Michael Pizzuto

Deep Neck Infections in Children: A New Approach to Diagnosis and Treatment

Forty‐seven children presented with the diagnosis of a deep neck infection‐either cellulitis or abscess‐between January 1991 and July 1996. Forty‐four (94%) had contrast‐enhanced computed tomography (CT) imaging consistent with this diagnosis. Three patients with no CT scan had confirmation of an abscess at surgical drainage. Parenteral antibiotics alone were effective in the treatment of 24 of 47 infections (51%): seven parapharyngeal, one retropharyngeal, and 16 combined. By CT scan these infections represented cellulitis in 17 of 24 (71%), an abscess in three of 24 (13%), and incomplete abscess in four of 24 (17%). The average duration of hospitalization for this group was 4.8 days, with symptomatic improvement usually seen within 24 hours. Surgical drainage was performed on 23 of 47 infections (49%): three parapharyngeal, 17 combined, and three of unknown specific location. In 22 of these 23 children (96%), transoral drainage of the abscess was used as the primary surgical approach. In 21 of these 22 (95%) there was complete resolution without complications or recurrence; one abscess required a subsequent external approach. CT scanning with contrast revealed that all deep neck infections were located medial (usually anteromedial) to the great vessels. Abscesses with volumes estimated to be greater than 2000 mm3 were more likely to undergo surgery, but these differences were not statistically significant. The use of contrast‐enhanced CT scanning provides information regarding abscess size, location, and relative position of the great vessels for safe and successful transoral drainage. Thus we recommend CT‐assisted transoral drainage for combined retropharyngeal/parapharyngeal abscesses and selected isolated parapharyngeal abscesses that do not respond to parenteral antibiotics.

A comparison of microbipolar cautery dissection to hot knife and cold knife cautery tonsillectomy

BACKGROUND Morbidity following tonsillectomy continues to be a major concern to parents, children, and physicians alike. Reduction in post-operative complications, optimal control of pain, and satisfactory return to a normal lifestyle are all important to both family and society. This study compares both the complication and recovery rates after microbipolar dissection (MBPD) technique of tonsillectomy to two well established tonsillectomy techniques: hot knife (HK) and cold knife/cautery (CK/C). METHODS A total of 200 consecutive patients presenting for tonsillectomy by the first author (MP) were randomized to either undergo MBPD or HK tonsillectomy. Concurrently, an additional two hundred patients were randomized to undergo MBPD or CK/C tonsillectomy by the second author (LB). Patients were prospectively followed for complications including bleeding and dehydration and multiple indicators of recovery rate. RESULTS Postoperative bleeding of any kind was significantly less in the MBPD group than in the CK/C and HK groups (5 vs 12.4 vs 12.5% (P<0.001). The need for post-operative intervention for bleeding, i.e. local control or return to the operating room, was also significantly less in the MBPD group. Return to normal activity occurred 2 days earlier in the MBPD group versus either CK/C or HK (P<0.001). Additionally, earlier recovery was reflected in fewer total doses of pain medication in the MBPD group. Operative time was 3-5 min longer for MBPD (24.2 min) than for CK/C or HK (21.1 and 16.5 min, respectively); blood loss was similar (within 15 cc) among all treatment groups. CONCLUSION MBPD tonsillectomy compared most favorably to conventional techniques (CK/C and to HK tonsillectomy). Important clinical outcome differences included a lower bleed rate, earlier recovery and fewer days lost from work and school. The financial impact is estimated to be quite favorable. MBPD tonsillectomy is now our preferred method in children.

Correlation of findings on direct laryngoscopy and bronchoscopy with presence of extraesophageal reflux disease.

Objective To determine the correlation between findings at direct laryngoscopy and bronchoscopy and presence of extraesophageal reflux disease (EERD).

Head and neck dog bites in children

Objectives: 1) Demonstrate patterns of dog bite injury to the head and neck in children. 2) Identify treatment outcomes of dog bite injuries to the head and neck. Study Design: Case series with chart review. Subjects and Methods: Children aged 0 to 19 years, treated for head and neck dog bites at our tertiary care childrens hospital (1999-2007), were included. Demographics, dog breed and ownership, seasonal incidence, wound location, characteristics, management, and complications were recorded. Results: Eighty-four children, aged 10 months to 19 years (mean, 6.19 years) underwent primary repair of head and neck dog bite injuries. The cheek (34%) and lips (21%) were involved most commonly. Average wound length was 7.15 cm. Dog bite incidence peaked during summer months. Infection occurred in 10.7 percent. Pulsed dye laser was used to improve cosmesis. Conclusions: Children are vulnerable to head and neck dog bite injuries. Wound healing is excellent despite a contaminated wound. Infections occur infrequently. Pulsed dye laser improves cosmesis.

Clinical presentation as a guide to the identification of GERD in children.

OBJECTIVE to determine if there is a correlation between common otolaryngologic symptoms and presence of gastroesophageal reflux disease (GERD) in children. METHODS charts of 295 children presenting with suspicion of GERD were reviewed for presenting symptoms including: (1) airway symptoms: stertor, stridor, frequent cough, recurrent croup, wheezing, nasal congestion, obstructive apnea, blue spells, hoarseness, throat clearing; (2) feeding symptoms: wet burps, globus sensation, frequent emesis, dysphagia, choking/gagging, sore throat, halitosis, food refusal, stomach aches, arching, drooling, chest pain, irritability, and failure to thrive. At least one positive test of barium esophagram, gastric scintiscan, pH probe or esophageal biopsy resulted in inclusion in the GERD positive group. RESULTS 214 children had GERD diagnosed while 81 had no positive tests for GERD. Between the GERD positive and GERD negative groups, the significantly different symptoms were stertor (P=0.040), cyanotic spells (P=0.043), frequent emesis (P=0.007), failure to thrive (P=0.006), and choking/gagging (P=0.044). Three pooled variables were created: airway flow (stertor, stridor, cyanotic spells), airway irritation (frequent cough, recurrent croup, throat clearing), and feeding (dysphagia, failure to thrive, frequent emesis). GERD patients who were 2 years or less were compared to those older than 2 years and all three of these pooled variables were significantly different between these groups (P<0. 001). CONCLUSION children who present with a certain constellation of airway or feeding symptoms are more likely to have a positive GERD test. Children 2 years old or less are more likely to present with airway symptoms or feeding difficulties while children older than 2 years are more likely to present with airway irritation.

Success rates in paediatric tympanoplasty

OBJECTIVE To determine if the success of paediatric tympanoplasty is dependent on certain criteria, which are determinable prior to surgery. DESIGN Retrospective chart review. SETTING An academic paediatric otolaryngology department. PATIENTS Seventy-seven patients who had undergone tympanoplasty with or without ossicular reconstruction, but without mastoidectomy, between April 1997 and May 1999. MAIN OUTCOME MEASURES Status of the repaired tympanic membrane at last follow-up visit measured by otoscopic examination and with tympanometry. RESULTS Eighty-nine tympanoplasties were performed during this period. The age range was 2.9 to 22 years. The success rate was 75% overall. For patients younger than 11 years (n = 43), the success rate was 82%, and for those 11 to 18 years (n = 44), it was 74%, which was not significantly different. In 18 patients 7.5 years or younger, the success rate was 79%. Perforation location, size, presence of myringosclerosis, status of the other ear or nose, history of the perforation, surgical approach, middle ear findings, canal packing, and gender were not shown to be significantly different between successful and unsuccessful tympanoplasty groups. CONCLUSION These young patients had a good success rate post-tympanoplasty, which we believe reflects less severe disease. These results mitigate against delaying tympanoplasty in young children.

Neonatal septoplasty: case report and review of the literature

Treatment of nasal septal deformity in childhood has received growing acceptance in recent years. Traditionally, concern about the role of the septum in the overall growth of the midface has led otolaryngologists to take a very cautious approach to correction of septal deformities in children. However, a great deal of evidence now suggests that severe traumatic septal deviation can and should be corrected early in childhood to prevent future nasal and systemic complications. Closed manipulation of the septum in the first 1-2 days of an infants life has been performed by many otolaryngologists with good results. The use of this technique, however, is usually limited to those subluxations of anterior cartilage which are diagnosed immediately or very shortly after birth. We present a case of severe traumatic nasal deformity presenting with obstructive asleep and awake apnea and cyanosis at the age of 8 days. The child underwent limited septoplasty using endoscopic techniques at age 14 days with resolution of both the apneic and cyanotic episodes immediately post-operatively. This unusual presentation and the literature surrounding infant nasal/septal surgery are discussed.

Airway obstruction in the Crouzon syndrome: case report and review of the literature

Craniofacial dysostosis (Crouzon syndrome) is a syndrome characterized by premature closing of calvarial and cranial base sutures as well as those of the orbit and maxillary complex. Orofacial manifestations of this disease include maxillary hypoplasia, external nasal deformity, and prognathism. Airway distress is a well described feature of this syndrome, and both upper and lower airway obstruction may be present in the Crouzon syndrome. Obstructions in the upper airway have been reported secondary to septal deviation, midnasal and choanal abnormalities, and nasopharyngeal narrowing. This study presents a child with the Crouzon syndrome who required tracheotomy during the first 2 years of life for airway obstruction caused in the newborn period (first 6 months) by midnasal stenosis and laser (6 months to 2 years) compounded by soft palate obstruction at the level of the oro/hypopharynx. A review of the English language literature revealed one similar patient presentation but no comprehensive review of this subject. Previously reported airway anomalies are reviewed and airway management is discussed in patients with Crouzon syndrome.

Supernumerary nostril: a rare congenital deformity

Duplication anomalies of the nose include polyhinia (double nose) and supernumerary nostril (assessory nostril). These are rare congenital nasal deformities resulting from aberrant embryological development. Differential diagnoses include glioma, encephalocele, nasal dermoid, nasolacrimal duct duplication, mid facial cleft and proboscis lateralis (K. Nakamura, T. Onizuka. Plast. Reconstr. Surg. 80 (3) (1987) 436-441). Our review of the English language literature revealed eight reported cases of duplication anomalies of the nose. Four of these were cases of polyrhinia (double nose). Of the cases remaining, one patient had a supernumerary nostril in association with a cleft lip, leaving only three reported cases of an isolated supernumerary nostril. We present a newborn infant with an isolated right supernumerary nostril. MRI, CT and photographic documentation are provided. Pertinent embryology, anatomy and a thorough review of the literature are included.

Clinical Classification as a Guide to Treatment of Sinusitis in Children

Evaluation of all 153 children undergoing CT scan of the paranasal sinuses for recalcitrant sinusitis symptoms between January 1988 and July 1992 was performed. Clinical categorization into groups of patients presenting with chronic sinusitis (CS) and recurrent acute sinusitis (RAS) was based upon pattern of disease and presentation. Clinical symptoms and signs, radiological examination, treatment, and outcome were compared between these distinct clinical groups. Eighty‐two (55%) children were categorized as RAS and 68 (45%) as CS. Children with CS presented more frequently with a persistent cough, purulent nasal discharge, immune deficiency, and more severe mucosal disease on CT than children with RAS. Medical therapy successfully controlled the symptoms of sinusitis in 79 (96%) with RAS versus 27 (40%) with CS. Surgery was performed in 44 children: 3 (3.6%) with RAS versus 41 (60%) with CS, p<0.01. At a mean follow‐up of 2.0 years, >80% of all the children were either asymptomatic or improved regardless of treatment modality. These data support the use of clinical classification as a guide to medical versus surgical therapy in children with sinusitis.