Richard Nicollas

The Biology and Management of Subglottic Hemangioma: Past, Present, Future†

Objectives/Hypothesis: Objectives were 1) to review the presentation, natural history, and management of subglottic hemangioma; 2) to assess the affect of five variables (age, gender, degree of subglottic narrowing, location and extent of subglottic hemangioma, and lack or presence of other hemangioma) and the outcome of six different treatment modalities (conservative monitoring, corticosteroid, laser surgery, tracheotomy, laryngotracheoplasty, and interferon) in the management of subglottic hemangioma; and 3) to present specific guidelines to help determine the best possible treatment modality at the time of initial presentation.

Congenital cysts and fistulas of the neck

This retrospective study describes a series of 191 children treated for congenital cysts and fistulas of the neck between 1984 and 1999 in the pediatric ORL Department of La Timone Childrens Hospital. Preauricular fistulas and cystic hygromas were not included. The anomalies in this series were classified as either malformations of the midline or malformations of laterocervical region. Malformations of the midline included the thyroglossal duct cysts (n=102) and dermoid cysts (n=21). The most common malformations of the laterocervical region were cysts and fistulas of the second cleft (n=37) followed by those of the first cleft (n=20),those of the fourth pouch (n=7), and thymic cysts (n=4). Diagnosis of malformations of the midline is usually straightforward. However, diagnosis of malformation of the laterocervical region can be problematic. Misdiagnosis often leads to inadequate treatment with recurrence and functional as well as cosmetic sequelae.

Fourth branchial pouch anomalies: A study of six cases and review of the literature

A retrospective study in the ENT departments of the Timone Childrens Hospital in Marseille and the Armand Trousseau Hospital in Paris and a review of the literature was performed in order to update knowledge about fourth branchial pouch anomalies. Over the 12-year period studied, a total of six children were treated: three boys and three girls. The lesions were located on the left side in all cases and infection was the most common manifestation. Clinical presentation ranged from suppurative thyroiditis in most cases to stridor in a few newborns. The most useful diagnostic examinations are CT-scan of the neck and endoscopy of the pyriform sinus. The authors emphasize the need for complete surgical resection including the cyst and fistulous tract down to the pyriform sinus.

Nasal and sinus polyposis in children

Nasal and sinus polyposis in the pediatric population is uncommon and its etiology is unclear. In this 11‐year retrospective study, the authors describe the etiologic features and evaluate the effectiveness of endoscopic sinus surgery in 46 children. Patients were divided into three groups according to whether nasal and sinus polyposis was isolated (n = 14), or associated with either asthma (n = 5) or cystic fibrosis (n = 27). An allergy was present in 10% of patients with isolated polyposis, 80% of patients with polyposis associated with asthma, and 22% of patients with polyposis associated with cystic fibrosis. The indications for surgery were disabling symptoms, especially chronic nasal obstruction, rhinorrhea, and mouth breathing, and failure to respond to medical treatment. No surgical complications were encountered. Most patients reported improvement in quality of life with reduction of nasal obstruction in 83% of cases and rhinorrhea in 61%. Minor asymptomatic recurrence (i.e., a few micropolyps localized on the roof of the ethmoid cavity) was observed in 24% of the cases in this series, and major recurrence with the same functional symptoms as before surgery in 12%. However, recurrences were higher in patients with cystic fibrosis, because minor recurrence with no clinical manifestation was observed in 32% of these cases and major recurrence in 16%. Endoscopic sinus surgery must be decided in collaboration with the pediatric and pulmonary physicians, and must be performed skillfully. With a mean follow‐up of 3.7 years, results in this series are encouraging.

Management of infantile subglottic hemangioma: acebutolol or propranolol?

The successful management of subglottic hemangioma with propranolol has been reported. We report three cases of subglottic hemangioma treated with the cardioselective beta-blocker acebutolol, 8 mg/kg/day. Treatment was efficient in two cases while an open procedure was necessary in the third child. In our experience, acebutolol could be easily administered in oral form twice-a-day only with a dose that was adaptable according to the growth of the child and showed no side effects. We also report a case of rebound growth after beta-mimetic drug use and the efficiency of propranolol treatment in such a recurrence. Considering the lack of side effects and the advantages in terms of administration, we suggest acebutolol as a first-line treatment of subglottic hemangiomas for which intervention is required.

Surgical removal of subglottic hemangiomas in children.

Objective: To examine the indications and the results of surgical excision of severe subglottic hemangiomas.

Cidofovir plasma assays after local injection in respiratory papillomatosis

Objective: To assess cidofovir plasma concentration after intralesional airway administration for recurrent respiratory papillomatosis.

Objective Voice Analysis in Dysphonic Patients: New Data Including Nonlinear Measurements

Objectives/Hypothesis: This report describes a comparative study of objective voice evaluation using a multiparametric protocol including aerodynamic parameters and linear and nonlinear acoustic parameters recorded on an EVA® workstation and perceptual voice analysis by a jury. Study Design: A total of 449 samples were retrospectively selected including 391 patients with pathological voices (308 women and 141 men) and 58 controls with normal voices (38 women and 20 men). A prospective complementary study concerning 43 female patients and 3 controls is presented. Methods: Objective measures included fundamental frequency (Fo), intensity, jitter, signal-to-noise ratio (SNR), Lyapunov coefficient (Lya), oral airflow (OAF), estimated subglottic pressure (ESGP), maximum phonatory time (MPT) and vocal range. A jury of 4 experienced listeners was instructed to classify voice samples (continuous speech) according to the G (overall dysphonia) component of the GRBAS score on a Visual Analogue Scale (VAS) secondarily transformed in a scale ranging from 0 for normal to 3 for severe dysphonia. Results: It was shown that a nonlinear combination of only 7 parameters in women (vocal range, Lya, ESGP, MPT, OAF, SNR, and Fo) and 6 parameters in men (vocal range, Lya, OAF, ESGP, Fo, SNR) allowed classification of 81% voice samples in the same grade as the jury in women and 84% in men. In the prospective study, 80.5% were correctly classified with the same set of objective measurements. Discussion: The relative importance of the different objective parameters in this type of discriminant analysis is dealt with. Special emphasis is placed on Lya.

Congenital tracheoesophageal fistula without esophageal atresia.

The authors report a series of eight cases of isolated tracheoesophageal fistula without esophageal atresia (or an H type fistula), treated in three pediatric ENT departments. This is a rare malformation whose diagnosis requires investigation for associated anomalies. The clinical signs are mainly respiratory but also digestive and the symptomatology can be severe. The diagnosis can be made with a barium swallow combined with cineradiography, but a tracheoesophageal endoscopy remains the investigation of choice. The treatment is surgical. In most cases, the fistula is accessible by a right or left cervicotomy, depending on the surgeons practice, with a much lower postoperative morbidity as compared to a thoracotomy. The postoperative management was straightforward in most of our cases. We discuss the role of gastro-esophageal reflux with respect to postoperative morbidity as well as systematic treatment for reflux peri-operatively. The pros and cons of the various surgical approaches are also discussed.

Primary cricotracheal resection in children: indications, technique and outcome

OBJECTIVE Treatment of subglottic stenosis has benefited greatly from development of grafting techniques such as larygontracheoplasty. Meanwhile, cricotracheal resection of the stenotic area and a major part of the cricoid cartilage have been shown to give excellent results in adults. PATIENTS AND METHODS From June 1993 to June 2000, we performed cricotracheal resection, as the primary surgical procedure, for acquired (n=13), congenital (n=2) or mixed (n=l) subglottic stenosis in 16 pediatric patients comprising seven boys and nine girls. At the time of surgery, the mean weight was 16 kg and the mean age was 5 years. Degree of stenosis was classified as grade II in one case, grade III in 12, and grade IV in three. Eight patients underwent two-stage procedures with postoperative tracheostomy. A rolled reinforced silastic stent was placed for a mean period of 20 days and the tracheostomy tube was removed within a mean period of 44 days after stent removal. Eight patients underwent single-stage procedures. The Portex endotracheal tube was used for a mean period of 4 days. RESULTS All patients underwent regular clinical and endoscopic postoperative examination. Mean follow-up was 38 months. No interference with laryngotracheal growth has been noted in any case, including the five with follow-ups longer than 5 years. CONCLUSIONS The indications for laryngotracheoplasty and cricotracheal resection in children with subglottic stenosis are still unclear. Decisions must be made on a case-by-case basis. In this article the authors discuss decisional factors in terms of clinical findings, surgical techniques, potential complications, and outcome.