Mark E. Gerber

Partial Cricotracheal Resection with Primary Anastomosis in the Pediatric Age Group

The traditional approach to severe subglottic stenosis (SGS) in the pediatric age group is laryngotracheal reconstruction (LTR). This approach may be complex and multistaged, with variable and unpredictable success rates in the individual patient. Excellent results have been reported in adults who had severe SGS and underwent partial resection of the cricoid and primary thyrotracheal anastomosis. This procedure has not been widely reported in infants and children. We report our experience with this procedure in 16 pediatric patients with grade III or IV SGS. Eleven patients had multiple previous LTR operations. The preoperative evaluation, surgical techniques, postoperative care, complications, and final results are described and discussed. Fourteen patients were decannulated after the procedure, 1 patient needed a second open procedure prior to decannulation, and 1 patient with concomitant bronchopulmonary dysplasia remains cannulated, for an overall 94% decannulation rate. Fourteen patients have no limitation of respiration, and 1 patient has moderate exercise intolerance. The results of this series suggest that partial cricotracheal resection with primary anastomosis is a relatively safe and effective procedure for pediatric patients with severe SGS.

Histoplasmosis: The otolaryngologist's perspective

Within the upper aerodigestive tract, histoplasmosis often mimics carcinoma, making prompt and accurate diagnosis imperative. More severe and potentially lethal infections with Histoplasma capsulaturn are now being seen as the numbers of patients at the extremes of age, as well as those with compromised immune systems, increase. We reviewed the cases of 115 hospitalized patients with disseminated histoplasmosis. Of these, 9 patients were identified with tolaryngologic manifestations: 4 were infected with human immunodeficiency virus (HIV), 1 was diabetic, and 3 were renal transplant patients. Sites of involvement included the larynx (in 2 cases) and the oral cavity and oral pharynx (in 7 cases). Eight of the 9 patients had a positive biopsy result; the other, a positive culture. Treatment with amphotericin B was generally effective, while the use of newer azole antifungal agents were less effective. As the number of immunocompromised patients continues to increase in modern clinical practice, histoplasmosis will undoubtedly be encountered more frequently in the head and neck area.

Vascular compression of the airway: indications for and results of surgical management.

Vascular compression of the airway is a significant cause of respiratory compromise in children. While the indications for surgical repair are sometimes life threatening, they can also be subtle. This retrospective study examines 45 surgical cases of tracheobronchial compromise secondary to vascular compression at a large childrens hospital between July 1983 and February 1996. A total of 34 were diagnosed with innominate artery compression, ten with a double aortic arch and one with an anomalous right subclavian artery. The 45 patients, 25 male and 20 female, ranged in age from 12 days to 11 years at surgery (average 13 months). A total of 21 (47%) presented with proven or suspected episodes of cyanosis or apnea. All 45 patients had evidence of vascular compression during microlaryngoscopy and bronchoscopy. The diagnosis was confirmed by magnetic resonance imaging (MRI) in 23/45 (51%), barium swallow in 22/45 (49%) and aortogram in 3/45 (7%). There was one death. One patient had a tracheotomy before surgery and continues to require it after surgery. Complete resolution of symptoms was achieved in 39/45 (87%) with five requiring more than one operation before their symptoms resolved completely. A total of four patients experienced a recurrence of symptoms within a variable length of time after surgery. Surgical indications and treatment alternatives will be discussed.

Factors Affecting Delays to Surgery for Oral Tongue Carcinoma in the National Cancer Data Base

Objectives: Surgery is the definitive treatment for oral tongue squamous cell carcinoma (OSCC). Studies have described correlates of delayed diagnosis. However, little is known about treatment delays after diagnosis. This study investigates time intervals from diagnosis to surgery for OSCC using the National Cancer Data Base (NCDB). Methods: The NCDB was queried for OSCC patients initially treated with surgery in 1998 through 2009. Patients were dichotomized based on time to surgery relative to the median. Chi-square and multivariable logistic regression models were used for statistical analyses. Results: A total of 14,270 patients were identified. The median age was 60 years (range, 18-90 years). For all stages, the median time from diagnosis to surgery was 27 days (SD = 42). Factors that predicted a longer interval to surgery included: advanced stage (28 days), Hispanic ethnicity (29 days), lack of health insurance (29 days), treatment at an academic/research facility (29 days), residence >75 miles from the hospital (31 days), treatment in the Middle (29 days) and South Atlantic (28 days) states, and having a referral to a different treating center (30 days). The strongest predictors of time delay were having a referral (odds ratio [OR] 1.97, 95% confidence interval [CI] 1.83-2.13, P < .001) and geographic location (Middle Atlantic: OR 1.83, 95% CI 1.57-2.14, P < .001). Conclusions: There is significant variation in the time from diagnosis to surgery for patients with OSCC. Several patient, geographic, and facility factors predict treatment delays. These findings can be used as a benchmark for quality of care and to guide further investigation into whether timing disparities affect outcomes.

Endoscopic Posterior Cricoid Expansion in Children

Objective: To review our experience with endoscopic posterior cricoid split and costal cartilage graft placement in the management of pediatric bilateral vocal fold immobility (BVFI), posterior glottic stenosis (PGS), and subglottic stenosis (SGS). Method: Multi-institutional retrospective case series of all patients treated with endoscopic posterior cricoid split and costal cartilage graft placement (EPCSCG) by any of the authors. Outcomes measured include: indications, complications, outcome. Results: Twenty-six patients underwent EPCSCG. Age range at time of surgery was 1 month to 15 years. Overall, there was an excellent success rate with 25/26 either never requiring tracheostomy or achieving decannulation and 24/26 having adequate symptom control. The mean follow-up was 23.15 months. Sixteen patients had resolution of their symptoms. Fourteen patients had SGS in isolation or in combination with cricoarytenoid fixation, glottic stenosis or vocal fold immobility. Thirteen achieved decannulation and/or had resolution of preoperative symptoms. Three patients had isolated PGS or cricoarytenoid fixation with 2 achieving decannulation without additional procedures and the third decannulated after revision endoscopic division of a congenital anterior glottic web. Nine patients had isolated BVFI. Two of the 9 had failed prior laryngeal surgeries and 4 did not have tracheostomies at the time of their EPCSCG. Of these 9 patients, 7 had resolution of their airway symptoms without additional procedures. Conclusion: Based on this experience, EPCSCG is worth consideration for the management of select pediatric patients with BVFI, PGS, and SGS.

Controversies in the Management of Pediatric Aspiration

Program Description: This miniseminar is supported by the Airway and Swallowing Committee. It will be an open forum and interactive discussion on the management of dysphagia and aspiration in the pediatric population. The panelists will discuss diagnostic methods as well as medical and surgical treatment options. They will assist the attendee in understanding the pathophysiology and morbidity of chronic aspiration in children. A case presentation format will be used and the audience will be able to help determine the focus of the discussion. Attendees will have the opportunity to submit a case for presentation by emailing to aspirationaao@me.com prior to the meeting. Each case presented will have a set of questions developed regarding differential diagnosis, evaluation, and treatment for the audience to select prior to discussion by the panel. The audience response will be a springboard for more in-depth discussions. Controversies that will be reviewed include the use of videofluoroscopic swallow studies vs fiber optic endoscopic evaluation of swallowing; sialorrhea management options, including botox, ductal ligation, and salivary gland excision, and surgical management options for persistent aspiration following maximal treatment for sialorrhea and GERD. Educational Objectives: 1) Understand diagnostic tests available for children with dysphagia and aspiration. 2) Formulate algorithm for investigation of children who present with symptoms of dysphagia and aspiration. 3) Understand treatment options for mild, moderate, and severe dysphagia and aspiration.

Correlation of Study Methods Assessing Gastroesophageal Reflux Induced Laryngeal Inflammation

Correlation of Study Methods Assessing Gastroesophageal Reflux Induced Laryngeal Inflammation