Roger R. Marsh

Pediatric Tracheostomy: A Changing Procedure?

In 1982, the experience with tracheostomy at The Childrens Hospital of Philadelphia was reported for 1971 through 1980. We have now reviewed 450 cases for the period from 1981 through 1992, and compared the characteristics of these cases with those in the previous review. Long-term follow-up was available on 83% of cases, and the median follow-up was 2.96 years. Patients received a tracheostomy for airway obstruction (38%), chronic ventilation (53%), or multiple indications (9%). The mean duration of tracheotomy (adjusted for death and loss to follow-up) was 2.13 years. The tracheostomy-related mortality was 0.5%, and the non–tracheostomy-related mortality was 22%. Nineteen percent of patients had complications in the first postoperative week, and 58% had 1 or more late complications. In comparison with the previous study from our institution, there was a great increase in long-term tracheostomy and a continuing trend away from tracheostomy for short-term airway management. Better monitoring and improvements in parental teaching may have contributed to a decrease in tracheostomy-related mortality.

Relief of Upper Airway Obstruction by Adenotonsillectomy

Adenotonsillectomy is often performed to relieve upper airway obstruction, even in children who do not present with severe apnea. Although adenotonsillectomy provides dramatic relief from obstructive sleep apnea, little evidence is available as to the efficacy of surgery in the far more prevalent cases of partial airway obstruction. We report the results of a prospective study of 100 children with adenotonsillar obstruction (without severe apnea) and 50 age-matched control children. The majority of patients exhibited appreciable sleep disturbances preoperatively, as compared to controls, and had substantial postoperative improvement, as demonstrated by parental questionnaire and sleep sonography—the computer-aided analysis of respiratory sounds. Mouth breathing and behavior problems were also prevalent preoperatively and were affected positively by adenotonsillectomy. It appears that surgery in such cases can have far-ranging benefits, even for the child whose obstruction does not demonstrate severe apnea.

Dexamethasone in adenotonsillectomy

Edema contributes substantially to the postoperative discomfort and morbidity of adenotonsillectomy. In a double-blind study, 58 children undergoing adenotonsillectomy were given a single intraoperative dose of either dexamethasone or saline. The steroid markedly affected the postoperative course in the first day after surgery. According to parental reports, the percentage of patients vomiting was reduced from 48 to 4%. Severe throat pain was reported in 57% of controls and only 20% of dexamethasone patients. Twice as many steroid patients as controls tolerated some soft food on the first postoperative day. It appears that dexamethasone can greatly improve patient diet and comfort after adenotonsillectomy.

Auditory short, middle, and long latency responses in acutely comatose patients.

For assessing comatose patients, the combination of auditory short, middle, and long latency evoked potentials (auditory brain stem response [ABR], middle latency component [MLC], and slow vertex response [SVR]) is more comprehensive than auditory brain stem response (ABR) only or ABR with slow vertex response (SVR). Fifty‐four acutely comatose patients were studied. Thirty‐four of the patients had severe head injury and others had coma of varied etiology. Within two months after admission, 25 patients survived, while 29 patients died.

Brain Stem Response Evoked by Electrical Stimulation of the round Window of the Guinea Pig

The wave that is believed to correspond to wave V in man is an appropriate indicator of auditory nerve excitability because it is not contaminated by nonauditory neurogenic responses to electrical stimulation. The responses to direct electrical stimulation of the auditory nerve could be distinguished from the electrophonic response by the steep input-output function and constant latency of the former. Myogenic responses are prominent unless a muscle relaxant is administered.

Effect of site of stimulation on the guinea pig's electrically evoked brain stem response.

Stimulation by a bipolar modiolus electrode yields a wider dynamic range than does monopolar stimulation at the same site. Stimulation via a single electrode in the scala tympani or scala vestibuli is characterized by a precipitous input-output function, but current passing from one scala to the other generates a discontinuous function with a shallow slope at low intensities and a steep slope at high intensities.

Ototoxicity of Antimycotics

Neither otomycoses nor defects of the tympanic membrane are rare. In cases of fungal infection when the tympanic membrane is not intact, the possibility exists that antimycotic medication could enter the middle ear and diffuse into the cochlea via the round window. Five antimycotic preparations were tested for acute ototoxic potential in guinea pigs. Those containing acetic acid or propylene glycol caused appreciable elevation of brainstem response thresholds, while little or no impairment resulted from tolnaftate or clotrimazole solutions in polyethylene glycol 400.

DEVELOPMENTAL PATTERNS OF NORMAL NUTRITIVE SUCKING IN INFANTS

The purpose of this investigation was to quantify normal nutritive sucking, using a microcomputer‐based instrument which replicated the infants customary bottle‐feeding routine. 86 feeding sessions were recorded from infants ranging between 1–5 and 11‐5 months of age. Suck height, suck area and percentage of time spent sucking were unrelated to age. Volume per suck declined with age, as did intersuck interval, which corresponded to a more rapid sucking rate. This meant that volume per minute of sucking time was fairly constant. The apparatus provided an objective description of the patterns of normal nutritive sucking in infants to which abnormal sucking patterns may be compared.

Contact Diode Laser Tonsillectomy in Children

OBJECTIVE: To compare contact diode laser (CDL) tonsillectomy to monopolar cautery (MPC) with regard to pain and other morbidity during recovery. STUDY DESIGN AND SETTING: Single-blind, randomized trial in a tertiary-care pediatric hospital. Tonsillectomy was performed by CDL in 30 children and by MPC in 28. Parents completed a daily questionnaire for 10 days after surgery. RESULTS: There was significantly less pain in the CDL group than in the MPC group. The CDL group also required much less medication, and was much less likely to experience multiple awakenings (P < 0.001 for all comparisons). CONCLUSION: Recovery after CDL tonsillectomy was associated with much less pain and discomfort than after MPC surgery. SIGNIFICANCE: Postoperative pain is a major concern for surgeons, patients, and their parents. The long recovery period also has costs in school days missed for the child and work missed for the parents. CDL tonsillectomy may greatly mitigate these burdens.

Childhood epiglottitis in recent years

Fifty-five cases of acute epiglottitis were diagnosed and treated at the Childrens Hospital of Philadelphia between 1985 and 1991. To evaluate the changing patterns of the disease over recent years, we compared the current results with those obtained from an earlier study reported at our institution in 1979. The overall annual incidence was higher in recent years than in the earlier study, with a sharp decline in new cases over the last two years. Thirty-six percent of the Hemophilus influenzae type B (HIB) infections were ampicillin-resistant in recent years, while no resistance had been found in the past. Twenty-seven percent of the cases were vaccine failures, all before 1990. Endotracheal intubation was the sole method for upper airway maintenance, while in the past 31% of the children underwent a tracheotomy. No mortality or long-term complications were found in either study.