N. Wendell Todd

Management of Nasopharyngeal and Oropharyngeal Stenosis in Children

Nasopharyngeal stenosis and oropharyngeal stenosis are rare and challenging problems in the pediatric population. The most common etiology is currently the surgical trauma associated with ade‐notonsillectomy. Stenosis can vary from a thin band to a complete obstructing cicatrix. Presenting symptoms range from mild hyponasal speech to severe airway obstruction. We present a series of eight children with varying degrees of stenosis and associated symptoms. Choice of treatment varied with the severity of disease. In our series, successful interventions included triamcinolone acetonide injection, lysis of adhesions, rotational and advancement mucosal flaps, and jejunal free flap. Preoperative evaluation and individualized surgical repair are essential for successful treatment.

Common Congenital Anomalies of the Neck: Embryology and Surgical Anatomy

A good knowledge of embryology and surgical anatomy allows for the anticipation of intraoperative findings, and, hence, for safer and more efficient care of patients with congenital anomalies of the neck. Presumptive thyroglossal anomalies that are at or above the level of the hyoid mandate extra vigilance: the patient may not have sufficient thyroid tissue in the usual thyroid location. The discontinuous character of thyroglossal tracts, related to ontogenesis, ordains dissection to the lingual mucosa. First branchial cleft cysts and fistulas require knowledge of facial nerve anatomy; in some of these cases, the facial nerve is best identified in the temporal bone. Branchial cysts, sinuses, and fistulas only can be assigned to a specific pouch-cleft by their anatomic relations to cervical structures.

Jugular bulb position and shape are unrelated to temporal bone pneumatization

The position and shape of the jugular bulb are undependable, and thus can add difficulty to temporal bone surgery. The present study addresses the hypothesis that position and shape of the jugular bulb correlate with the extent of temporal bone pneumatization. Systematic study was done in 25 unilateral cadaver specimens. Pneumatization was determined using both the classic Runström II radiograph, and computed tomography. Jugular bulb shape and position were determined by anatomic dissection and computed tomography. No association of jugular bulb shape or position, with pneumatization, was found. However, the dissection‐determined distance from the plane of the lateral semicircular canal to the roof of the jugular bulb (2 to 15 mm), had a good correlation (r = 0.70, p < .001) with the distance from the internal auditory canal to the apex of the jugular bulb (1.5 to 15.0 mm).

Tracheostomy Decannulation in Children: Approaches and Techniques

Various approaches and techniques are used in discontinuing tracheostomy in children. The variability in the use of resources is considerable. The objective of this study was to assess decannulation in children attended in a university‐affiliated childrens hospital. A retrospective analysis was made of the medical records of patients who had both tracheostomy (n = 177) and decannulation (n = 30) from 1985 to 1994. Tracheostomies, placed at a mean age of 38 months, were discontinued (on the average) 22 months later. Most children underwent airway endoscopy in the operating room in preparation for decannulation. Twenty‐four children had downsizing, then capping of the tracheostomy as a functional trial. Six children underwent staged laryngotracheoplasty before decannulation. Two children had decannulation as part of a single‐stage laryngotracheoplasty. Attention to at least one comorbid factor (e.g., pulmonary, neurologic, or cardiac disease) was important in the decannulation of each patient in this series. The individualization of tracheostomy decannulation is necessary for children.

Head Shape and Abnormal Appearance of Tympanic Membranes

We examined 187 males to evaluate the hypothesis that short-headed persons more often have otitis media than long-headed persons. The subjects were seen as part of routine health screening before attending recreational summer camp. The photographic appearance of each tympanic membrane was judged on two separate occasions by an otolaryngologist who categorized them as “normal”, “abnormal”, or “cannot determine”. The repeatability of the categorizations was fair: kappa = 0.44. Only the tympanic membranes categorized identically twice were used for data analysis. The left-right symmetry of the tympanic membrane categorizations was fair: correlation coefficient phi = 0.42. Subjects categorized as having bilaterally normal tympanic membranes were considered to have not had previous otitis media (N = 95). In contrast, subjects categorized as having at least one abnormal tympanic membrane were considered to have had previous otitis media (N = 13). Head length and width, measured by calipers, and the cephalic index (width divided by length) × 100 were determined for each person. On the average, the cephalic index of the normal subjects was lower than that for the subjects with otitis media (t = 3.06, p < 0.005). These data support the suggestions of Pautow (1925) and Worley et al. (1987): dolichocephalic persons have otitis media less often than do brachycephalic persons. Though this association is not useful in clinical care of the individual patient, it may be considered a weak external manifestation of the different cranial base and eustachian tube anatomy found in persons with otitis media.

Mastoid Size Determined with Lateral Radiographs and Computerized Tomography

Minimal pneumatization of the temporal bone is characteristic of otitis media. The classic radiographic assessment of mastoid air cell system size is the Runstrom II view, but the Law lateral view is the commonly used clinical view in the United States. Isolated temporal bone specimens are most accurately positioned using a modified Law lateral view (with the film perpendicular to the central X-ray beam). Computerized tomography is the best radiographic means of assessing mastoid pneumatization. The mathematical relationships of mastoid pneumatization size determined by the Runstrom II, Law, and modified Law lateral radiographs, and computerized tomography were determined in 30 adult cadaver specimens. These data may facilitate additional study of otitis media.

Temporal bone pneumatization in cystic fibrosis patients

Cystic fibrosis patients commonly have nasal polyps and sinusitis, but surprisingly are spared from an increased occurrence of otitis media. Twenty cystic fibrosis patients whose ages ranged from 13 to 2G years were studied. Only one of these patients had a history of otitis. Minimal temporal bone pneumatization, as determined by computed tomography, was used as an indicator of childhood otitis. The computed tomography had been done as part of the medical evaluation of their symptomatic paranasal sinusitis.

Multicentric infantile myofibromatosis

Infantile myofibromatosis (IM) is a rare tumor of infancy and childhood, typically presenting as a firm, nodular mass involving soft tissue, bone or viscera. Approximately one-third of cases involve the head and neck. These tumors can be solitary or multicentric. Biopsy reveals tumor cells that resemble myofibroblasts. Spontaneous regression may occur. A high degree of suspicion is necessary to differentiate this entity from other more aggressive processes histiocytosis, fibrosarcoma, rhabdomyosarcoma. We describe the case of a male infant with multicentric myofibromatosis, presenting with multiple thoraco-abdominal subcutaneous nodules and lytic mass lesions of the temporal bone and calvarium. The characteristic clinical, radiologic and histopathologic features of this process are reviewed along with diagnostic and therapeutic options.

Autoimmune hypothesis of acquired subglottic stenosis in premature infants

Acquired subglottic stenosis is a devastating additional burden for nearly 4% of premature infants receiving neonatal intensive care. The duration of endotracheal intubation is considered the most important etiologic factor. Surprisingly, most premature infants do not acquire subglottic stenosis. Infants with similar clinical characteristics and care have varying laryngeal outcomes. We hypothesized an autoimmune mechanism to type‐II collagen to explain the varying laryngeal outcomes of these infants.

Orientation of the manubrium mallei: inexplicably widely variable.

Background: There is no consensus why the manubrium of the malleus, as viewed clinically through the external ear canal, generally points downward and posteriorly.