Kenneth M. Grundfast

Congenital Laryngeal Stridor (Laryngomalacia): Etiologic Factors and Associated Disorders

Congenital laryngeal stridor (CLS) and laryngomalacia are terms used to describe a common disorder characterized by onset, at or soon after birth, of a harsh respiratory sound mostly audible during inspiration. Typically, laryngoscopy reveals flaccid supraglottic structures which tend to prolapse medially toward the glottis during inspiration. Despite reports of this disorder dating back to the mid-19th century, specific etiology and pathogenesis remain nebulous. Analysis of findings in 30 infants indicate that there are often associated manifestations of delayed development in neuromuscular control. Associated findings include gastroesophageal reflux, obstructive and central apnea, hypotonia, failure to thrive, and pneumonitis. A retrospective review of relevant medical literature along with results of laryngeal dissections and analysis of clinical findings in the 30 cases leads to the conclusion that CLS may be a mild form of localized hypotonia rather than an isolated idiopathic type of anatomic abnormality.

Management of congenital preauricular pit and sinus tract in children

Although its exact incidence is not well-documented, preauricular pit/sinus tract (PAP/S) occurs commonly in children. Controversy regarding indications for surgical excision of PAP/S and a tendency for recurrence or persistence make management of this congenital abnormality difficult

Prospective Study of Subglottic Stenosis in Intubated Neonates

Although numerous retrospective studies have attempted to investigate the incidence, etiology, and pathogenesis of subglottic stenosis, there have been few prospective studies. The retrospective studies focused initially on diagnosed cases, then drew inferences regarding incidence and causality based upon data obtained from review of patient records. In contrast, this prospective study accrued data on all neonates intubated for 48 hours or longer during the 1-year intake period. There were 195 neonates entered in the study; then 36 were excluded, leaving 159 for data analysis. Parameters assessed included age at intubation (mean, 5.7 days), duration of intubation (mean, 12.3 days), and number of times reintubated (mean, 0.79). Results of this prospective study are compared to results from previous retrospective studies.

Anterior cricoid split: a "simple" surgical procedure and a potentially complicated care problem.

The anterior cricoid split (ACS) has been described as an alternative to tracheotomy in management of the premature infant who develops upper airway compromise after extubation. Sixteen patients at the Childrens Hospital National Medical Center (CHNMC) and ten patients at four other hospitals had the ACS operation. For the patients at the CHNMC, average gestational age was 29 weeks, birth weight was 1,264 g, and length of time intubated was 6.2 weeks. Overall success in achieving extubation after the ACS was 69% at the CHNMC and 40% for the group of other hospitals. However, a success rate in achieving extubation after ACS was 75% for both the CHNMC and the group of other hospitals in patients who had become stable enough to have been previously discharged from a neonatal intensive care unit. Problems encountered following the ACS include malposition of tip of the endotracheal tube, increased need for assisted ventilation, myocardial infarction, subcutaneous emphysema, and unexplained inability to ventilate. Analysis of results suggests that the ACS is a valuable operative procedure that can avoid need for tracheotomy in infants with adequate pulmonary function who have narrowing within the airway at the subglottic level. Postoperative care may be problematic and the infant having had the ACS is best managed by an experienced team of experts who are familiar with care of the infant with respiratory insufficiency.

Airway compromise from nasal obstruction in neonates and infants

Nasal obstruction in neonates can cause significant airway compromise and even be life-threatening. In general, otolaryngologists are familiar with management of the neonate born with choanal atresia but there have been few reports and there are no guidelines for management of the neonate or young infant who presents with nasal obstruction and airway compromise but who does not have choanal atresia (NOWCA). This study demonstrates the difficulty in diagnosis, variability in severity of airway compromise, and delineates the problematic aspects of management.

Subglottic Stenosis: Retrospective Analysis and Proposal for Standard Reporting System

A retrospective analysis was undertaken reviewing management of 67 patients treated for subglottic stenosis (SGS) at the Childrens Hospital National Medical Center (CHNMC) between 1980 and 1985. Forty-seven (90%) of the patients were followed for at least 18 months from the time diagnosis was made. Twenty-three (66%) of the patients followed for at least 18 months were successfully decannulated or had an adequate airway without tracheotomy. To compare efficacy of management of SGS at the CHNMC with management outcomes previously reported, a review of medical literature was undertaken and data from the most significant reports on management of SGS were collated and tabulated. Since analysis of published reports did not yield a consensus regarding optimal methods for management, and statistics in many published reports were absent or unclear, authors of the previously published reports were contacted personally by means of a letter and survey questionnaire. Results of the survey show that many authors have not performed a statistical review of their case data to determine relative efficacy of different surgical procedures. Thus, retrospective review of cases managed at the CHNMC as well as information obtained from leading experts in management of SGS indicate that there is no single optimal procedure or technique for management of all cases of SGS. Further, the way in which surgical procedures for management of SGS are being reported makes difficult the process of meaningfully comparing results reported by different surgeons. a reporting system is proposed that uses specific terms and objective parameters.

A targeted problem and its solution: An improved stent method for choanal atresia repair

Short intranasal stents secured sublabially have a number of advantages. They provide secure fixation without an external ligature across the columella. The short length of the stents allows them to sit only in the operative area where the atretic plate had been removed. This lessens the chance of intranasal syechiae formation and eliminates the possibility of erosion in the anterior septal and nasal alar region from pressure exerted by a stent. Since the stents do not protrude from the nose, they cannot be grasped by infants or young children and are not visible externally. School-aged children who have undergone repair of a unilateral choanal atresia can attend school without having to suffer the embarrassment of being teased about a tube protruding from the nose. When compared with other stenting methods, the posterior stent is more secure and less likely to become dislodged.

Congenital hereditary bilateral abductor vocal cord paralysis.

Congenital hereditary bilateral abductor vocal cord paralysis has been found in a father, his son and daughter. Though the disorder was previously believed to be inherited in a sex-linked manner, it now appears that there is an autosomal dominant variant. The vocal cord paralysis was associated with swallowing difficulty during infancy in all three of the family members. Although both the son and daughter required tracheostomies during the neonatal period, both manifested improvement of vocal cord movement during infancy so that decannulation was possible before 14 months of age. Localized delay in neurologic maturation is suspected as the etiology.

A review of the efficacy of systemically administered decongestants in the prevention and treatment of otitis media.

Studies designed to determine the efficacy of alpha-adrenergic agents and antihistamines in the prevention and treatment of otitis media are reviewed. Although some studies demonstrate a pharmacologic rationale for use of decongestants, results of clinical trials fail to demonstrate conclusively that decongestant medication is effective as primary or adjunctive therapy for otitis media. The clinician is advised to await results of future studies before accepting the notion that the systemic administration of sympathomimetic agents and antihistamines is effective in the treatment of otitis media.

External auditory canal stenosis and partial atresia without associated anomalies

Unilateral or bilateral ear canal stenosis or atresia occurring without microtia or associated anomalies may go undetected during early childhood. Summaries of ten cases illustrate difficulties in making early diagnoses. An unusual case of inherited isolated bilateral external canal atresia occurring in a mother and daughter is included. Potential pitfalls in diagnosis and management are discussed.