Matthew T. Brigger

Adenoidectomy outcomes in pediatric rhinosinusitis: A meta-analysis☆☆☆

OBJECTIVE To evaluate the currently available literature regarding the reported effectiveness of adenoidectomy alone in the management of medically refractory pediatric chronic rhinosinusitis. METHODS The MEDLINE and EMBASE databases were systematically searched for English language manuscripts reporting on effectiveness of adenoidectomy alone in management of medically refractory pediatric rhinosinusitis. Additional manuscripts were identified by manual searching. Random effects modeling was performed to produce summary estimates of adenoidectomy effectiveness. RESULTS Nine studies met the inclusion criteria. Six were cohort studies (level 2b) and four were case series (level 4). Mean sample size was 46 subjects (range = 10-121) with grand mean age of 5.8 years (range 4.4-6.9 years). All studies showed that sinusitis symptoms or outcomes improved in half or more patients after adenoidectomy. Eight studies were sufficiently similar to undergo meta-analysis. The summary estimate of the proportion of patients who significantly improved after adenoidectomy was 69.3% (95% CI = 56.8-81.7%, p < 0.001). The possibility of author bias was explored as one author group contributed a large proportion of patients to the study group. CONCLUSION Adenoidectomy reduces caregiver reported symptoms of chronic rhinosinusitis in a majority of pediatric patients. Given its simplicity, low risk profile, and apparent effectiveness, adenoidectomy should be considered first line therapy for medically refractory, uncomplicated pediatric rhinosinusitis.

Outpatient tonsillectomy in children: A systematic review

OBJECTIVE: To evaluate the level of evidence regarding the safety of outpatient pediatric tonsillectomy. STUDY DESIGN AND SETTING: The medical literature addressing outpatient pediatric tonsillectomy was systematically reviewed. The level of evidence was assessed, and data were pooled. RESULTS: Seventeen articles met inclusion criteria. Each article suggested that outpatient tonsillectomy was safe. The overall level of evidence was fair (grade B —). Pooled data analysis in the perioperative period showed a complication rate estimate of 8.8% (95% confidence interval [CI], 5.5%–12.1%; P ≤ 0.001) and an unplanned admission rate estimate of 8.0% (95% CI, 5.3%-10.7%; P ≤ 0.001). Subgroup analysis suggests that children under age 4 are at a higher risk of complications in the perioperative period with an odds ratio of 1.64 (95% CI, 1.16–2.31). CONCLUSION: The level of evidence supporting the safety of outpatient pediatric tonsillectomy is fair. The analyzed data show a higher rate of early complications and unplanned admissions in children under age 4. SIGNIFICANCE: The current evidence supports the practice of outpatient tonsillectomy in properly selected children. EBM rating: A-1a

Surgery for Pediatric Vocal Cord Paralysis: A Retrospective Review

To determine the outcome of surgical procedures for bilateral vocal cord paralysis in children, we performed a retrospective review of children under 18 years of age with bilateral vocal cord paralysis and a previous tracheotomy who underwent a primary procedure at a single tertiary care institution with an aim of decannulation. The primary outcome measure was the operation-specific decannulation rate (OSDR). The overall decannulation rates, as well as morbidity rates, were also recorded. Fifty-two children met the inclusion criteria (mean age at time of primary surgery, 6.2 years; SD, 5 years). Vocal cord lateralization procedures combined with a partial arytenoidectomy achieved the highest OSDR (17/24 or 71%). This OSDR was statistically higher than the OSDRs for CO2 laser cordotomy or arytenoidectomy procedures (OSDR, 5/17 or 29%, p = .008), for isolated arytenoidopexy procedures (OSDR, 1/4 or 25%, p = .000004), or for posterior costal cartilage graft procedures (OSDR, 3/5 or 60%, p = .0004). Neither of the 2 children who underwent isolated arytenoidectomy achieved primary decannulation. The incidence of aspiration following posterior cartilage graft procedures was 15% (2/15). Subanalysis by age failed to reveal differences in OSDR. We conclude that vocal cord lateralization procedures with partial arytenoidectomy afford the highest OSDR among primary procedures for pediatric vocal cord paralysis. The CO2 laser procedures, while having limited success as a primary procedure, are effective for revision.

Surgery for pediatric vocal cord paralysis: A meta-analysis ☆

OBJECTIVE: The study goal was to determine the impact of various surgical procedures for bilateral vocal cord paralysis in children by using established principles of meta-analysis. STUDY DESIGN AND SETTING: We conducted a retrospective review of the literature in which a predetermined protocol was used to identify articles for meta-analysis. Six articles met inclusion criteria, and pertinent data were extracted. RESULTS: Pooled data analysis demonstrated primary procedure-specific decannulation rates for external arytenoidopexy for 19 of 24 (79%), external arytenoidectomy for 14 of 19 (74%), CO2 laser arytenoidectomy for 4 of 10 (40%), and costal cartilage graft procedures for 2 of 2 (100%). External arytenoid procedures are more efficacious than CO2 laser procedures in terms of primary decannulation (P = 0.02). CONCLUSION: Meta-analysis of the existing literature reveals that external arytenoidopexy and external arytenoidectomy are equivalently effective procedures and that the two combined are significantly more effective than CO2 ablative procedures. SIGNIFICANCE: External procedures appear to be more effective as a first-line treatment in pediatric vocal cord paralysis, with arytenoidopexy with or without partial arytenoidectomy offering an attractive first-line surgical option.

A Cytokine-Independent Approach To Identify Antigen-Specific Human Germinal Center T Follicular Helper Cells and Rare Antigen-Specific CD4+ T Cells in Blood

Detection of Ag-specific CD4+ T cells is central to the study of many human infectious diseases, vaccines, and autoimmune diseases. However, such cells are generally rare and heterogeneous in their cytokine profiles. Identification of Ag-specific germinal center (GC) T follicular helper (Tfh) cells by cytokine production has been particularly problematic. The function of a GC Tfh cell is to selectively help adjacent GC B cells via cognate interaction; thus, GC Tfh cells may be stingy cytokine producers, fundamentally different from Th1 or Th17 cells in the quantities of cytokines produced. Conventional identification of Ag-specific cells by intracellular cytokine staining relies on the ability of the CD4+ T cell to generate substantial amounts of cytokine. To address this problem, we have developed a cytokine-independent activation-induced marker (AIM) methodology to identify Ag-specific GC Tfh cells in human lymphoid tissue. Whereas Group A Streptococcus–specific GC Tfh cells produced minimal detectable cytokines by intracellular cytokine staining, the AIM method identified 85-fold more Ag-specific GC Tfh cells. Intriguingly, these GC Tfh cells consistently expressed programmed death ligand 1 upon activation. AIM also detected non-Tfh cells in lymphoid tissue. As such, we applied AIM for identification of rare Ag-specific CD4+ T cells in human peripheral blood. Dengue, tuberculosis, and pertussis vaccine–specific CD4+ T cells were readily detectable by AIM. In summary, cytokine assays missed 98% of Ag-specific human GC Tfh cells, reflecting the biology of these cells, which could instead be sensitively identified by coexpression of TCR-dependent activation markers.

Dexamethasone and Tonsillectomy Bleeding A Meta-Analysis

Objective. To use meta-analytic techniques to examine the effect of dexamethasone on the risk of postoperative bleeding following tonsillectomy. Data Sources. PubMed and Embase databases accessed on April 23, 2009, and April 28, 2009. Review Methods. Using principles of meta-analysis, inclusion and exclusion criteria were developed to identify all randomized controlled trials of patients undergoing tonsillectomy in which perioperative intravenous dexamethasone was administered in at least 1 treatment arm and bleeding complications were reported. Electronic databases were searched to identify candidate articles. Two authors independently abstracted data from each article. Discrepancies were resolved by consensus. A fixed-effects model was used to pool relative risks among studies using the Mantel-Haenszel method. Studies were assessed for publication bias using a funnel plot of studies’ effect size vs standard error of the effect size as well as Begg test and Egger test. A P value <.05 was considered significant. Results. The primary search identified 85 potential studies. Fourteen met inclusion criteria and were selected for meta-analysis. No significant heterogeneity was found among studies (I2< 0.1%; 95% confidence interval [CI], 0%-55%; P = .68). The pooled relative risk (RR) of postoperative bleeding did not differ significantly between patients receiving dexamethasone and controls (RR, 1.02; 95% CI, 0.65-1.61; P = .92). When studies were stratified by age, primary vs secondary hemorrhage, and follow-up duration, no further significant differences in bleeding rate were identified. No evidence of publication bias was found using Begg (P = .70) or Egger (P = .73) tests. Conclusion. The results of this meta-analysis indicate that perioperative dexamethasone does not confer an increased risk of postoperative bleeding in patients undergoing tonsillectomy.

Adenoidectomy as an Adjuvant to Primary Tympanostomy Tube Placement A Systematic Review and Meta-analysis

IMPORTANCE Adenoidectomy at initial tympanostomy tube placement (TT) may reduce the rate of repeated surgery for otitis media. OBJECTIVE To assess the effectiveness of primary adenoidectomy as an adjuvant to TT (Ad + TT) compared with TT alone. DATA SOURCES PubMed and EMBASE electronic databases were searched with no publication year restrictions beyond those of the individual databases. STUDY SELECTION Articles that compared outcomes of children having undergone primary Ad + TT with children having undergone TT alone for middle ear disease. DATA EXTRACTION Medical literature addressing Ad + TT was systematically reviewed. Data extracted included study design, age of children, and follow-up time frame. Level of evidence was assessed, and data were pooled where possible. MAIN OUTCOMES AND MEASURES Proportion of children requiring repeated TT (r-TT). Secondary outcomes included proportion of children with recurrent acute otitis media (RAOM), otitis media with effusion (OME), otorrhea, or any combination of the 3. RESULTS Fifteen articles met inclusion criteria. Ten studies (n = 71,353) reported that primary Ad + TT decreased the risk of r-TT or risk of RAOM, OME, or otorrhea compared with TT alone. Four studies (n = 538) reported no difference between Ad + TT groups compared with TT-only groups in the prevention of r-TT or of RAOM, OME, or otorrhea. Despite significant heterogeneity, limited meta-analysis and pooling of data revealed that the estimated rate of r-TT for children undergoing primary adenoidectomy was 17.2% (95% CI, 12.2%-22.2%) vs 31.8% (95% CI, 23.9%-39.8%) for children undergoing primary TT only. When stratified by age younger than 4 years, the protective effects of adenoidectomy were diminished. CONCLUSIONS AND RELEVANCE The current evidence suggests that primary Ad + TT may be superior to TT only in decreasing the risk of r-TT and the risk of RAOM, OME, or otorrhea. Limitations include heterogeneity of the source data, with the predominance of retrospective data as well as studies with older children supporting the superiority of adjuvant adenoidectomy. The practice of Ad + TT may decrease the risk of repeated surgery in children older than 4 years.

Injection Pharyngoplasty With Calcium Hydroxylapatite for Velopharyngeal Insufficiency: Patient Selection and Technique

OBJECTIVE To identify children who may benefit from calcium hydroxylapatite (CaHA) injection pharyngoplasty for symptomatic velopharyngeal insufficiency (VPI). DESIGN Retrospective review of children with VPI who underwent injection pharyngoplasty with CaHA. SETTING Multidisciplinary pediatric aerodigestive center. PATIENTS Children with symptomatic VPI as defined by abnormal speech associated with subjective and objective measures of hypernasality. INTERVENTION Posterior pharyngeal wall augmentation with injectable CaHA. MAIN OUTCOME MEASURE Nasalence scores recorded as number of standard deviations (SDs) from normalized scores, and perceptual scoring recorded as standardized weighted score and caretaker satisfaction from direct report. RESULTS Twelve children who had undergone injection pharyngoplasty with CaHA were identified. Of the 12 children, 8 demonstrated success at 3 months as defined by nasalence (<1 SD above normal nasalance scores), perceptual scoring (decrease in weighted score), and overall caretaker satisfaction. Four children were followed up for more than 24 months and continued to demonstrate stable success. The 4 children who failed the procedure all failed before the 3-month evaluation and demonstrated increased baseline severity of VPI as defined by increased preoperative nasalence scores (5.25 SD vs 2.4 SD above normalized scores), perceptual scores (weighted score, 4.25 vs 3.85), and characteristic nasendoscopy findings of a broad-based velopharyngeal gap or unilateral adynamism. Three of the 4 treatment failures occurred early in the senior authors (C.J.H.) experience with the technique. CONCLUSIONS Injection pharyngoplasty with CaHA is a useful adjunct in the treatment of children with mild VPI. Efficacy and safety have been demonstrated more than 24 months after injection. Patient selection and operative technique are critical to the success of the procedure. Success is seen most often in children with mild VPI and small well-defined velopharyngeal gaps consistent with touch closure.

Dexamethasone Administration and Postoperative Bleeding Risk in Children Undergoing Tonsillectomy

OBJECTIVE To assess whether administration of dexamethasone during tonsillectomy is associated with a dose-dependent increased rate of postoperative tonsillectomy hemorrhage. DESIGN Retrospective review of 2788 children and adolescents who underwent tonsillectomy with or without adenoidectomy for sleep-disordered breathing or infectious tonsillitis and received perioperative dexamethasone between January 1, 2002, and March 3, 2009. Patients underwent 1 of 3 methods of tonsillectomy, including extracapsular electrosurgical tonsillectomy, extracapsular radiofrequency ablation tonsillectomy, or intracapsular microdebrider tonsillotomy. SETTING Massachusetts Eye and Ear Infirmary. PATIENTS Two thousand seven hundred eighty-eight children and adolescents aged 2 to 18 years (hereinafter referred to as children) who underwent tonsillectomy with or without adenoidectomy. INTERVENTIONS Each child received 1 of 2 distinct intravenous doses of perioperative dexamethasone (0.5 mg/kg or 1.0 mg/kg) based on the protocol of the surgeon who performed the tonsillectomy; other aspects of care, including anesthetic technique, perioperative analgesia, and postoperative care, were equivalent between children. MAIN OUTCOME MEASURES Occurrence of postoperative hemorrhage based on 3 severity stratification levels. RESULTS Ninety-four of the 2788 children experienced 104 episodes of postoperative hemorrhage. After adjusting for age, sex, primary diagnosis, and surgical technique, the odds ratio of experiencing a postoperative hemorrhage of any severity in children who received the 1.0-mg/kg compared with the 0.5-mg/kg dose was 0.66 (95% confidence interval [CI], 0.42-1.05). Children requiring readmission with or without the need for operative intervention demonstrated an adjusted odds ratio of 0.83 (95% CI, 0.51-1.36). An adjusted odds ratio of 0.71 (95% CI, 0.39-1.28) was seen in children requiring operative intervention. CONCLUSION In this observational review of children undergoing tonsillectomy or adenotonsillectomy, perioperative dexamethasone administration is not associated with a dose-dependent elevation of postoperative hemorrhage rates after adjusting for age, sex, primary diagnosis, and surgical technique.

Management of tracheal stenosis.

Purpose of reviewThe treatment for pediatric tracheal stenosis has evolved over the past 50 years. Open airway reconstruction has traditionally been the treatment of choice for this condition. Numerous recent publications now support the use of endoscopic techniques to both augment and sometimes replace open procedures. Recent findingsDuring the past 12 months, a significant interest in expanding the role of airway dilation with balloons to manage airway stenoses has emerged. Development of novel airway stents, to include bioabsorbable products, holds promise to decrease the morbidity of stenting procedures. Continued improvement in preoperative imaging, in the form of virtual bronchoscopy, may someday replace airway endoscopy for planning purposes. Additionally, perioperative management strategies and the use of novel adjuvants have been introduced with a goal of improving outcomes in both endoscopic and open techniques through better control of granulation. Ultimately, advances in tissue engineering may provide yet another reconstructive option in the future. SummaryEndoscopic techniques have an increasing role in the management of pediatric subglottic and tracheal stenosis. However, open airway reconstructive procedures are still required in cases of mature scar, high-grade stenosis, and long-segment stenosis.