Lawrence W. C. Tom

Pediatric Tracheostomy: A Changing Procedure?

In 1982, the experience with tracheostomy at The Childrens Hospital of Philadelphia was reported for 1971 through 1980. We have now reviewed 450 cases for the period from 1981 through 1992, and compared the characteristics of these cases with those in the previous review. Long-term follow-up was available on 83% of cases, and the median follow-up was 2.96 years. Patients received a tracheostomy for airway obstruction (38%), chronic ventilation (53%), or multiple indications (9%). The mean duration of tracheotomy (adjusted for death and loss to follow-up) was 2.13 years. The tracheostomy-related mortality was 0.5%, and the non–tracheostomy-related mortality was 22%. Nineteen percent of patients had complications in the first postoperative week, and 58% had 1 or more late complications. In comparison with the previous study from our institution, there was a great increase in long-term tracheostomy and a continuing trend away from tracheostomy for short-term airway management. Better monitoring and improvements in parental teaching may have contributed to a decrease in tracheostomy-related mortality.

Pediatric neck masses: guidelines for evaluation

Neck masses are frequent findings in the pediatric population. Unlike the adult, there are few established guidelines for evaluation of these children. The etiology of cervical masses includes many conditions. Knowledge of these conditions and their clinical presentations is essential. To elucidate the clinical characteristics which may help in establishing a correct diagnosis, the charts of 445 patients with biopsies of neck masses performed at the Childrens Hospital of Philadelphia were analyzed. There were 244 (55%) congenital lesions, 118 (27%) inflammatory lesions, 23 (5%) non-inflammatory benign masses, 12 (3%) benign neoplasms, and 48 (11%) malignancies. The preoperative diagnosis was correct in 270 (61%) patients. Guidelines are established for the evaluation of the child presenting with a neck mass.

Dexamethasone in adenotonsillectomy

Edema contributes substantially to the postoperative discomfort and morbidity of adenotonsillectomy. In a double-blind study, 58 children undergoing adenotonsillectomy were given a single intraoperative dose of either dexamethasone or saline. The steroid markedly affected the postoperative course in the first day after surgery. According to parental reports, the percentage of patients vomiting was reduced from 48 to 4%. Severe throat pain was reported in 57% of controls and only 20% of dexamethasone patients. Twice as many steroid patients as controls tolerated some soft food on the first postoperative day. It appears that dexamethasone can greatly improve patient diet and comfort after adenotonsillectomy.

The Histologic Relationship of Preauricular Sinuses to Auricular Cartilage

OBJECTIVE To conduct a meta-analysis of the cost-utility of the cochlear implant in adults. DATA SOURCES MEDLINE literature search, review of article bibliographies, and consultation with experts. STUDY SELECTION Studies that reported (1) data on adults (age > or = 18 years) with bilateral, postlingual, profound deafness; (2) a health-utility gain from cochlear implantation on a scale from 0.00 (death) to 1.00 (perfect health); (3) a cost-utility ratio in terms of dollars per quality-adjusted life-year (QALY); and (4) at least 1 conventional statistical parameter (ie, SD, 95% confidence interval [CI], or P value). DATA EXTRACTION From each study, we extracted the number of subjects, study design, health-utility instrument used, health-utility associated with profound deafness, health-utility gain from cochlear implantation, cost-utility of cochlear implantation, and reported statistical parameters. DATA SYNTHESIS Weighted averages were calculated using a statistical weight of 1 per variance. Pooling 9 reports (n = 619), the health-utility of profoundly deaf adults without cochlear implants was 0.54 (95% CI, 0.52-0.56). Pooling 7 studies (n = 511), the health-utility of profoundly deaf adults after cochlear implantation was 0.80 (95% CI, 0.78-0.82). This improvement of 0.26 in health-utility resulted in a cost-utility ratio of

Is outpatient tonsillectomy appropriate for young children

12,787 per QALY. CONCLUSIONS Profound deafness in adults results in a substantial health-utility loss. Over half of that loss is restored after cochlear implantation, yielding a cost-utility ratio of

Ototoxicity of Common Topical Antimycotic Preparations

12,787 per QALY. This figure compares favorably with medical and surgical interventions that are commonly covered by third-party payers in the United States today.

Complications of frontal sinusitis in adolescents: case presentations and treatment options

The current literature suggests that outpatient tonsillectomy is a safe, cost‐effective procedure. These reports have based their conclusions on the low rates of postoperative bleeding and dehydration. Generally, they have not examined other factors that may influence the postoperative course or identified groups of patients in whom outpatient management may not be appropriate. The literature regarding tonsillectomy in young children is conflicting. A retrospective analysis of the records of 223 children, 36 months of age and younger who had tonsillectomies, was performed. Postoperative airway complications including oxygen desaturation and airway obstruction developed in 115 patients. Seventeen (7.6%) children required postoperative care in an intensive care unit while an additional 117 (52.5%) patients received more than standard management. Preoperative apnea, an age of less than 12 months, and the presence of accompanying medical conditions were associated with a higher incidence of postoperative airway complications. It is recommended that tonsillectomy in patients under 36 months of age be planned as an inpatient procedure.

Periauricular Cysts and Sinuses

Objective To determine the ototoxic effects of five commonly used topical antimycotic agents—clotrimazole, miconazole, nystatin, tolnaftate, and gentian violet—in the guinea pig.

Nontuberculous Mycobacterial Cervical Adenitis

Frontal sinusitis in adolescents can be a serious condition because of the severity of potential complications and rapid progression of disease. These complications may arise as a result of extension of the infection intracranially, to the frontal bone, and to the orbit. Infection may spread hematogenously or by direct extension. A series of seven adolescent patients with complications of frontal sinusitis is presented. Surgical options are necessitated by the location and extent of infection and include trephination, frontal sinus obliteration, and craniotomy. Recent advances in endoscopic sinus surgery have provided surgeons another access to the frontal recess. However, a combined otolaryngological/neurosurgical approach is essential for patients with intracranial complications.

Surgical Management of Obstructive Sleep Apnea in Children With Cerebral Palsy

Periauricular cysts, sinuses, and fistulas occur commonly in the pediatric population. They arise from developmental defects of the first branchial cleft and first branchial arch. In most instances the diagnosis and management of these conditions are straightforward, but exceptional presentations sometimes occur. Failure to recognize these unusual cases may result in inadequate treatment and subsequent recurrence, and even if the correct diagnosis is made, surgical management of these lesions may be complicated. A series of 15 cases of periauricular congenital lesions is reviewed, of which three cases illustrating a diagnostic or surgical challenge are presented. The embryology, presentation, and management of these anomalies are discussed. This is one of the largest series of first branchial cleft anomalies reported in the literature, and our paper uniquely discusses first branchial cleft anomalies and preauricular sinuses together, with an emphasis on the surgical management of facial nerve, external ear, and middle ear involvement.