Marcella R. Bothwell

Outcome of reflux therapy on pediatric chronic sinusitis.

OBJECTIVE The cause of pediatric chronic sinusitis is multifactorial, but nasal edema appears to be the initial pathologic step. The objective of this study is to evaluate gastronasal reflux as a possible cause of pediatric sinusitis. METHODS Thirty children with chronic sinusitis were believed to be appropriate candidates for functional endoscopic sinus surgery. Children were evaluated retrospectively for their response to reflux therapy with regard to their sinus symptoms and avoidance of sinus surgery. RESULTS Two of the 30 children were eventually excluded because they were taken to surgery for the specific purpose of contact point release. Chart review at 24-month follow-up indicated that 25 of the 28 children (89%) avoided sinus surgery. CONCLUSION After reflux treatment, the number of children requiring sinus surgery was dramatically reduced. The results of this preliminary pediatric study indicate that gastronasal reflux should be evaluated and treated before sinus surgical intervention.

Long-term outcome of facial growth after functional endoscopic sinus surgery

OBJECTIVE: We sought to determine whether functional endoscopic sinus (FES) surgery performed in children with chronic rhinosinusitis alters facial growth. STUDY DESIGN AND SETTING: This was a retrospective age-matched cohort outcome study performed at a tertiary care hospital. RESULTS: Sixty-seven children participated. There were 46 boys and 21 girls, and the mean age was 3.1 years at presentation and 13.2 years at follow-up. There were 46 children who underwent FES surgery and 21 children who did not undergo FES surgery. Quantitative anthropomorphic analysis was performed using 12 standard facial measurements. A facial plastic expert performed qualitative facial analysis. Both quantitative and qualitative analyses showed no statistical significance in facial growth between children who underwent FES surgery and those who did not undergo FES surgery. CONCLUSIONS: In this study, there was no evidence that FES surgery affected facial growth. SIGNIFICANCE: These results will aid physicians when discussing with parents the risks of FES surgery.

Congenital Tracheal Diverticulum

Recurrent respiratory tract disease in an infant or child should raise the suspicion of a congenital airway anomaly. Upper aerodigestive tract anomalies are more common than lower aerodigestive tract anomalies. Congenital airway anomalies that are often reported include posterior laryngeal clefts, tracheoesophageal fistulas, laryngomalacia, tracheomalacia, subglottic stenosis, congenital webs, and vascular anomalies causing external compression of the airway. A rare lesion reported in the literature is the congenital tracheal diverticulum. Rokitansky1 first described tracheal diverticuli in 1838. Since that original description, few cases have been reported in the literature. We report 2 cases of patients who recently presented at our institution and provide clinical photographs.

Actinomycosis: A potential complication of head and neck surgery

Actinomycosis is a granulomatous infection occasionally found in the head and neck region that potentially may complicate a major head and neck oncologic surgical procedure. A case presentation, a review of the pertinent literature, and the treatment of this infectious complication are the primary elements of this report. A chronic infection of the neck caused by Actinomyces ssp developed postoperatively in a patient treated for head and neck cancer. Despite relapse after an initial course of long-term antibiotic therapy, the infection was successfully eradicated. Actinomycosis after surgery for head and neck cancer is unusual. However, the etiologic agent, Actinomyces ssp, is a common, potential microbial contaminant of head and neck surgery characterized by oral cavity or pharyngeal entry. Recognition of the typical manifestation of this infection in the neck facilitates prompt, appropriate treatment.

The adequate stimulus for mammalian linear vestibular evoked potentials (VsEPs)

Short latency linear vestibular sensory evoked potentials (VsEPs) provide a means to objectively and directly assess the function of gravity receptors in mammals and birds. The importance of this functional measure is illustrated by its use in studies of the genetic basis of vestibular function and disease. Head motion is the stimulus for the VsEP. In the bird, it has been established that neurons mediating the linear VsEP respond collectively to the rate of change in linear acceleration during head movement (i.e. jerk) rather than peak acceleration. The kinematic element of motion responsible for triggering mammalian VsEPs has not been characterized in detail. Here we tested the hypothesis that jerk is the kinematic component of head motion responsible for VsEP characteristics. VsEP amplitudes and latencies changed systematically when peak acceleration level was held constant and jerk level was varied from ∼0.9-4.6 g/ms. In contrast, responses remained relatively constant when kinematic jerk was held constant and peak acceleration was varied from ∼0.9 to 5.5 g in mice and ∼0.44 to 2.75 g in rats. Thus the mammalian VsEP depends on jerk levels and not peak acceleration. We conclude that kinematic jerk is the adequate stimulus for the mammalian VsEP. This sheds light on the behavior of neurons generating the response. The results also provide the basis for standardizing the reporting of stimulus levels, which is key to ensuring that response characteristics reported in the literature by many laboratories can be effectively compared and interpreted.

Upper Esophageal pH Monitoring of Children With the Bravo pH Capsule

INTRODUCTION Reflux of gastric contents is a common, welldocumented occurrence among adults. Since the early 1980s, gastroesophageal reflux disease (GERD) has been increasingly recognized as a clinical entity among children. Several investigators have noted that approximately half of all newborns have reflux. In the study of Nelson et al., peak incidence of reflux occurred at approximately 4 months of age; approximately 67% of these infants exhibited signs of reflux disease. Prevalence decreased to approximately 5% at 1 year of age. Left untreated, gastroesophageal reflux most commonly results in vomiting (spitting up), abdominal or chest pain, heartburn, arousal from sleep, and regurgitation. Studies have found that up to 75% of patients with symptoms of upper or lower respiratory tract disorders such as asthma, croup, bronchitis, pneumonia, sinusitis, laryngomalacia, and subglottic stenosis have reflux disease. Gastroesophageal reflux may also be associated with more serious complications such as apparent lifethreatening events, isolated bradycardia with irregular respiratory efforts, apnea, hypotension, reduced cerebral blood flow, and sudden infant death syndrome (SIDS). Although reflux is a common occurrence among young children, making a confirmatory diagnosis is difficult in the clinical setting. Pediatric patients are not always cooperative with a 24-hour pH study. Questions about the validity of such studies exist, and the interpretation of the findings can be difficult. TECHNIQUE Children suspected of having gastroesophageal reflux affecting the upper airway have a pH probe or “capsule” put into place in the operating room while undergoing other procedures (predominantly, direct laryngoscopy with bronchoscopy) If there are no plans for surgery, the traditional pH probe is placed through the nose by our colleague. The Bravo capsule technique is used to enhance the diagnosis of reflux, ot to completely change how we diagnose reflux. The delivery system and capsule are manufactured by Medtronic (reference no. 9012B1001, Shoreview, MN). The delivery system is 100 cm long, and the size of the capsule is 26 ! 6.0 ! 6.3 mm (Fig. 1). For an otolaryngologist trained in upper airway management, this technique has been uncomplicated. After securing intubation with an appropriately sized endotracheal tube, the Parsons laryngoscope is reinserted, lifting the larynx forward. This identifies the cricopharyngeal opening to the esophagus. The capsule is placed in the proper position, and the suction device is attached. A small amount of mucosa is gathered and pinned by the delivery device. The capsule is released from the delivery system and remains in place. When detaching the capsule from the delivery system, it is important to turn off the suction machine and also disconnect the suction device from the delivery vehicle to remove any residual suction from the system. This allows a much easier release of the capsule onto the esophageal mucosa without injury. This also aids in the prevention of capsule-related complications. Esophagoscopy has been routinely used to confirm appropriate placement in the upper esophagus, but it is not necessary. Although it would be ideal to have pH measurements from the posterior pharynx to diagnose extraesophageal reflux, this capsule should rest just below the closed cricopharyngeal muscle in the upper esophagus. The cricopharyngeal muscle is composed of striated muscle and is tonically contracted to protect the airway from refluxed esophageal contents (Figs. 2 and 3). While the capsule is in place, the child wears a receiver device, which is approximately the size of a pager. The receiver need not be worn but should remain within 3 feet of the child to ensure proper recording of the data. The child can go home and is allowed to eat normally. No changes in dietary habits are necessary with the capsule. Some procedures require children to be on From the Department of Otolaryngology (M.B., S.B.) and the Departments of Pediatrics (M.B.) and Surgery (J.P.), University of Missouri–Columbia, Columbia, Missouri, U.S.A. Editor’s Note: This Manuscript was accepted for publication November 3, 2003. Send Correspondence to Marcella Bothwell, MD, Department of Otolaryngology and Department of Pediatrics, University Hospital and Clinics, One Hospital Drive, DC027.00, Columbia, MO 65212, U.S.A. Email: bothwellm@health.missouri.edu

Long‐Term Follow‐Up for Children Treated With Surgical Intervention for Chronic Rhinosinusitis

Objectives/Hypothesis: The goal of this study is to retrospectively compare the long‐term, 10 year, outcomes of surgical versus medical management of young children with chronic rhinosinusitis.

Bradycardia with sevoflurane induction in patients with trisomy 21.

Summary The authors present a series of three paediatric patients with trisomy 21 who developed significant bradycardia during inhalation induction with sevoflurane. All three were undergoing adenotonsillectomy. The possible association of such problems with trisomy 21 and treatment options are reviewed. Although the occurrence of bradycardia in these three patients may have been a random occurrence, given its occurrence in three of five consecutive patients with trisomy 21, a causal relationship may be involved and future observation of these patients appears warranted.

Perioperative care of a patient with Beare–Stevenson syndrome

Beare–Stevenson syndrome is a craniofacial syndrome consisting of a specific pattern of craniosynostosis resulting in a cloverleaf skull deformity and hydrocephalus, down‐slanting palpebral fissures, proptosis, hypertelorism, strabismus, dysmorphic ears, choanal atresia, cleft palate, cutis gyratum, acanthosis nigricans, and abnormal genitalia. Its primary cause has been identified as a single amino acid substitution in fibroblast growth factor receptor 2. Of primary importance to the anesthesiologist are issues related to airway management resulting from midface hypoplasia, choanal atresia, and airway abnormalities (tracheal stenosis). Additional issues affecting airway management include associated cervical spine and foramen magnum abnormalities. The authors present their experience caring for a patient with Beare–Stevenson syndrome and discuss the anesthesia care of these patients.

Prevalence of Elevated Total IgE and Food Allergies in a Consecutive Series of ENT Pediatric Patients

OBJECTIVE: Food allergies in childhood have been found to vary in frequency from 6% to 8% in the general population. Previous studies indicate milk allergy affects approximately 2.5% of infants and egg allergy has been estimated at 1.6% to 2.6%. Numerous allergists believe that the prevalence of food allergies is rising, similar to the rise in other atopic conditions. Prior studies have demonstrated that food-specific IgE is a useful test for diagnosing symptomatic allergies to certain foods, including milk and eggs, and could decrease the need to perform cumbersome multiple double-blind, placebo-controlled food challenges in children based on history alone. The purpose of this study was to determine the prevalence of food allergies and elevated IgE in a consecutive series of pediatric otolaryngology patients. STUDY DESIGN AND SETTING: ImmunoCap™ studies were drawn in a 2-year series of children undergoing ENT procedures of bilateral myringotomy with tubes (BMT) with or without adenoidectomy or tonsillectomy or adenoidectomy alone between 2001 and 2003. Sera was analyzed for increased total IgE antibodies, as well as specific IgE antibodies to antigens, including milk, egg, beef, and environmental allergens. A positive patient history or family history of allergy were documented. RESULTS: A total of 242 patients were assessed. Of the study population, milk allergy was found in 10.7%; egg white allergy was found in 5.0%. The prevalence of elevated IgE among participants was 11.2%. The overall food allergy prevalence was 14.5%. CONCLUSIONS: Although we cannot imply causality, the study demonstrated an increased prevalence of food allergy in children undergoing ENT procedures, specifically milk and eggs, than in previous population studies.