Maria T. Pena

The Effect of Intranasal Fentanyl on the Emergence Characteristics After Sevoflurane Anesthesia in Children Undergoing Surgery for Bilateral Myringotomy Tube Placement

Children undergoing placement of bilateral myringotomy tubes (BMT) often exhibit pain-related behavior (agitation) in the postanesthesia care unit. We compared the emergence and recovery profiles of pediatric patients who received sevoflurane with or without supplementary intranasal fentanyl for BMT surgery. By using a prospective, double-blinded design, 150 children 6 mo to 5 yr of age, scheduled for routine BMT surgery, were anesthetized with sevoflurane (2%–3%) in a 60% N2O/O2 gas mixture. Patients were randomized to receive equal volumes of intranasal saline (Control), 1 &mgr;g/kg fentanyl or 2 &mgr;g/kg fentanyl. A blinded observer evaluated each patient using a previously described 4-point agitation scale and the Steward recovery scale. Response to parental presence was observed after a score of six (full recovery) was achieved on the Steward recovery scale. There were no significant differences among the three groups regarding age, weight, surgeon, duration of anesthesia, or ear condition. Recovery times and emergence characteristic scores were not statistically different. Agitation scores were significantly reduced in the 2-&mgr;g/kg Fentanyl group as compared with the Control group (P = 0.012). Fentanyl 2 &mgr;g/kg is recommended to reduce the incidence of agitation seen in these patients.

Management of pediatric orbital cellulitis in patients with radiographic findings of subperiosteal abscess

Objective: Controversies remain regarding the management of orbital cellulitis (OC). The objective of this study was to examine the outcomes of patients admitted to our institution for orbital cellulitis during a 7-year period. Study Design: Case series with chart review. Setting: Tertiary referral pediatric hospital. Subjects and Methods: Charts of 465 consecutive OC admissions were reviewed for presentation, imaging, medical and surgical treatment, and outcome. Results: Of these patients, 189 were treated in the emergency room and 276 were admitted. CT scan was performed on 240 patients. Subperiosteal abscess (SPA) was noted in 68 patients. Of these, 47 were treated medically and 21 had surgery. Surgical patients were older (8.3 vs 6.2 years, P = 0.039), had larger abscesses (>10 mm, P < 0.001), required a longer admission (10.2 vs 6.6 days, P < 0.001), and had higher temperatures on admission (38.0°C vs 37.3°C, P = 0.03). Conclusion: The majority of small SPAs as diagnosed on CT scans in younger children can be successfully treated medically. Surgery, however, should be considered for a worsening clinical examination. Our findings confirm those of previous reports on this clinical entity.

Clinical Consensus Statement: Pediatric Chronic Rhinosinusitis

Objective To develop a clinical consensus statement on the optimal diagnosis and management of pediatric chronic rhinosinusitis (PCRS). Methods A representative 9-member panel of otolaryngologists with no relevant conflicts of interest was assembled to consider opportunities to optimize the diagnosis and management of PCRS. A working definition of PCRS and the scope of pertinent otolaryngologic practice were first established. Patients of ages 6 months to 18 years without craniofacial syndromes or immunodeficiency were defined as the targeted population of interest. A modified Delphi method was then used to distill expert opinion into clinical statements that met a standardized definition of consensus. Results After 2 iterative Delphi method surveys, 22 statements met the standardized definition of consensus while 12 statements did not. Four statements were omitted due to redundancy. The clinical statements were grouped into 4 categories for presentation and discussion: (1) definition and diagnosis of PCRS, (2) medical treatment of PCRS, (3) adenoiditis/adenoidectomy, and (4) endoscopic sinus surgery (ESS)/turbinoplasty. Conclusion Expert panel consensus may provide helpful information for the otolaryngologist in the diagnosis and management of PCRS in uncomplicated pediatric patients.

Perioperative Airway Complications following Pharyngeal Flap Palatoplasty

This study was performed to determine the incidence and types of perioperative airway complications after pharyngeal flap palatoplasty. We conducted a retrospective chart review of 88 patients who underwent correction of velopharyngeal insufficiency between April 30, 1983, and April 30, 1997, in a tertiary care hospital. Some degree of airway obstruction developed in 7 patients. One child developed laryngobronchospasm and required immediate endotracheal intubation. He was successfully extubated without sequelae. Another patient developed severe obstructive sleep apnea and required flap revision. A third patient was found asystolic and apneic. She was immediately intubated; however, she subsequently died. Two patients aspirated blood, presumably resulting in pneumonia. They were managed with parenteral antibiotics. Another child developed worsening sleep apnea and required flap revision. One patient developed nasal obstruction that resolved with time. Airway compromise in patients who undergo pharyngeal flap palatoplasty can be a potentially fatal complication. Careful surveillance should be maintained over patients with underlying neurologic, craniofacial, or cardiopulmonary disorders.

Human bronchial epithelial cells differentiate to 3D glandular acini on basement membrane matrix.

To create a model system that investigates mechanisms resulting in hyperplasia and hypertrophy of respiratory tract submucosal glands, we developed an in vitro three-dimensional (3D) system wherein normal human bronchial epithelial (HBE) cells differentiated into glandular acini when grown on a basement membrane matrix. The differentiation of primary HBE cells into glandular acini was monitored temporally by light microscopy. Apoptosis-induced lumen formation was observed by immunofluorescence analysis. The acinar cells expressed and secreted MUC5B mucin (marker for glandular mucous cells) and lysozyme, lactoferrin, and zinc-α2-glycoprotein (markers for glandular serous cells) at Day 22. β-Tubulin IV, a marker for ciliated cells, was not detected. Expression of mucous and serous cell markers in HBE glandular acini demonstrated that HBE cells grown on a basement membrane matrix differentiated into acini that exhibit molecular characteristics of respiratory tract glandular acinar cells. Inhibition studies with neutralizing antibodies resulted in a marked decrease in size of the spheroids at Day 7, demonstrating that laminin (a major component of the basement membrane matrix), the cell surface receptor integrin α6, and the cell junction marker E-cadherin have functional roles in HBE acinar morphogenesis. No significant variability was detected in the average size of glandular acini formed by HBE cells from two normal individuals. These results demonstrated that this in vitro model system is reproducible, stable, and potentially useful for studies of glandular differentiation and hyperplasia.

Complications in Pediatric Deep Neck Space Abscesses

Objectives. To determine the incidence and demographic profile of children who develop complications from deep neck space abscess. Study Design. Case series. Setting. Tertiary children’s hospital. Subjects and Methods. One hundred thirty-eight patients admitted for deep neck space abscesses between 1998 and 2008. Inclusion criteria were age younger than 18 years and computed tomography scan demonstrating an abscess in the retropharyngeal, parapharyngeal, or peritonsillar spaces. Children were diagnosed with abscess if purulence was encountered on operative incision and drainage. Results. In the first 5 years of the study, 45 children met the inclusion criteria, whereas in the latter 5 years, 93 children were treated for abscesses. There were no differences between these cohorts in terms of age (P = .70), gender (P = .08), abscess site (P = .23), or rate of surgical intervention (P = .83). The total major complication rate was 9.4% (n = 13) with mediastinitis being the most frequent (n = 9) complication. The number of complications between the first (n = 3) and second (n = 10) groups was not significantly different (P = .55). The factors that predisposed patients to develop complications were younger age at presentation and retropharyngeal abscess location. Children with complications were more likely to have Staphylococcus aureus identified as the causative organism (P = .007). Only 1 of 4 children with methicillin-resistant S aureus had a complicated clinical course. Conclusions. Deep neck space abscesses continue to cause significant morbidity in children. Factors that predict complications include young age, retropharyngeal location, and S aureus. Providers must maintain a high index of suspicion to promptly diagnose and treat these complications.

Outcomes of Balloon Dilation in Pediatric Subglottic Stenosis

Objectives: We report outcomes of balloon dilation in the endoscopic management of pediatric subglottic stenosis (SGS) and discuss the role of balloon dilation in both primary and adjuvant therapy. Methods: We performed a retrospective review of treatment with noncompliant, high-pressure balloons for SGS in the past 2 years at a tertiary pediatric hospital. Fifty-one dilations were performed in 28 children with SGS. The childrens mean age was 42 months. The mean SGS grade was 2.46. Results: Fifteen children had primary balloon dilation, and 13 had adjuvant balloon dilation. Overall, 16 children (57.1%) had successful balloon dilation. Of those who underwent primary dilation, 9 (60.0%) were able to avoid open reconstruction or tracheotomy and 6 had their symptoms temporarily improved (average, 36 days) until definitive open reconstruction. Of the patients who underwent adjuvant dilation, 7 (53.8%) were successfully decannulated. Nine of the 12 failed balloon dilations were in children who had concomitant airway disorders; in contrast, only 6 of 16 children in whom treatment was successful had concomitant airway disorders (p = 0.048). There was no statistical association between successful versus failed treatment and age (51.6 versus 27.9 months; p = 0.23), degree of stenosis (grade 2.3 versus grade 2.6; p = 0.41), presence of lung disease (33.3% versus 70%; p = 0.07), or soft versus firm stenosis (60.0% versus 53.1%; p = 0.71). Conclusions: Balloon dilation plays an important role in the primary and adjuvant management of pediatric SGS. The presence of concomitant airway lesions is significantly associated with failure of balloon dilation treatment. Meticulous surveillance of the dilated airway is necessary, given this failure rate.

Orbital Complications of Acute Sinusitis: Changes in the Post–Pneumococcal Vaccine Era

IMPORTANCE The widespread use of the 7-valent pneumococcal conjugate vaccine (PVC7), developed to combat invasive Streptococcus pneumoniae infections, has the potential to influence the prevalence and antibiotic resistance patterns of pathogens associated with orbital complications from acute sinusitis. Given the significant morbidity that may result from inadequate treatment of orbital infections related to acute sinusitis, determining the impact of PCV7 on the bacteriology and drug resistance of the pathogens associated with these infections may provide critical information needed to accurately guide optimal clinical management. OBJECTIVE To determine if the characteristics of orbital complications from acute sinusitis in children have changed in the post-PCV7 era. DESIGN Review of clinical data. SETTING Tertiary care childrens hospital. PARTICIPANTS Patients with a diagnosis of orbital cellulitis and/or subperiosteal abscess from January 1, 1996, to December 31, 2009. Patients with immune deficiency or orbital trauma were excluded. Patients were divided into pre-PCV7 (before 2003 [n = 128]) and post-PCV7 (2003 and after [n = 145]) groups. Statistical analyses were used to compare the 2 groups. MAIN OUTCOME MEASURES Differences in patient demographics, signs and symptoms, laboratory study results, computed tomography scan findings, and microbiological analyses between the pre-PCV7 and post-PCV7 groups. RESULTS A total of 273 children met the inclusion criteria. The post-PCV7 group was older (71.4 months vs 88.8 months [P = .007]) than the pre-PCV7 group. A significant decrease in S pneumoniae and Streptococcus viridans -positive sinus or blood cultures were observed (22.4% vs 0% [P < .001] and 12.24% vs 0% [P = .005], respectively). An increase in Staphylococcus aureus was seen in the post-PCV7 group (20.4% vs 42.37% [P = .02]). Methicillin-resistant S aureus (MRSA) was isolated only in the post-PCV7 group (P = .002). The pre-PCV7 group had a significantly longer hospital stay than the post-PCV7 group (7.15 days vs 5.47 days [P = .004]). CONCLUSIONS AND RELEVANCE Although universal PCV7 vaccination has eliminated S pneumoniae as an etiologic pathogen in acute sinusitis complications in this series, there has been a parallel and significant increase in S aureus, including an increase in the prevalence of MRSA associated with orbital infections related to acute sinusitis.

The effect of dexmedetomidine during myringotomy and pressure‐equalizing tube placement in children

Background:  Bilateral myringotomy (BMT) is a commonly performed otolaryngologic procedure in children.

Pediatric Tracheotomy Wound Complications: Incidence and Significance

OBJECTIVES To determine the incidence and to describe wound complications and associated risk factors of pediatric tracheotomy. DESIGN Retrospective case series. SETTING Freestanding tertiary care academic pediatric hospital. PATIENTS Sixty-five consecutive children undergoing tracheotomy over 15 months. MAIN OUTCOME MEASURES Postoperative wound complications objectively and independently documented by an advanced practice nurse specializing in tracheotomy care. Secondary outcome measures included comorbidities, mortality rates, and wound status after subsequent examinations and management. RESULTS The mean (SEM) patient age at tracheotomy was 45 (8.7) months (median age, 9.1 months). The most common indication for tracheotomy was pulmonary disease (36.9%), followed by neurologic impairment and laryngeal abnormalities. There were 19 patients (29%) with and 46 patients (71%) without wound complications. There were no significant differences between the 2 groups in age (P = .68) or weight (P = .55); however, infants younger than 12 months had an increased complication rate (39% vs. 17%, P = .04). The type of tracheotomy tube was predictive of postoperative wound complications (P = .02). All patients with wounds received aggressive local wound care. Five of 13 patients had complete resolution of stomal wounds, whereas 8 patients had persistent wound issues. There were 5 non-wound-related mortalities. CONCLUSIONS With attempts to classify tracheotomy wound breakdowns as reportable events, including never events, increasing emphasis is being placed on posttracheotomy care. This study demonstrates that wound breakdown in pediatric tracheotomy patients is common. These complications can be mitigated, although not prevented completely, with aggressive wound surveillance and specialized wound care.