Matija Daniel

Airway, feeding and growth in infants with Robin sequence and sleep apnoea

OBJECTIVE Robin sequence (RS) is associated with airway abnormalities that result in functional problems of obstructive sleep apnoea (OSA), feeding difficulties, and consequent poor growth. We evaluated the relationships between OSA severity, airway and feeding interventions, and weight at 12 months in infants with RS and OSA. METHODS Retrospective notes review of children with RS managed at our neonatal unit (1998-2010, inclusive). RESULTS Of 39 infants studied, 10 (25.6%) had mild/moderate OSA, and 29 (74.4%) severe. Infants with severe OSA required more airway interventions in hospital (82.8 vs 30.0%, p = 0.004) and at discharge (72.4 vs 20.0%, p = 0.007) than those with mild/moderate OSA; 30.0% of infants with mild/moderate OSA required continuous positive airway pressure (CPAP) during admission and 20.0% on discharge, but amongst those with severe OSA 82.8% required airway interventions as an inpatient, 17.2% underwent mandibular distraction osteogenesis, and 55.2% required CPAP on discharge. Those with severe OSA were also more likely to require tube feeding on discharge (89.7 vs 50.0%, p = 0.02). Overall, children were on a lower weight centiles at discharge compared to birth (-10.2 centiles) and at 12 months of age compared to birth (-14.8 centiles), but this occurred irrespective of OSA severity or need for airway interventions or tube feeding. CONCLUSIONS Infants with RS commonly have OSA, feeding and airway difficulties. Weight at 12 months appeared not to be influenced by OSA severity, feeding or airway problems, suggesting that current intervention/management strategy results in the severely affected infants growing as well as those affected less severely.

Biofilm Eradication With Biodegradable Modified-Release Antibiotic Pellets A Potential Treatment for Glue Ear

OBJECTIVE To develop a biodegradable, modified-release antibiotic pellet capable of eradicating biofilms as a potential novel treatment for biofilm infections. DESIGN Pellets containing poly(DL-lactic-co-glycolic acid) microparticles, rifampin and clindamycin hydrochloride (3.5%, 7%, or 28% antibiotic by weight), and carrier gel (carboxymethylcellulose or poloxamer 407) were tested in vitro. Drug release was assessed using serial plate transfer testing and high-performance liquid chromatography, and pellets were tested against biofilms in an in vitro model of Staphylococcus aureus biofilm grown on silicone. RESULTS Serial plate transfer testing demonstrated continuing bacterial inhibition for up to 21 days for all pellets studied. High-performance liquid chromatography showed high levels of drug release for 2 to 4 days, with greatly reduced levels subsequently; continued measurable clindamycin (but not rifampin) release for up to 21 days was achieved. Pellets made with poloxamer released higher drug levels for a longer period. Irrespective of the carrier gel used, pellets containing 7% and 28% (but not 3.5%) antibiotic eradicated biofilms successfully. CONCLUSIONS Antibiotic pellets can release antibiotics for up to 21 days and are able to eradicate biofilms in an in vitro model. Use of modified-release antibiotic formulations in the middle ear as a treatment for biofilms appears to be a potentially promising new therapy for otitis media with effusion.

Do orally administered antibiotics reach concentrations in the middle ear sufficient to eradicate planktonic and biofilm bacteria? A review

INTRODUCTION Infectious conditions of the middle ear are a common and significant cause of morbidity and mortality worldwide. Systemic antibiotics are frequently used, but their effectiveness will depend on whether an adequate antibiotic concentration is achieved in the middle ear; this is especially important in biofilm infections such as otitis media with effusion (OME), where high antibiotic concentrations are typically required for effective treatment. OBJECTIVE This review examines what antibiotic levels can be reached in the middle ear with oral administration, as a means of guiding rational antibiotic choice in the clinic and future research, and to determine whether levels high enough for biofilm eradication are reached. METHODS A literature search of studies measuring levels of antibiotics in the plasma and in the middle ear after oral administration was conducted. These levels were compared to the minimum inhibitory concentrations (MIC) provided by the European Committee for Antimicrobial Susceptibility Testing (EUCAST) to determine if antibiotic doses were reaching sufficient levels to inhibit planktonic bacteria. The middle ear concentrations were then calculated as a multiple of the MIC to determine if the concentrations were reaching biofilm eradication concentrations (typically up to 1000×MIC). RESULTS The highest antibiotic levels against Staphylococcus aureus reach 8.3×MIC, against Moraxella catarrhalis 33.2×MIC, against Haemophilus influenzae 31.2×MIC, and against Streptococcus pneumoniae 46.2×MIC. The macrolide antibiotics reach higher levels in the middle ear than in plasma. CONCLUSIONS Orally administered antibiotics reach levels above the MIC in the middle ear. However, they do not reach levels that would be likely to eradicate biofilms.

Vocal cord reconstruction to treat aspiration caused by a post-intubation posterior glottic furrow

OBJECTIVE To present the case of a premature child with a furrow in the posterior vocal cord as a result of prolonged intubation, with symptoms of aspiration and poor voice, treated with a novel method of vocal cord reconstruction. METHODS The vocal cord was reconstructed endoscopically by freeing up the edge of cord remnant and suturing this to a flap of inter-arytenoid mucosa to create a new cord. RESULTS The resulting neo-cord was able to achieve full glottic closure with resolution of aspiration, and this was also accompanied by improvement in voice quality. CONCLUSION The described vocal cord reconstruction method proved to be a useful treatment for aspiration and poor voice caused by a post-intubation vocal cord furrow.

Sub-labial packing: A novel method of stopping epistaxis from Little's area

Epistaxis is frequently managed both by patients in the community and by health professionals. Many methods have been described in the literature about how to manage this condition. Epistaxis is usually due to anterior circulation bleeding at an area known as Kiesselbachs plexus (Littles area). Five vessels supply Littles area; one of these, the septal branch of the superior labial artery, can be compressed via an easy and novel technique, sub-labial packing. Sub-labial packing is a technique proposed as an adjunct to the standard 15 min ala nasi compression as a simple yet effective technique to stop epistaxis. We hereby report two cases of managing epistaxis from Littles area using sub-labial packing.

Laryngotracheal stenosis and airway surgery--an outcomes based approach.

OBJECTIVES To review the outcomes of endoscopic, open or a combination of both surgical modalities for laryngotracheal stenosis and establish which factors influence results. METHODS Records of all children undergoing laryngotracheal procedures (excluding laryngomalacia and aspirated foreign bodies) by the Department of Otolaryngology at The Childrens Hospital at Westmead between January 2003 and November 2011 were reviewed. Specific data on population, intervention, covariates and outcomes were recorded and analysed. RESULTS A total of 104 patients undergoing 277 procedures were included. 211 (76%) of the procedures were endoscopic, remaining 66 (24%) open. Patients undergoing open surgery were more likely to have significant co-morbidity, prior intubation, require ICU admission or tracheostomy and have a longer hospital stay. 57 (54.8%) patients were successfully treated with a single procedure (48 endoscopic and 9 open). Of the endoscopic patients requiring further surgery, 16 were managed with multiple endoscopic procedures, whilst 12 underwent subsequent open procedures. Open surgery was performed on 66 patients, 63.6% (42/66) of all open procedures required further endoscopic intervention and 45.2% (19/42) of these avoided further open surgery. CONCLUSIONS Both open and endoscopic surgery have a role in laryngotracheal stenosis, and many patients benefit from a combination of both. Ultimately the decision depends on experience of the treating team, social considerations, and institutional capabilities. A multi-centre prospective data collection would be a useful tool to further investigate optimal management approach.

Emergency EXIT: an urgent ex utero intrapartum tracheostomy for giant fetal neck mass

The ex utero intrapartum treatment (EXIT) procedure was first described in 1989 for airway obstruction caused by fetal head and neck masses and has also been used in cases of congenital diaphragmatic hernia. The procedure involves delivery of the head and one shoulder of the foetus via Caesarean section under maternal general anaesthesia. The foetus does not take a breath, while oxygenation is maintained on uteroplacental circulation, for up to 1.5 h. An EXIT procedure is indicated when a foetus requires tracheal intubation, tracheostomy, immediate resection of a mass, extracorporeal membrane oxygenation or separation from a conjoined twin at the time of delivery. Uterine hypotonia is essential for maintaining placental circulation and is achieved through maternal anaesthesia using high-dose sevoflurane anaesthesia and glyceryl trinitrate infusion. Leaving most of the foetus within the uterus and running fluid into the uterine cavity maintains uterine distension and prevents uterine contraction and placental shearing. Fetal anaesthesia is achieved through the maternal anaesthetic and additional agents such as muscle relaxants can be administered intramuscularly to the foetus if required. Advances in prenatal ultrasound and magnetic resonance imaging (MRI) have improved the intrauterine diagnosis of conditions such as congenital high airway obstruction, severe congenital diaphragmatic hernias and large lung or mediastinal masses, allowing the planning of an EXIT procedure for some cases. Our case is an emergency EXIT procedure for a foetus with a giant cervical mass. Prenatal ultrasound at 28 weeks diagnosed polyhydramnios and a left-sided neck mass measuring 3.7 × 8.0 × 5.0 cm. A subsequent ultrasound at 30 weeks confirmed an enlarging mass with internal vascular flow. MRI was planned for 34 weeks. However, spontaneous rupture of the membranes occurred at 32 weeks. Within 2 h, a team consisting of adult and paediatric anaesthetists, paediatric ears, nose and throat (ENT) surgeon, a neonatologist and an obstetrician, fellows and registrars had been assembled and all necessary equipment was transferred from the neighbouring tertiary paediatric hospital. The head and shoulders were delivered and a large neck mass was seen anterolaterally on the left. Attempts at oral intubation via direct and fibre optic laryngoscopy as well as via the ventilating rigid bronchoscope were unsuccessful. Resection of the mass on placental support was deemed not possible due to its extensive nature, difficulty identifying landmarks and lack of available imaging. A decision was made to proceed to tracheostomy with a horizontal incision made low in the neck. Despite complete distortion of neck anatomy by the mass, the thymus was located on the far right of the neck, and posterior to it a soft white vertical structure was identified; this appeared to contain no cartilage and it was non-pulsatile. A vertical incision was made in this structure and intubation using a 3.0-mm

Evaluation of combinations of putative anti-biofilm agents and antibiotics to eradicate biofilms of Staphylococcus aureus and Pseudomonas aeruginosa

Objectives: To evaluate potential anti‐biofilm agents for their ability to enhance the activity of antibiotics for local treatment of localized biofilm infections. Methods: Staphylococcus aureus and Pseudomonas aeruginosa in vitro biofilm models were developed. The putative antibiotic enhancers N‐acetylcysteine, acetylsalicylic acid, sodium salicylate, recombinant human deoxyribonuclease I, dispersin B, hydrogen peroxide and Johnsons Baby Shampoo (JBS) were tested for their anti‐biofilm activity alone and their ability to enhance the activity of antibiotics for 7 or 14 days, against 5 day old biofilms. The antibiotic enhancers were paired with rifampicin and clindamycin against S. aureus and gentamicin and ciprofloxacin against P. aeruginosa. Isolates from biofilms that were not eradicated were tested for antibiotic resistance. Results: Antibiotic levels 10×MIC and 100×MIC significantly reduced biofilm, but did not consistently eradicate it. Antibiotics at 100×MIC with 10% JBS for 14 days was the only treatment to eradicate both staphylococcal and pseudomonal biofilms. Recombinant human deoxyribonuclease I significantly reduced staphylococcal biofilm. Emergence of resistance of surviving isolates was minimal and was often associated with the small colony variant phenotype. Conclusions: JBS enhanced the activity of antibiotics and several other promising anti‐biofilm agents were identified. Antibiotics with 10% JBS eradicated biofilms produced by both organisms. Such combinations might be useful in local treatment of localized biofilm infections.

Does the weekend effect influence the length of stay in patients admitted with tonsillitis, quinsy and epistaxis? A review of 363 emergency admissions over a 12‐month period

• The all-in-one tympanostomy tube (TT) insertion device with its preloaded tympanostomy tube allows a safe, intuitive and rapid myringotomy and TT insertion. • In plastic ear models, the TT was successfully inserted into the tympanic membrane in all cases. • In cadavers, TT insertion was successful in all 14 ears, but with one premature deployment. • The all-in-one TT device has the potential to be used without the requirement for general anaesthesia (GA) in appropriately selected adults and children. • The all-in-one TT device could reduce waiting times and costs.

Which outcome measures are reported by clinical trials investigating OME treatment? A case for standardised reporting.

INTRODUCTION Many different OME treatment trials have been published using different outcomes measures to evaluate the success of particular interventions. We set out to identify the variation in reporting of outcome measures in OME trials that exists at present. This has been achieved by reviewing published trials to determine which outcome measures have been reported. METHOD The literature review was carried out using PUBMED database (1980 to 2013). Data were collected on the treatment outcomes reported, with particular focus on the methods of assessment and the number of treatment outcomes used in each study. RESULTS The 171 studies identified used 12 broad treatment outcome measures. The most common outcome measure was OME resolution (48%) followed by hearing level (36%). Only 95 studies used a single outcome measure, with 76 studies using between 2 and 4 outcome measures. The method of assessment varied between studies that used the same treatment outcome measures. CONCLUSION OME treatment trials report a wide range of measures and comparison across studies is thus difficult. Establishing a core set of outcome measures to be reported by all trials in the future could be useful, and would allow comprehensive comparison of different studies and minimise potential for reporting bias.