Shelagh A. Cofer

Tracheotomy in the First Year of Life: Outcomes in Term Infants, the Vanderbilt Experience

OBJECTIVE: In an era emphasizing critical care of preterm infants, we characterize the indications and outcomes of tracheotomies performed in the first year of life in term infants compared to preterm infants. METHODS: Retrospective study of 127 tracheotomies performed in the first year of life at a tertiary-care childrens hospital between 1988-2004. RESULTS: Mean gestational ages of the term and preterm groups were 38.97 and 29.71 weeks, respectively (P < 0.001). Indications for tracheotomy were upper airway abnormalities in 53% for the term group. The number of subsequent airway procedures required was 1.39 in the term group, achieving decannulation in 36.3%, with a 20.5% mortality rate. CONCLUSION: Compared to preterm infants, the term decannulation rate was favorable, as chronic lung disease was uncommon. However, non-tracheotomy-related mortalities remained high. SIGNIFICANCE: Tracheotomies are often performed for relief of upper airway obstruction, and congenital and acquired comorbidities not related to tracheotomy are associated with adverse outcomes in term infants. EBM rating: C-4 ©2006 American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. All rights reserved.

Tracheotomy in the preschool population: indications and outcomes.

OBJECTIVE: Although more tracheotomy procedures are performed within the first year of life than in any other age group, preschool-aged children requiring tracheotomy remain understudied. We characterize the indications and outcomes for patients between the ages of 3 and 6 years undergoing tracheotomy. METHODS: Out of 480 pediatric tracheotomy procedures performed at a tertiary-care hospital between 1988 and 2004, 15 patients underwent primary tracheotomy between 3 and 6 years of age. RESULTS: Most (60%) procedures were performed for pulmonary toilet. Upper-airway obstruction represented the second most common indication (40%), and trauma necessitated tracheotomy procedures more often than had been predicted (40%). The decannulation rate was 40%; 2 patients died. CONCLUSION: Trauma contributed to both upper-airway obstruction as well as requirements for pulmonary toilet. These procedures performed secondary to trauma will likely continue to increase. SIGNIFICANCE: Tracheotomy procedures in the preschool population remain uncommon; however, nearly half of those studied were performed as a direct result of otherwise preventable trauma.

Comparison of clonidine, local anesthetics, and placebo for pain reduction in pediatric tonsillectomy.

OBJECTIVE To determine if pretonsillectomy injection of local anesthetics with and without clonidine reduces pain following tonsillectomy in children. DESIGN A prospective, randomized, double-blind, placebo-controlled trial. SETTING Tertiary care academic medical center. PATIENTS A total of 120 children, ages 3 to 17 years, presenting for tonsillectomy. INTERVENTIONS Patients were randomized to 1 of 3 pretonsillectomy injection groups: (1) saline, (2) lidocaine plus bupivacaine, or (3) lidocaine plus bupivacaine plus clonidine. MAIN OUTCOME MEASURES The total number of analgesic doses consumed on postoperative days (PODs) 1, 3, 5, and 7. Secondary outcome variables included total time and intravenous analgesic doses required in the recovery room, visual analog scale pain scores, and maximum tolerated diet on postoperative days 1, 3, 5, and 7. RESULTS The total number of analgesic doses on PODs 1, 3, 5, and 7 were not significantly different between the randomization groups (P = .53). The median numbers (interquartile ranges) of analgesic doses were 12.0 (9.0-16.8) for the lidocaine plus bupivacaine plus clonidine group, 12.0 (10.0-16.5) for the lidocaine plus bupivacaine group, and 14.0 (9.0-15) for the placebo group. The placebo group was found to have a more advanced diet on POD 1 (P = .04) and significantly less pain on POD 3 (P = .02). Multivariable analysis showed children in the lidocaine plus bupivacaine plus clonidine group were significantly less likely to need intravenous pain medication in the recovery room compared with children in the placebo group and again showed that the placebo group achieved a significantly more advanced diet and had less pain on PODs 1 and 3. CONCLUSION Pretonsillectomy injection of lidocaine, 1%, and bupivacaine, 0.5%, with or without clonidine (25 μg) is not recommended for the reduction of posttonsillectomy pain. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00678379.

Comparative analysis of fracture characteristics of the developing mandible: The Mayo Clinic experience

OBJECTIVE To review and compare the epidemiology and treatment of mandibular fractures in subgroups of a pediatric population. METHODS We conducted a retrospective review of pediatric patients (age, ≤18 years) with mandibular fractures treated at our institution from January 1996 through November 2011. RESULTS We identified 122 patients (93 [76%] male) with 216 mandibular fractures. The prevalent mechanisms of injury were motor vehicle accidents (n=52 [43%]), sports injuries (n=24 [20%]), and assault (n=13 [11%]). The most common fracture sites were subcondylar, parasymphyseal, angle, and body. Two patients (2%) were treated conservatively by observation only, 67 (55%) underwent maxillomandibular fixation alone, 41 (34%) underwent maxillomandibular fixation with plate fixation, and 7 (5.7%) underwent plate fixation only. The average duration of maxillomandibular fixation was 26 days (range, 7-49 days). Complications occurred in 11 patients (9.0%) over a mean follow-up of 92 days (range, 21-702 days). Fifty patients (41.0%) had comorbid conditions or a history of mental illness at the time of injury, including attention deficit hyperactivity disorder (n=11 [9%]), mental disorders other than attention deficit hyperactivity disorder (n=23 [19%]), and asthma (n=17 [14%]). Twenty-six patients (21%) had a history of substance use, the most common being tobacco (n=18 [15%]), alcohol (n=13 [11%]), and marijuana (n=11 [9%]). CONCLUSIONS Treatment approach and outcomes were affected by age and fracture characteristics. In addition, a marked proportion of this cohort had preexisting mental disorders and history of substance use, which may have implications on treatment approach.

Haemorrhagic complications with adenotonsillectomy in children and young adults with bleeding disorders.

Haemorrhagic complications remain a challenge with surgical procedures in patients with bleeding disorders. In children and young adults, the most commonly performed surgeries are tonsillectomies and/or adenoidectomies. Adequate haemostasis in these patients with bleeding disorders is centred on comprehensive perioperative haemostatic support and dexterous surgical technique. The aim of this study was to assess postoperative bleeding complications with tonsillectomy and/or adenoidectomy in children and young adults with known bleeding disorders. Retrospective review of all patients aged <25 years with known bleeding disorders who underwent tonsillectomy and/or adenoidectomy at Mayo Clinic, Rochester MN between July 1992 and July 2012. In contrast to reported literature, we observed a higher rate of bleeding complications (10/19, 53%) despite aggressive haemostatic support and appropriate surgical techniques. Delayed bleeding (>24 h postoperatively) was more common than early bleeding; and recurrent bleeding was associated with older age. Children and young adults with haemorrhagic diatheses undergoing adenotonsillectomy are at a higher risk of delayed bleeding and require close monitoring with haemostatic support for a prolonged duration in the postoperative period. A uniform approach is needed to manage these patients perioperatively by establishing standard practice guidelines and ultimately reduce postsurgical bleeding complications.

Structure and functions of pediatric aerodigestive programs: A consensus statement

We present a multi-disciplinary consensus definition of the aerodigestive care model with specific recommendations regarding associated personnel, infrastructure, research, and outcome measures. Aerodigestive programs provide coordinated interdisciplinary care to pediatric patients with complex congenital or acquired conditions affecting breathing, swallowing, and growth. Although there has been a proliferation of programs, as well as national meetings, interest groups and early research activity, there is, as of yet, no consensus definition of an aerodigestive patient, standardized structure, and functions of an aerodigestive program or a blueprint for research prioritization. The Delphi method was used by a multidisciplinary and multi-institutional panel of aerodigestive providers to obtain consensus on 4 broad content areas related to aerodigestive care: (1) definition of an aerodigestive patient, (2) essential construct and functions of an aerodigestive program, (3) identification of aerodigestive research priorities, and (4) evaluation and recognition of aerodigestive programs and future directions. After 3 iterations of survey, consensus was obtained by either a supermajority of 75% or stability in median ranking on 33 of 36 items. This included a standard definition of an aerodigestive patient, level of participation of specific pediatric disciplines in a program, essential components of the care cycle and functions of the program, feeding and swallowing assessment and therapy, procedural scope and volume, research priorities and outcome measures, certification, coding, and funding. We propose the first consensus definition of the aerodigestive care model with specific recommendations regarding associated personnel, infrastructure, research, and outcome measures. We hope that this may provide an initial framework to further standardize care, develop clinical guidelines, and improve outcomes for aerodigestive patients.

Augmentation pharyngoplasty for treatment of velopharyngeal insufficiency in children: Results with injectable dextranomer and hyaluronic acid copolymer.

To evaluate the effectiveness, durability, and safety of a tissue filler (dextranomer and hyaluronic acid copolymer) when injected submucosally in the nasopharynx to treat velopharyngeal insufficiency (VPI) in pediatric patients.

Trans-nasal flexible bronchoscopy in wheezing children: Diagnostic yield, impact on therapy, and prevalence of laryngeal cleft

Persistent or recurrent wheezing is a common indication for flexible bronchoscopy, as anatomic and infectious or inflammatory changes are highly prevalent. We sought to evaluate the prevalence of anatomic, infectious, and inflammatory disease in a cohort of children undergoing flexible bronchoscopy for wheezing or poorly controlled asthma.

Hypopharyngeal gastric choristoma in an infant resulting in airway obstruction.

Gastric choristoma (GC) is a relatively common congenital condition characterized by the presence of heterotopic gastric tissue outside the bounds of the gastric cavity. Although GCs may occur anywhere along the alimentary tract, they rarely occur in the hypopharynx. Hypopharyngeal GCs often declare themselves clinically during the neonatal period with life-threatening obstructive respiratory symptoms and/or feeding difficulty. We present a case of GC of the posterior pharyngeal wall manifesting as progressive dysphagia with failure to thrive and intermittent stridor.

Three-dimensional printed models in multidisciplinary planning of complex tracheal reconstruction

Three‐dimensional printed models are increasingly used in medicine and surgery, but applications of these models in the planning of operative procedures is not well described. In particular, their benefits have not been documented in complex, multiservice, high‐risk operations. We describe five cases of complex pediatric tracheal reconstruction for which three‐dimensional models had specific benefits in planning as well as in education of trainees, operating room staff, and patient families. We also describe our method for producing models so that others can adopt the technology if desired. Laryngoscope, 127:967–970, 2017