Stephen F. Conley

Prediction of uvulopalatopharyngoplasty response using cephalometric radiographs

PURPOSE To evaluate the relationship between facial cephalometric measures and response to uvulopalatopharyngoplasty (UPPP). PATIENTS AND METHODS Retrospective analysis of skeletal cephalometric measures obtained from a consecutive sample of 43 patients with obstructive sleep apnea syndrome (OSAS) who underwent body mass index (BMI) measures, UPPP, upright lateral cephalometric radiographs, and preoperative and postoperative polysomnography. Significant clinical effect by uvulopalatopharyngoplasty was arbitrarily defined as having a 50% reduction in the respiratory disturbance index (RDI). The cephalometric measurements used were based solely on skeletal landmarks. RESULTS No skeletal measurement predicted response to UPPP for the entire study population. When the patients were classified on the basis of retrognathia, 33 were identified without retrognathia. In that group, posterior airway length was the greatest predictor of response to UPPP (P < or = .05; odds ratio, 83.2). The distance between hyoid and mandible and the maxillary-mandibular relationship were also predictive of response (P < or = .05). CONCLUSION The skeletal anatomy supporting the airway directly impacts the response to UPPP. Prediction of response requires stratification by skeletal subtype.

Pierre Robin Sequence: Secondary Respiratory Difficulties and Intrinsic Feeding Abnormalities

Objective: There is considerable variation in opinion regarding the optimal management of patients with Pierre Robin sequence (PRS). No single method of airway intervention or feeding strategy is universally appropriate and effective. This study was performed to examine methods used for airway and feeding management and to identify specific problems encountered.

Age of Child, More than HPV Type, Is Associated with Clinical Course in Recurrent Respiratory Papillomatosis

Background RRP is a devastating disease in which papillomas in the airway cause hoarseness and breathing difficulty. The disease is caused by human papillomavirus (HPV) 6 or 11 and is very variable. Patients undergo multiple surgeries to maintain a patent airway and in order to communicate vocally. Several small studies have been published in which most have noted that HPV 11 is associated with a more aggressive course. Methodology/Principal Findings Papilloma biopsies were taken from patients undergoing surgical treatment of RRP and were subjected to HPV typing. 118 patients with juvenile-onset RRP with at least 1 year of clinical data and infected with a single HPV type were analyzed. HPV 11 was encountered in 40% of the patients. By our definition, most of the patients in the sample (81%) had run an aggressive course. The odds of a patient with HPV 11 running an aggressive course were 3.9 times higher than that of patients with HPV 6 (Fishers exact p = 0.017). However, clinical course was more closely associated with age of the patient (at diagnosis and at the time of the current surgery) than with HPV type. Patients with HPV 11 were diagnosed at a younger age (2.4y) than were those with HPV 6 (3.4y) (p = 0.014). Both by multiple linear regression and by multiple logistic regression HPV type was only weakly associated with metrics of disease course when simultaneously accounting for age. Conclusions/Significance Abstract The course of RRP is variable and a quarter of the variability can be accounted for by the age of the patient. HPV 11 is more closely associated with a younger age at diagnosis than it is associated with an aggressive clinical course. These data suggest that there are factors other than HPV type and age of the patient that determine disease course.

Mediastinitis associated with foreign body erosion of the esophagus in children

OBJECTIVE Timely and experienced intervention for esophageal foreign bodies generally allows for removal with minimal morbidity. However, esophageal foreign bodies present a risk for esophageal perforation and subsequent mediastinitis, especially if the diagnosis of the foreign body is delayed. Although much has been written about the management of esophageal foreign bodies and their complications, little has been mentioned in recent literature about the specific complication of mediastinitis. This review was performed to examine our experience with this uncommon complication of esophageal foreign bodies. METHODS A retrospective review of the esophageal foreign body database at Childrens Hospital of Wisconsin from 1987 to 1997 was performed to identify patients with esophageal foreign bodies and subsequent mediastinitis. RESULTS Four patients with esophageal perforation with associated mediastinitis secondary to retained esophageal foreign bodies were identified. Three of the four patients were treated with conservative measures consisting of foreign body removal, intravenous antibiotics and discontinuing of oral nutrition. These patients all achieved resolution of their mediastinitis and esophageal perforation with subsequent return to normal diets and no significant morbidity. One patient, with vascular erosion, required aggressive, invasive therapy. CONCLUSION From review of this limited number of patients, in the absence of major vascular erosion, conservative methods of treating children with foreign body esophageal perforation and subsequent mediastinitis appears to be effective.

Recurrent respiratory papillomatosis in children: masquerader of common respiratory diseases.

BACKGROUND. Recurrent respiratory papillomatosis in children is an uncommon but potentially life-threatening benign tumor of the respiratory tract with laryngeal predilection. The diagnosis of recurrent respiratory papillomatosis may be challenging unless there is a high index of suspicion and awareness of the variable presentations. METHODS. We reviewed the medical charts of children with recurrent respiratory papillomatosis treated at a tertiary children’s hospital. The presentation of recurrent respiratory papillomatosis is illustrated by a series of case reports. We provide a paradigm to assist in the early diagnosis of children with recurrent respiratory papillomatosis. RESULTS. Five patients, aged 2 to 6 years, were erroneously diagnosed with recurrent croup, asthma, laryngeal hemangioma, and tracheomalacia after presenting with variable degrees of chronic dyspnea, cough, stridor, dysphonia, weak cry, and syncope. Once the diagnosis of recurrent respiratory papillomatosis was made, recurring surgical ablation of papillomata was initiated. CONCLUSIONS. Any child presenting with a voice disturbance with or without stridor is recommended to have diagnostic flexible fiber-optic laryngoscopy. Recurrent respiratory papillomatosis should be considered in children when other common pediatric airway diseases either do not follow the natural history or do not respond to treatment of the common disorder.

Gastroesophageal reflux complicating choanal atresia repair

Four infants with bilateral congenital choanal atresia (CCA) underwent transpalatal (3) or transnasal (1) repairs. Postoperatively all four infants experienced gastroesophageal reflux (GER) with intermittent nasal reflux. GER was documented by GER radionuclide scanning in one patient and by dual nasopharyngeal and esophageal pH probe studies in the remaining three patients. The infants with documented GER required prolonged stenting and dilations for choanal restenosis and granulations. The literature emphasizes the importance of the technical repair for prevention of these complications; GER can be a significant complicating factor.

Non‐hodgkin's lymphoma of the head and neck: The university of iowa experience

The evaluation of a patient with a mass in the head and neck may require the consideration of lymphoma in the process of differential diagnosis. Non‐Hodgkins lymphoma is a well‐described heterogeneous group of lymphoid malignancies characterized by a natural history ranging from indolent to aggressive growth. Little has been written, however, concerning the specific features of this disease in the head and neck.

Long-Term Efficacy of Intra-Oral Surgery for Sialorrhea

OBJECTIVES: To investigate the efficacy and quality of life impact of intra-oral surgery for sialorrhea and to provide long-term outcome measures. METHODS: A retrospective review and telephone survey of patients seen in a multi-disciplinary saliva control clinic who underwent surgery between 1999 and 2003. RESULTS: Sixteen of 31 patients underwent 4-duct ligation, 12 patients underwent submandibular gland duct ligation, and three patients underwent a 3-duct ligation procedure. The mean presurgical drooling score (maximum 10) was 9.5, 8.8, and 9, respectively. Recurrence was seen in 68% of patients at a mean of four months. Additional surgery was required in five patients. Phone survey was accomplished in 10 patients. Two of 10 caregivers reported sustained improvement of sialorrhea at two and three years. CONCLUSIONS: Intra-oral surgery provides minimal longterm control of sialorrhea. Additional medical and surgical therapy was needed in a significant portion of patients in this long-term review.

Pediatric deep space neck infections: the Medical College of Wisconsin experience.

A retrospective review was performed on 39 patients with deep space neck infection admitted to the Childrens Hospital of Wisconsin over a nine year period. The signs and symptoms as well as issues of diagnosis and treatment were reviewed with attention to the use of computed tomography (CT) scans. Beta hemolytic streptococcus was the most commonly cultured organism followed by alpha hemolytic streptococcus. Sixteen patients underwent CT scans. Twelve were diagnosed with an abscess by CT scan. An abscess was confirmed in ten patients. Necrotic lymph nodes mimicked abscesses on CT scans and resulted in negative surgical findings. Airway obstruction occurred in 30% of the children in the study. Children under the age of 36 months had a significantly higher rate of airway obstruction upon presentation compared to older children (P < 0.05). There should be a high index of suspicion of upper airway compromise in children under the age of 36 months with a deep neck infection.

Plastic bronchitis: An unusual bronchoscopic challenge associated with congenital heart disease repair

Plastic bronchitis is a rare disorder characterized by the formation of branching mucoid bronchial casts. Several pathophysiologic conditions are associated with development of these intrabronchial casts, including congenital heart defects. The management of plastic bronchitis presents an unusual and interesting bronchoscopic challenge. We describe a patient who underwent a Fontan procedure for correction of a congenital heart defect and subsequently developed respiratory distress secondary to plastic bronchitis on two occasions. In both cases, endoscopic intervention was required to remove these casts. A review of the literature, including the proposed etiologies, diagnosis, and current medical and surgical management, is also undertaken.