Michael Haupert

Predicting complications after adenotonsillectomy in children 3 years old and younger

OBJECTIVES To identify risk factors for complications in the first 24h after surgery in the young (<4 years old) adenotonsillectomy patient. METHODS A retrospective chart review was performed at a tertiary care childrens hospital. Consecutive records of all children of age 3 years and younger undergoing adenotonsillectomy over a 5 year period were included in the study. The main outcomes measured were total and airway complications occurring on post-operative days 0-1. RESULTS 993 patients were included in the study. The mean age was 2.94 years old. Witnessed apneas (74.1%) and snoring (59.2%) were the most frequent pre-operative symptoms. 700 children were admitted with a mean length-of-stay of 1.22 days (0-9 days) and a mean time-to-oral intake of 0.28 days (0-4 days) among those patients admitted. The total number of complications was 102 in 98 patients (9.9%). There were 35 complications on post-operative days (POD) 0-1 (3.5%), and 23 of those were airway-related (2.3%). With regard to all complications on POD 0-1, significant predictors were nasal obstruction, gastroesophageal reflux disease, prematurity and a history of cardiovascular anomalies. Significant predictors of airway complications on POD 0-1 were younger age (1-2 years old), larger adenoid size, nasal obstruction, and a history of cardiovascular anomalies. CONCLUSIONS Knowing the stated risk factors for complications in the early post-operative period after adenotonsillectomy in the younger pediatric patient can help select certain patients for closer monitoring. Specifically, children aged 1-2 years old with a history of nasal obstruction from large adenoids, gastroesophageal reflux disease, prematurity, and/or cardiovascular anomalies appear to be at higher risk for early complications and should warrant closer observation.

Biofilm density in the pediatric nasopharynx: recurrent acute otitis media versus obstructive sleep apnea.

Objectives: We compared the biofilm surface density of adenoids removed from children with recurrent acute otitis media (RAOM) to that of adenoids removed from children with a diagnosis of obstructive sleep apnea (OSA). Methods: We performed a comparative microanatomic study of adenoid mucosa using scanning electron microscopy in patients with diagnoses of RAOM and OSA (27 female and 41 male; age range, 3 months to 15 years). Results: The adenoids removed from patients with RAOM had dense, mature biofilms covering nearly their entire mucosal surfaces. More specifically, the adenoids removed from patients with RAOM had an average of 93.53% of their mucosal surface covered, versus an average of 1.01% coverage on the adenoids removed from patients with OSA. These differences were statistically significant (p < 0.0001). Conclusions: The adenoids removed from patients with RAOM had almost their entire mucosal surface covered with biofilms, versus scant coverage for patients with OSA. Recurrent acute otitis media is notoriously resistant to antibiotic treatment, and aspirates of middle ear fluid repeatedly yield negative cultures. It is these properties that have led biofilms to become increasingly implicated in the pathogenesis of RAOM. Thus, the resistance of biofilms to antimicrobials, together with their planktonic shedding of organisms, may be an important mechanism in the development of RAOM.

Propofol Decreases Waste Anesthetic Gas Exposure During Pediatric Bronchoscopy

Objective: This study compared the anesthetic gas exposure and operating conditions during insufflation anesthesia with halothane‐alone versus halothane‐propofol in children undergoing direct laryngobronchoscopy.

The utility of common surgical instruments for pediatric adenotonsillectomy

To evaluate the correlation between surgical instrumentation and intraoperative surgical time, postoperative hemorrhage, and associated healthcare cost for pediatric adenotonsillectomy.

Novel Application of Steroid Eluting Stents in Choanal Atresia Repair A Case Series

Purpose: To describe the application of mometasone furoate eluting sinus stent technology in the treatment of choanal atresia (CA) in the hopes of preventing postsurgical stenosis. Methods: We analyzed 3 consecutive patients aged 4 days to 16 years undergoing repair of CA at a tertiary pediatric hospital. Mometasone furoate eluting sinus stents were placed intraoperatively. Postoperative need for revision surgery as well as routine surveillance endoscopy were used to determine success of surgery. Results: Three patients of varying age and etiology underwent successful repair of choanal atresia/stenosis. The steroid eluting sinus stent was deployed successfully in all 3 cases. There was no identifiable restenosis in any of the 3 patients with 12-month follow-up. There were no complications noted throughout the follow-up period. Conclusions: Choanal atresia is a rare disorder that can prove difficult in postsurgical management. In our case series, mometasone furoate eluting stents were effective and safe for the management of this disease process. Further prospective studies are needed to determine the exact safety profile, long-term consequences, and efficacy of steroid eluting sinus stents in the pediatric population.

Incidence of Pediatric Superior Semicircular Canal Dehiscence and Inner Ear Anomalies: A Large Multicenter Review.

Objective: To determine the pediatric incidence and association of superior semicircular canal dehiscence (SSCD) with inner ear (IE) anomalies. Study Design: Retrospective chart review. Setting: Two tertiary referral centers. Patients: Children less than 18 years who received a 0.5 mm or less collimated computed tomography study including the temporal bones between 2010 and 2013 for reasons including, but not limited to, hearing loss, trauma, and infection. Interventions: Images were reformatted into Pöschl and Stenver planes. Five hundred three computed tomography studies (1,006 temporal bones) were reviewed by experienced, blinded neuroradiologists. Main Outcome Measures: Incidence of SSCD and IE anomalies. Patient age, sex, and diagnosis were recorded. Statistical analysis was performed to compare outcome measures among patient demographics. Results: The incidence of SSCD was 6.2% (31/503) and an IE anomaly was 15.1% (76/503) of individuals. The incidence of SSCD with an IE anomaly was not significantly correlated (1.1%, 40/1,006; p = 0.23; LR = +1.29). The mean age of children with SSCD was lower (5.9 versus 9.8 yr; p = 0.002). SSCD incidence decreased with age (ages <2, 2–8, and 9–18 yr were 36.7%, 5.6%, and 3.2%; p<0.001) and SSC bone thickness nonsignificantly increased with age. Children with SSCD were commonly male (74.2%, p = 0.041). Conclusion: SSCD and IE anomalies are unlikely related. SSCD incidence is highest in children <2 years, with SSC bone increasing until 2 to 8 years of age. This supports the theory of a congenital precedent to SSCD, with overlying bone maturation occurring during early childhood. Age <2 years was a significant predictor of SSCD.

Acute sphenoid sinusitis leading to contralateral cavernous sinus thrombosis: a case report

INTRODUCTION The objective of this article was to report a case of isolated, acute, right-sided sphenoid sinusitis that progressed to contralateral cavernous sinus thrombosis in an 18-year-old male patient. We describe the atypical presentation of this case and discuss the relevant anatomy, pathogenesis, presentation, diagnostic evaluation and treatment. CASE REPORT A case report of sphenoid sinusitis leading to contralateral cavernous sinus thrombosis was reviewed and presented along with a comprehensive literature review of the relevant anatomy, pathophysiology, microbiology, diagnostic work-up and treatment options. CONCLUSION Cavernous sinus thrombosis is a rare clinical entity in the antibiotic era. However, limited sphenoid sinusitis may progress to cavernous sinus thrombosis in spite of maximal medical treatment, as highlighted in this case report. The mainstay of treatment includes early diagnosis allowing aggressive intravenous antibiotics and appropriate surgical management.

Gastroesophageal reflux as a predictor of complications after adenotonsillectomy in young children

OBJECTIVE To examine characteristics of young children with gastroesophageal reflux (GER) who experienced complications within the first 24h after adenotonsillectomy. STUDY DESIGN Subset analysis of a larger retrospective cohort. METHODS A retrospective chart review was performed at a tertiary care childrens hospital. Consecutive records of children 3 years old and younger undergoing adenotonsillectomy (AT) over a 5-year period were reviewed. Children with a clinical history of GER were selected for the study. RESULTS 993 children were included in the initial analysis, and GER was found to be a significant independent variable predictive of early complications. 81 children with a history of GER were included in this study and 8 (9.9%) were found to have experienced complications within the first 24h. Six of the complications were airway-related; two required re-intubation within the first 24h. All 8 children with complications had symptoms of sleep-disordered breathing and two had documented severe obstructive sleep apnea (AHI 18.6 and 27.2). Seven children had other risk factors for complications after AT. Eighteen (22%) children had a prolonged length of stay (range 2-7 days); additional risk factors were present in these patients as well. CONCLUSIONS Knowledge of risk factors for complications following adenotonsillectomy is critical for identifying at-risk patients that may warrant closer post-operative observation. GER has been previously identified as a risk factor for complications in young children. Upon closer analysis, young children with GER who have other known risk factors may be at a further increased risk for airway complications and prolonged hospitalization. Parents of these children can be counseled on the post-operative risks and the possibility of a longer hospitalization.

Airway management for rigid bronchoscopy via a freshly performed tracheostomy in a child with Goldenhar syndrome

A case of tooth aspiration in a 6 year old boy with Goldenhar syndrome and known difficult intubation is presented. A fresh tracheostomy was performed after a failed fiberoptic intubation and dental aspiration. The patient was transferred to our tertiary-care childrens hospital for emergency bronchoscopy through the fresh tracheostomy for removal of an aspirated tooth. Rigid bronchoscopy performed via a fresh tracheostomy presents several challenges. The major complications associated with bronchoscopy performed via a fresh tracheostomy, as well as management of airway emergencies are discussed.

The Utility of Various Common Surgical Instruments for Pediatric Adenotonsillectomy: Analysis of Time, Hemorrhage, and Cost:

Objectives: Evaluate the correlation between surgical instrumentation and intraoperative surgical time, postoperative hemorrhage and associated health care cost for pediatric adenotonsillectomy. Methods: Retrospective chart analysis from a tertiary care pediatric hospital of patients who underwent adenotonsillectomy from 2011 to 2013. Monopolar electrocautery, radiofrequency ablation, and PlasmaBlade instruments were compared for intraoperative surgical time and postoperative hemorrhage rate. Univariate analysis of variance (ANOVA) and chi-square analysis was used to evaluate differences between instrumentation and variables. Cost analysis examining instrumentation and intraoperative anesthesia was also reviewed. Results: A total of 1280 patients who underwent adenotonsillectomy were evaluated. There was no significant overall difference in age, sex, or preoperative diagnosis identified between the 3 instrumentation groups. When examining the various instruments’ effects on procedure time in minutes, univariate ANOVA did demonstrate a significant difference overall between the 3 groups (F = 8.79; P < .001). Post hoc pairwise comparisons identified significantly faster surgical times for monopolar cautery than either both PlasmaBlade (P = .03) or radiofrequency ablation (P < .001). The difference in the number of patients who experienced a postoperative bleed by instrument was not statistically significant (χ2 = 2.36; P = .31). After instrumentation expenses were added to anesthesia cost, the overall average costs by instrument and surgical time were estimated as