Kin-Sun Wong

Robin sequence: review of treatment modalities for airway obstruction in 110 cases

OBJECTIVE The objective of this paper is to assess the treatment protocols used in our institution for the management of airway obstruction among patients with Robin sequence and to suggest a rationale for management based on the findings. METHOD A retrospective study of 110 children with Robin sequence seen from 1988 to 1997 at the Chang Gung Memorial Hospital was done. Results of the management in airway obstruction and feeding difficulty were studied. RESULTS Prone posturing was effective in the treatment of mild airway obstruction in 82 patients who had noisy breathing sounds. Twenty-eight infants required endotracheal intubation due to severe respiratory distress. Seven received a tongue to lip adhesion (TLA) operation. Three of these patients showed a relief of airway obstruction, while four of them needed a tracheotomy to maintain a patent airway because of wound dehiscence. Two other patients underwent tracheotomy without TLA. All the six patients who received tracheotomy were eventually decannulated. A nasopharyngeal tube was inserted in two other patients, and one of them improved only temporarily. With regards to feeding difficulties, 46 patients needed nasogastric tube feeding, while the rest were aided through the use of a cleft palate bottle and nipple. A gastrostomy was not needed in any of the patients in this series. CONCLUSION The morbidity and mortality among Robin sequence patients had been widely decreased through the teamwork of the pediatrician, anesthesiologist, otolaryngologist, dentist, and plastic surgeon. Based on our experience, conservative management was sufficient for those patients with mild airway obstruction, while endotracheal intubation was required for patients with cyanosis, respiratory failure and sleep apnea. Tracheotomy was a better option than TLA for airway management among patients with failed extubation.

Vallecular cyst: an uncommon cause of stridor in newborn infants

Abstract Vallecular cyst, a rare but generally benign lesion in the larynx, may cause stridor and even life-threatening airway obstruction in early infancy. We retrospectively studied 14 cases of newborn infants with vallecular cyst. There was no gender predilection and most cases were full-term and appropriate for gestational age. The clinical presentations included stridor, chest wall retraction, feeding difficulties and failure to thrive. Laryngomalacia was the most common associated anomaly. Flexible laryngoscopy was sufficient for diagnosing the vallecular cyst and larygmalacia. Maintenance of airway patency, nutritional support, and de-roofing of the cyst were the mainstays of management. Conclusion Vallecular cyst should be included in the differential diagnosis of stridor in newborn infants. Respiratory and feeding difficulties in these patients can be dramatically improved after appropriate surgical removal of the cyst.

Idiopathic pulmonary haemosiderosis: An Oriental experience

Objectives:  Idiopathic pulmonary haemosiderosis (IPH) is a rare but potentially lethal disorder. A retrospective analysis of documented cases of IPH in our hospital was conducted in order to study the clinical spectrum and radiographic features, and to explore therapeutic strategies.

Scoring system for empyema thoracis and help in management

Objective : To evaluate the implications of a newly defined severity scoring of empyema in children for the prediction of surgical management and to compare the length of hospitalization as an outcome measure of patients treated using medical therapy, salvage video-assisted thoracoscopic surgery (VATS)vs early elective VATS.Methods : A retrospective chart review of parapneumonic empyema of patients below 18 years of age admitted to a tertiary children’s hospital in northern Taiwan from April 1993 to December 2002 was performed. Patients were categorized into a medical group who received antibiotic therapy, needle aspirations with/without tube thoracostomy; a salvage VATS group when the patients required surgery for the relief of persistent fever > 38°C, chest pains or dyspneic respirations despite initial medical therapy; an early VATS group when the patients received elective surgery early after admission. The demographic data, clinical features, laboratory findings, and duration of hospitalization were compared using a severity score of empyema (SSE).Results :Streptococcus pneumoniae was the most common infecting organism, followed byStaphylococcus aureus, Pseudomonas aeruginosa. No organisms were recovered in 39% of patients. A pleural pH < 7.1 increases the odds of requiring surgical intervention by 6 times among this cohort. Children who required decortication of empyema had a higher severity score (mean 4.8 vs 3.0, p < 0.005). The duration of hospitalization for patients having early VATS showed a shortening stay (mean 18 vs 28 days) as compared to salvage VATS.Conclusion : A pleural pH < 7.1 and a newly designed clinical severity score of empyema ≥4 are two predictors of surgical intervention for fibrinopurulent empyema in the present study. Early elective VATS may be adopted not later than 7 days after failure of appropriate antibiotic therapy and adequate drainage of empyema to decrease the length of stay and minimize morbidity.

Impact of bacterial and viral coinfection on mycoplasmal pneumonia in childhood community-acquired pneumonia.

BACKGROUND/PURPOSE Coinfection of Mycoplasma pneumoniae is not uncommon in children with respiratory syndromes. The purpose of this study was to investigate the impact of bacterial and viral coinfection on mycoplasmal pneumonia in hospitalized children with community-acquired pneumonia (CAP). METHODS Children coinfected with M. pneumoniae in a prospective study of the etiology of CAP at a tertiary pediatric facility Childrens Hospital were enrolled and retrospectively reviewed. The data of clinical characteristics, complications, and outcomes of these children were collected and analyzed. RESULTS A total of 59 children were enrolled and stratified into three groups: M. pneumoniae infection alone (n = 31), M. pneumoniae with Streptococcus pneumoniae coinfection (n = 9), and M. pneumoniae with virus coinfection (n = 19). As compared with children infected with M. pneumoniae alone, coinfection of children with S. pneumoniae was more likely to occur under the age of 5 years with a longer duration of fever and hospital stay. Furthermore, total leukocyte count and serum C-reactive protein level were also significantly higher in these children (p < 0.01). However, no significant difference in clinical characteristics, complications, and outcomes was observed between the patients infected with either M. pneumoniae alone or with virus coinfection. CONCLUSION In children with CAP, the influence on the clinical outcomes of M. pneumoniae infection may be heavily dependent on the coinfected pathogen. A potential coexistence of M. pneumoniae infection should be considered in children with features suggesting typical bacterial pneumonia.

Retrieval of bronchial foreign body with central lumen using a flexible bronchoscope

A 5 year-old boy aspirated a metal spring accidentally. The right bronchial foreign body was removed by threading the alligator of a biopsy forceps through the lumen of the spring while opening its jaws distally. This case illustrates that a foreign body with a central lumen in a child can be successfully removed using a flexible bronchoscope, thus obviating the need for general anesthesia and rigid bronchoscopy.

Costal exostosis presenting with hemothorax: report of one case

Spontaneous hemothorax as a result of costal exostosis has been reported infrequently [1– 6]. We present a case of hemothorax presenting as chest pain in a patient with hereditary multiple exostoses and costal exostosis. A 9-year-old girl suffered from a sudden onset of chest pain after performing exercises during gymnastics. She subsequently suffered from a localized, right-sided anterior chest pain. She denied fever, cough, shortness of breath, palpitation, dizziness, and any preceding traumatic history. Her past medical history was significant for a small osteochondroma on her left distal radius that was detected during a bone survey ordered for a short-stature work-up. Also, her father and a younger brother had past histories of multiple exostoses. At the emergency department, there was no evidence of fever, tachypnea, respiratory distress or cyanosis. Her vital signs were normal. Physical examination showed decreased breath sounds over the right lower lung field. The complete blood count was normal. Electrocardiography was normal and the chest radiograph showed a rightsided pleural effusion (Fig. 1). Thoracentesis yielded 20 cc of an uncoagulated bloody aspirate with a hematocrit of 45.2%. A costal exostosis of the right seventh rib was seen protruding inwardly on a thoracic computed tomography scan. She was discharged in a stable condition, and has been followed up for 2 years without recurrent complaint. Hereditary multiple exostosis is a rare autosomal-dominant condition characterized by the presence of multiple osteochondromas [6]. Most cases are identified in patients between the ages of 5 and 15 years based upon the discovery of a bony mass or skeletal deformity. An osteochondroma arising from the ribs is exceedingly rare and usually asymptomatic [3]. Few cases have been complicated by the development of a hemothorax. Costal exostosis commonly presents as a bony protuberance, and it can cause mechanical penetrating injury of adjacent anatomic structures [3]. Shearing of pleura or the diaphragm by the sharp margins of the intrathoracic exostosis is potentially lethal. Repetitive chest infections and loculated empyema occurred infrequently [2]. Most authors have suggested that inward-protruding bony spicules of rib exostosis require surgical excision [1, 2, 4]. A conservative followup was advised in this case by avoiding further strenuous physical activities, and we plan to proceed to surgical removal of the exostosis only if hemothorax recurs.

Spontaneous pneumomediastinum: analysis of 87 pediatric patients.

Objectives Early reports on pneumomediastinum studied the adult population, and recent analyses of pneumomediastinum in pediatric patients contain small numbers of patients. We aimed to summarize the experience of a larger number of pediatric patients with spontaneous pneumomediastinum (SPM) in a tertiary children’s facility in northern Taiwan. Methods We performed a retrospective chart review of clinical manifestations and outcome of SPM on pediatric patients who were admitted to our hospital during a 10-year period. Results Forty-three patients (49.4%) had primary SPM, with a male predominance in adolescents. None of the 16 patients younger than 6 years had primary SPM; 43 of 71 patients older than 6 years had secondary SPM (0% vs 60.6%, P < 0.05). The common causes of secondary SPM were asthmatic exacerbation, pneumonia or lower respiratory tract infections, or choking. Ten patients had normal frontal chest radiograph finding (sensitivity, 89.1%); the lateral neck radiographs clearly demonstrated subcutaneous emphysema in 9 of these 10 patients. Conclusions All patients younger than 6 years with SPM were secondary; therefore, they should be vigilantly examined for predisposing causes. For adolescent patients with SPM with no catastrophic events, asthma with exacerbation should be considered first, and extensive or invasive diagnostic examinations are not needed. Primary SPM usually requires conservative treatment only with no sequel or recurrence. Lateral neck radiograph has a higher sensitivity for the demonstration of subcutaneous emphysema in doubtful cases.

Non-infectious epiglottitis in children : Two cases report

Two young children who suffered from thermal injuries to the epiglottis after swallowing corrosive agent and hot water respectively. Findings, clinically and radiologically, in both children were similar to acute infectious epiglottitis. Both recovered quickly with close observation and parenteral antibiotics. Although Haemophilus influenzae type b (Hib) is the major pathogen of epiglottitis, in areas with low incidence of Hib infection and high vaccination rates, non-infectious epiglottic swelling should be considered first.

Demonstration of tracheal bronchus associated with tracheal stenosis using direct coronal computed tomography

A 2‐year‐old boy presented with chronic wheezes and was refractory to medical treatment. A high carina with bilateral bronchial stenosis was erroneously diagnosed by bronchoscopic examination. Serial direct coronal computed tomographic scans showed a displaced right upper lobe tracheal bronchus associated with tracheal stenosis below the abnormal bronchus. A direct coronal computed tomographic scan of the tracheobronchial tree is a useful imaging technique for the delineation of airway configuration when the bronchoscope fails to pass beyond a stenotic region. A coronal computed tomographic scan may make invasive tracheobronchography unnecessary. Pediatr. Pulmonol. 1998; 25:133–135.