Rodrigo C. Silva

Efficacy of disinfecting solutions in removing biofilms from polyvinyl chloride tracheostomy tubes.

Bacterial biofilms are prevalent in pediatric tracheostomy tubes (TTs) and are not completely cleared by standard cleaning with gauze and household detergents. We aimed to examine the effectiveness of different disinfecting solutions to remove Staphylococcus aureus (SA) and Pseudomonas aerginosa (PA) biofilms from TTs.

The Effects of Balloon Dilation Laryngoplasty in Children With Congenital Heart Disease

OBJECTIVE To determine the utility of performing balloon dilation laryngoplasty of subglottic stenosis (SGS) in children with underlying congenital heart disease (CHD). DESIGN Retrospective study. SETTING Tertiary care academic health center. PATIENTS Children with an underlying diagnosis of CHD who subsequently underwent balloon dilation laryngoplasty for SGS from January 1, 2006, through December 31, 2011. MAIN OUTCOME MEASURES Clinical improvement and avoidance of tracheotomy. RESULTS We identified 16 children who had a diagnosis of CHD and underwent direct laryngoscopy and bronchoscopy. Five patients (3 girls and 2 boys) underwent a total of 11 balloon dilations for SGS. Their ages at initial dilation ranged from 1 to 4 months. All 5 patients had grade III SGS. Only 1 patient required a salvage tracheotomy for a thick glottic web and associated SGS after her first balloon dilation failed to improve airway patency. The remaining 4 patients have had long-term success in avoiding tracheotomy with symptomatic improvement. CONCLUSIONS Balloon dilation represents a valuable treatment option in patients with CHD and SGS in whom a tracheostomy should be avoided.

Effectiveness of pediatric tracheostomy tube cleaning.

OBJECTIVE To determine the effectiveness of typical reprocessing of pediatric tracheostomy tubes (TTs) with detergent-soaked gauze pads. DESIGN In vitro microbiologic study. SETTING Department of Otolaryngology, University of Florida, Gainesville. PARTICIPANTS Polyvinyl chloride and silicone TTs of 3 different manufacturers. INTERVENTION Thirty TTs were cultured with Pseudomonas aeruginosa or Staphylococcus aureus and reprocessed after 4 days. Eighteen additional TTs were exposed to plasma and then cultured with P aeruginosa or S aureus for 7 days. MAIN OUTCOME MEASURES The presence of biofilms was assessed before and after cleaning by quantitative bacterial counts and scanning electron microscopy. RESULTS Bacterial counts that were obtained before cleaning of the tubes did not differ among brands. Reprocessing reduced P aeruginosa and S aureus bacterial counts in the 4-day group (P = .003 and P = .004, respectively), but clean TTs had a mean count of 10(5) colony-forming units/mL. Reprocessing did not significantly reduce S aureus or P aeruginosa bacterial counts in TTs pretreated with plasma and exposed to 7-day culture. CONCLUSIONS P aeruginosa and S aureus biofilms in pediatric TTs are not eradicated by standard cleaning methods. Further research is needed to determine the clinical significance of these findings and whether strategies to prevent biofilm formation or more effective disinfection methods would result in improved clinical outcomes.

Endoscopic Treatment of Plastic Bronchitis

Plastic bronchitis is a rare condition, characterized by the formation of thick mucus plugs that cause airway obstruction. It is seen in a variety of disorders, including congenital cyanotic heart disease following palliative surgery. We describe the case of a 5-year-old child with hypoplastic left-heart syndrome who had undergone a Fontan procedure and developed recurrent bronchial cast formation. These casts were treated aggressively with repeated rigid bronchoscopy and adjuvant medical therapy. We present a brief review of the pathogenesis, treatment options, and description of the challenges involved with endoscopic removal of bronchial casts.

Effect of repeated tracheostomy tube reprocessing on biofilm formation

To determine the effect of repeated reprocessing of pediatric tracheostomy tubes (TTs) on biofilm formation.

Use of fiberoptic endoscopic evaluation of swallowing (FEES) in the management of psychogenic dysphagia in children

OBJECTIVES To describe the use of fiberoptic endoscopic evaluation of swallowing (FEES) as an adjunct in the management of children presenting with psychogenic dysphagia, defined as food avoidance and excessive fear of eating without identifiable anatomic or functional swallowing abnormalities. METHODS Case series of patients presenting to the otolaryngology clinic of a tertiary pediatric teaching hospital between 2007 and 2008 that were evaluated and managed with the utilization of FEES. The outcomes measured were age, gender, duration of symptoms, findings of FEES, additional work-up and resolution of symptoms at follow-up. RESULTS Five patients (4 males, 1 female) with ages ranging from 5 to 13 years old (mean=8.6). The median duration of symptoms before presentation was 3 weeks. Four families described refusal of solids starting after choking episode and variable estimated weight loss (mean 2.8kg). One child presented with vague complaints of intermittent odynophagia and food refusal. Fiberoptic endoscopic evaluation of swallowing was performed on all patients. No abnormalities of the oropharyngeal swallow were appreciated. Additional management included different combinations of modified barium swallow study, esophagastroduodenoscopy (EGD), upper GI series, antibiotics, and psychotherapy. Mean follow-up with clinic visit was 4.2 months. Three of the five children reported complete resolution of symptoms after FEES at follow-up visit. CONCLUSION Fiberoptic endoscopic evaluation of swallowing can be a useful management tool in children with psychogenic dysphagia as it provides direct visualization of the oropharyngeal swallowing mechanism. This can be used to provide visual reassure and biofeedback to patients and parents. Additional workup should be decided on an individual basis.

A comparison of two methods of endoscopic dilation of acute subglottic stenosis using a ferret model

Balloon dilation is accepted as a first line treatment of acute subglottic stenosis, but its effects on the subglottic tissue remain largely unknown. We aimed to develop an animal model of acute subglottic stenosis using endoscopic techniques. Once developed, this model was used to compare the immediate effects of balloon dilation and endotracheal tube dilation on subglottic tissue.

Biofilm formation on coated silicone tympanostomy tubes

OBJECTIVES Tympanostomy tube (TT) surface modifications have been promoted as a means of reducing biofilm formation, otorrhea, and occlusion. The goal of this study was to determine if biofilm formation on silicone TTs could be prevented by commercially available surface coatings. METHODS Silicone TTs with and without polyvinylpyrrolidone (PVP) or/and silver oxide were exposed to human plasma and cultured with Pseudomonas aeruginosa or Staphylococcus aureus (22 TTs per group). After 4 days, antibiotics were added to kill planktonic bacteria. Biofilm formation was assessed by quantitative bacterial counts and scanning electron microscopy. RESULTS PVP, silver, and PVP-silver coatings reduced P. aeruginosa biofilm formation relative to silicone by over 1 log (p<0.0001). PVP was superior to silver (p=0.04) and PVP-silver (p<0.0001). PVP and PVP-silver coatings increased S. aureus biofilm formation nominally (p=0.01 & 0.003). CONCLUSION PVP and silver coatings reduce P. aeruginosa biofilm formation on silicone TTs. Combining PVP and silver coatings does not further improve biofilm resistance. TT surface coatings warrant further study through clinical trials.

Novel rat model of tympanostomy tube otorrhea

OBJECTIVE Tympanostomy tube otorrhea (TTO), caused by the presence of pathogenic bacteria in the middle ear, is the most common complication of TT insertion. No studies have described a reproducible animal model of TTO. We aimed to develop a rat model of TTO which, in turn, could be used to assay the levels of TNF-α and IL-1β through the course of the infection. METHODS The left Eustachian tubes of 55 male Sprague-Dawley albino rats were occluded with gutta-percha (ETO=Eustachian Tube Occlusion). Middle ear (ME) effusion was ascertained by weekly otomicroscopy. At 3 weeks tympanostomy tubes were placed bilaterally and the MEs were inoculated bilaterally with Streptococcus pneumoniae through the tubes. The rats were randomly assigned to one of two daily ototopical treatments: ciprofloxacin/dexamethasone (CDX) or placebo. The animals in each of the two treatment groups were further divided to receive 1, 2, 5 or 7 days of treatment. The rats were sacrificed after treatment was finished. The rates of otorrhea, positive middle ear (ME) cultures, and levels of TNF-α and IL-1β in the ME fluid were measured. RESULTS Left ETO followed by ME inoculation with S. pneumoniae and treatment with placebo resulted in persistent infection (100% culture-positive ME fluid at 10 days) and otorrhea (85.7%). Persistent infection of the left ear was accompanied by significantly elevated the levels of IL-1β and TNF-α. Ears treated with CDX had lower rates of otorrhea at all time points and lower levels of IL-1β and TNF-α. CONCLUSIONS This study is the first to describe a reproducible animal model of acute TTO. Surgical obstruction of the ET, followed by TT placement and ME inoculation with S. pneumoniae induced persistent otorrhea and infection. Both IL-1β and TNF-α appear to be potential markers of persistent middle ear infection. This novel model may be used in future studies of the pathogenesis and therapy of TTO.

Persistent Foramen of Huschke Mimicking a Branchial Cleft Anomaly

Apersistent foramen of Huschke, or foramen tympanicum, results from the defective ossification of the anteroinferior aspect of the tympanic portion of the temporal bone. We describe 2 girls, aged 5 and 6 years, with histories of recurrent cervical abscesses, draining submandibular sinuses, and defective tympanic plates adjacent to the tympanic ring. Surgical resection of the fistulous tract extending from the submandibular triangle to the bony ear canal successfully controlled the symptoms.