Nathan Gonik

Patient selection in congenital pyriform aperture stenosis repair – 14 year experience and systematic review of literature

PURPOSE Congenital nasal pyriform aperture stenosis (CNPAS) is a rare cause of respiratory distress in neonates that may necessitate early surgical intervention. Restenosis and granulation are postoperative concerns that may prompt a return to the operating room. Reoperation places children at increased risk of perioperative complications and prolonged hospital stays. We are presenting a review of our institutional experience of 16 patients treated for CNPAS over a 14 year period and a systematic review with pooled data analysis to determine the effect of craniofacial and neurologic anomalies on surgical success. METHODS Retrospective chart review of all cases of CNPAS treated at our tertiary childrens hospital between 1999 and 2013. Systematic review of English language literature was conducted adhering to the PRISMA statement to determine the effect of neurologic anomalies and craniofacial dysmorphism (CFD) on surgical failure for CNPAS treatment. Univariate and exact multiple logistic regression were used for analysis of an individual patient data analysis. RESULTS 10 patients had surgery and 6 were treated medically. Average pyriform apertures were 5.71±1.72mm for the surgical group and 4.83±1.26mm for the medical group (p=0.38). 31% had neurological impairments. 31% had craniofacial dysmorphisms (CFD). 2 patients developed restenosis and 1 required tracheotomy. Both of these patients had other CFDs. Literature review captured 63 surgical patients and 9 failures in 6 series of CNPAS. 4.6% of patients without CFD and 36.8% of patients with CFD required surgical revision (p=0.023, OR13.8). CONCLUSION When repairing CNPAS, co-morbidities must be considered. Impaired respiration, central neurologic deficits and extensive craniofacial anomalies may require additional surgeries or an alternative approach.

Radiofrequency ablation of pediatric vallecular cysts

OBJECTIVE Pediatric congenital vallecular cysts are an infrequent cause of infantile airway obstruction that can cause difficulty breathing or feeding, and lead to failure to thrive or death. There have been many different techniques proposed for effective treatment. We present three cases of congenital vallecular cyst, all excised utilizing a bipolar radiofrequency plasma ablation (RFA) device. The bipolar RFA device provides excellent hemostasis without the risk of airway fire. We offer a review of literature and a discussion of the potential advantages of this modality in treating neonatal/infantile vallecular cysts. METHODS Retrospective case series of three infants all between 2 and 3 months old who presented with failure to thrive due to partially obstructive vallecular cysts. The cysts were removed surgically utilizing a bipolar RFA device. Patients were followed by complications and signs of recurrence for periods ranging from 9 to 20months. RESULTS All cysts were excised completely in a single operation. All children are feeding well and without stridor or evidence of recurrence between 9 and 20 months postoperatively. CONCLUSIONS RFA appears to be an effective and safe modality for removing vallecular cysts. We were able to demonstrate complete removal of lesions in our patients. This provides an alternative to other ablative modalities in treating cystic lesions of the vallecula and larynx.

Pectus excavatum in children with laryngomalacia

BACKGROUND Laryngomalacia is the most common congenital laryngeal anomaly and is associated with several disorders including gastric reflux, sleep apnea, hypotonia and failure to thrive. Pectus excavatum (PE) is the most common chest wall deformity affecting 1-300/1000 individuals. Though many authors presume a relationship between PE and laryngomalacia, there is no published data to establish this association. GOAL To test the hypothesis that patients referred to our pediatric otolaryngology clinic for evaluation of laryngomalacia exhibit higher rates of PE than the general population. METHODS Retrospective review of prospectively enrolled children who presented with laryngomalacia (January 2008-June 2012) to a tertiary care, hospital based, pediatric otolaryngology practice. Each chart was examined for a concurrent diagnosis of pectus deformity. RESULTS Of the 137 laryngomalacia patients, 9 (6.6%) had documented PE. This represents a significantly increased rate of PE when compared to children without laryngomalacia (p = 0.001). Four of the 9 children with PE underwent supraglottoplasty for laryngomalacia, a significantly greater proportion than the 9/128 of the children with isolated laryngomalacia who underwent supraglottoplasty (p = 0.004). CONCLUSIONS This study suggests an association between laryngomalacia and PE. Pediatric otolaryngologists should be cognizant of this relationship, though further studies are needed to elucidate the nature of this association.

Randomized Controlled Trial Assessing the Feasibility of Shortened Fasts in Intubated ICU Patients Undergoing Tracheotomy.

Objective American Society of Anesthesiology guidelines recommend preoperative fasts of 6 hours after light snacks and 8 hours after large meals. These guidelines were designed for healthy patients undergoing elective procedures but are often applied to intubated intensive care unit (ICU) patients. ICU patients undergoing routine procedures may be subjected to unnecessary prolonged fasts. This study tests whether shorter fasts allow for better nutrition delivery and patient outcomes without increasing the risk. Study Design Randomized blinded controlled trial. Setting Tertiary academic medical center. Subjects ICU patients undergoing bedside tracheotomy. Methods Intubated ICU patients who were receiving enteral feeding and for whom bedside tracheotomy was indicated were enrolled prospectively and randomly allocated to 2 parallel preoperative fasting regimens: a 6-hour fast (control) and a 45-minute fast (intervention). Patients were assessed for aspiration, caloric delivery, metabolic markers, and infectious and noninfectious complications. Results Twenty-four patients were enrolled and randomized. There were no complications related to the procedure. There were no cases of intraoperative aspiration identified. There was a single postoperative pneumonia in the control group. Median (interquartile range) length of fast and caloric delivery were significantly different between the control group and the shortened fast group: 22 hours (18, 34) vs 14 hours (5, 25; P < .001) and 429 kcal (57, 1125) vs 1050 kcal (825, 1410; P = .01), respectively. Conclusions Shortening preoperative fasts in intubated ICU patients allowed for better caloric delivery in the preoperative period.

Intraoperative inflation of laryngocele with LMA

OBJECTIVES Laryngoceles are pathologic air filled dilations of the laryngeal ventricle. They are most often benign and incidental findings. Resection may be necessary in the setting of infection, airway obstruction, dysphagia, and phonatory disturbances. External laryngoceles are almost universally treated with open resection via a lateral or midline cervical approach. Care must be taken to resect the laryngocele in its entirety to avoid recurrence. In cases of recurrent infection, normal surgical planes are often fibrosed and obscured increasing the risk of neurovascular sacrifice and functional losses. METHODS We are reporting a case of recurrent infections in a large, palpable external laryngocele. During resection the patient was ventilated using an endotracheal tube (ETT). Additionally, a laryngeal mask airway (LMA) was inserted posterior to the ETT, resting in the hypopharynx and attached to a Jackson Rees circuit. Air was passed through the LMA to inflate the laryngocele and better define its borders. The LMA was also used to identify the root of the laryngocele in the paraglottic space and ensure its airtight closure. RESULTS The LMA assisted our dissection and helped progress the surgery safely in a fibrosed surgical field. We have not seen this method described previously. The patient continues to be free of recurrence 2 years after surgery. CONCLUSION While in most cases, with careful surgical technique, even a fibrotic and scarred laryngocele can be excised in its entirety without neurovascular sacrifice. In some cases where this may be difficult with a traditional approach, we offer the intra-operative trumpet maneuver as a viable method of better delineating the borders of a laryngocele.

Complicated pediatric subglottic granular cell tumor with extensive intraluminal and extraluminal invasion

Subglottic granular cell tumors (GCT) are rare, potentially life threatening benign tumors. Complete resection is necessary, yet care must be taken to preserve laryngeal function. We present the first description of a pediatric subglottic GCT with extensive invasion beyond the confines of the subglottis to include the vocal folds and central neck. Urgent endoscopic debulking avoided tracheotomy and facilitated extubation. Later, complete resection required hemithyroidectomy, laryngofissure and partial cricotracheal resection. We conclude that endoscopic debulking is an appropriate initial treatment. Transmural extension should be suspected in tumors larger than 1cm and warn of the need for tracheal resection.

Transoral resection of stylopharyngeus calcification: a unique manifestation of a stylohyoid complex syndrome

Background: Eagle syndrome is often considered in the work-up of odynophagia and neck pain. Classically, this is manifested by ossification or calcification of the stylohyoid ligament or styloid process. There are no reported cases of stylopharyngeal calcification leading to these symptoms. Case: We describe a patient with a suspected submucosal pharyngeal foreign body who was found to have a calcified stylopharyngeus muscle and tendon during surgery. The patient experienced full resolution of symptoms after transoral robotic resection. This diagnosis was initially missed because the radiology was inconsistent with Eagle syndrome. Conclusion: This is the first report of isolated stylopharyngeal calcification, and this unique manifestation of a stylohyoid complex syndrome should be considered in patients with symptoms of Eagle syndrome without styloid elongation.