obstructive type. CONCLUSION The majority of patients with laryngomalacia showed a central type apnea. Patients with various laryngeal diseases did not present a predominant type of apnea.

Achados polissonográficos em crianças portadoras de laringopatias

O exame diagnostico padrao-ouro para SAOS na infância e a polissonografia. Quando pode ser efetuado, a polissonografia separa com clareza portadores de ronco primario de pacientes com apneia (obstrutiva, central e mista) do sono. A causa mais frequente da SAOS na infância e a hipertrofia adenoamigdaliana. Laringomalacia e a causa mais comum de estridor na infância, porem sua fisiopatologia permanece desconhecida. Entre as teorias mais aceitas estao a imaturidade do arcabouco cartilaginoso da laringe e/ou a imaturidade neuromuscular. OBJETIVO: Nossa proposta foi descrever os achados polissonograficos de criancas portadoras de laringomalacia e outras alteracoes laringeas isoladas, ou seja, sem alteracoes nas vias aereas superiores. METODOS: Foram selecionadas 29 criancas portadoras de alteracoes laringeas exclusivas. Todas foram submetidas a exame otorrinolaringologico, nasofibrolaringoscopia e polissonografia. Foram tabulados dados relativos a idade, nasofibrolaringoscopia e polissonografia. Para analise, as criancas foram separadas em 2 grupos: portadores de laringomalacia e portadores de outras doencas laringeas. RESULTADOS: Dentre as 18 criancas com diagnostico de laringomalacia, 18 apresentaram eventos respiratorios do tipo central, sendo a maioria dos episodios associados a dessaturacao de oxigenio e alguns a bradicardia. Nesse mesmo grupo, 3 criancas apresentaram apneia do tipo obstrutivo. Por outro lado, as 11 criancas portadoras de outras alteracoes laringeas nao apresentaram predominância entre um tipo ou outro de apneia, 4 apresentaram eventos respiratorios do tipo central, 2 do tipo obstrutivo. CONCLUSAO: A maioria dos pacientes acometidos por laringomalacia apresentou eventos respiratorios do tipo central quando avaliados pela polissonografia. Ja os pacientes com outras doencas laringeas nao apresentaram predominância entre um tipo ou outro de apneia.

Aplicação local de cidofovir como tratamento adjuvante na papilomatose laríngea recorrente em crianças

OBJECTIVE: Evaluate the efficacy of local application of cidofovir in association with surgical treatment of recurrent laryngeal papillomatosis in children. Study design: Prospective. METHODS: Fourteen patients, with an average age of 4.7 years and with two or more relapses after surgical treatment, were submitted to resection of the papillomas and injection of 22.5 mg of cidofovir (7.5 mg/ml) in the tissue where the lesions had been removed. After 2 to 3 week intervals, the same dose of cidofovir was repeated two or three times. In the case of relapse, a new cycle of surgery followed by local applications of cidofovir was repeated. Five children presented HPV-6 and five HPV-11, while in four, the type was not determined. RESULTS: Before beginning of the study, patients were submitted, on the average, to 2 operations a year for control of relapses. After treatment with cidofovir, the annual rate for surgery dropped to 1.1 (p = 0.013). The average interval between relapses before beginning of the study was 1.4 months; at the end of the study, the interval reached 4.4 months (p = 0.014). Patients with HPV-6 did not show a significant change in the intervals between relapses after treatment with cidofovir, while 60% of the children with HPV-11 were disease free at the study end. CONCLUSION: Cidofovir was found to be an effective adjuvant in the treatment of recurrent laryngeal papillomatosis in children, when used in the form of local applications in association with surgical resection of the lesions. HPV-11 may be more susceptible to the beneficial effects of cidofovir.

Salivary gland surgery for control of chronic pulmonary aspiration in children with cerebral palsy

OBJECTIVE To evaluate the outcome of surgical saliva reduction to decrease pulmonary aspiration in children with cerebral palsy and its repercussions in respiratory infection control. METHODS Twenty-nine children with neurological impairment and diagnosis of chronic pulmonary aspiration were submitted to bilateral submandibular gland excision and bilateral parotid duct ligation at the Association for the Welfare of Physically Handicapped Children, from December 2001 to December 2004. Postoperative frequency of lower respiratory tract infection, hospitalization rate due to pulmonary infection and airway secretion level after the surgery were compared to preoperative period. RESULTS Twenty-nine children with cerebral palsy aged 18 months to 9 years were submitted to submandibular glands excision and parotid ducts ligation. All children had gastrostomy and no oral intake. There were no major complications; two children had reopening of one parotid duct. Frequency of lower respiratory tract infections, rate of hospitalization for treatment of pulmonary infections and level of airway secretion were statistically reduced. Preoperative mean rate of lower respiratory tract infection was 6.9/year; in postoperative period, rate was 2.4/year (p<0.001). Pneumonia hospitalization mean rate was 63.4 days/year preoperatively and 17.5 days/year postoperatively (p<0.001). There was also a significant improvement in the need for suctioning of upper airway secretion (mean 11 times/day in preoperative period and 3.1 times/day in the postoperative period; p<0.001). CONCLUSION In children with cerebral palsy, surgical saliva reduction by submandibular glands excision and parotid ducts ligation is an effective and safe technique for frequency reduction of lower respiratory tract infection and level of airway secretion.

Postoperative acute respiratory insufficiency following adenotonsillectomy in children with neuropathy

OBJECTIVE Evaluate the incidence of acute respiratory insufficiency (ARI) in the immediate postoperative period following adenotonsillectomy in children with neurological diseases. METHODS Medical records from all pediatric adenotonsillectomies performed from January 1997 through August 2003 at the Roberto de Abreu Sodré Hospital of the Association for the Welfare of Physically Handicapped Children (AACD) in São Paulo were reviewed. Data were collected for patient age, neurological diagnosis, associated comorbidities, index of respiratory insufficiency in the immediate postoperative period and period of hospitalization. RESULTS One hundred and nine patients charts had sufficient documentation to be included in this study. Of these, 15 (13.7%) developed ARI in the immediate postoperative period. Ages ranged from 1 to 12 years old (average of 5). Of the 15 patients that presented ARI, 10 (67%) were intubated in the first 3h following extubation. The predominant neurological diagnosis was non-progressive chronic encephalopathy, observed in 84 children (77%), and, among that, 14 (17%) presented ARI. Other neurological diagnoses present in this study were Rett syndrome, neuromuscular disease and meningomyelocele. All of the children that developed ARI presented quadriplegia. Among children that did not develop ARI, the predominant motor pattern was: 28 with quadriplegia, 38 diplegia, 10 hemiplegia, 12 with involuntary movement (choeroathethosis) and six without motor involvement. Children presenting ARI needed mechanical ventilation for an average of 37.87 h (1.5 days) in the intensive care unit. ARI increased the period of hospitalization; these children had an average length of stay of 7 days versus 1.5 days for those that did not develop complications. CONCLUSION Children with neurological disorders, especially those with quadriplegic pattern of motor involvement and severe oropharyngeal dysphagia, are at higher risk for respiratory insufficiency in immediate postoperative period of adenotonsillectomy and should be observed in intensive care unit.