Steven D. Handler

Pediatric Tracheostomy Experience during the Past Decade

A retrospective review of a decade of experience with pediatric tracheostomy encompassed 420 children. Analysis was performed with respect to primary diagnosis, age, duration of tracheostomy and hospitalization, early and late complications and mortality. While the incidence of tracheostomy per hospital admission decreased over the period of review, there was substantial increase in duration of tracheostomy. Approximately half of the patients sustained complications. While overall mortality approached 28%, tracheostomy-related deaths occurred in only eight patients (2%). Almost one fifth of children with tracheostomies were discharged to home care, and 3% were involved in our home ventilator program.

Post‐Tonsillectomy Hemorrhage: Incidence, Prevention and Management

Tonsillectomy (with or without adenoidectomy) continues to be a commonly performed operation in the United States. Over the years, the incidence of post‐tonsillectomy hemorrhage (reported between 0% and 20%) has decreased, but continues to pose serious problems. We reviewed 1,445 tonsillectomies performed over a 2‐year period to study the incidence of post‐tonsillectomy hemorrhage. Thirty‐eight of 1,445 children (2.62%) had postoperative bleeding. The incidence of primary hemorrhage (within 24 hours) was 0.14%. Delayed hemorrhage requiring operative intervention or observation in the hospital was 1.03% and 0.76%, respectively. Ten patients (0.69%) had delayed hemorrhage of a minor nature that had stopped by the time they reached the hospital; these children were treated with observation alone and did not require hospitalization or operative intervention. The proposed reasons for this low rate of post‐tonsillectomy hemorrhage include complete preoperative coagulation screening, meticulous attention to surgical technique, use of suction‐cautery to obtain hemostasis and, possibly, use of postoperative antibiotics. Management of hemorrhage is discussed with respect to observation, surgical intervention, and blood transfusion.

Late effects after treatment of twenty children with soft tissue sarcomas of the head and neck: experience at a single institution with a review of the literature

Twenty children with soft tissue sarcomas of the head and neck, treated at the Childrens Hospital of Philadelphia and the Hospital of the University of Pennsylvania from 1972 to 1981, were evaluated for the late deleterious effects of treatment. All patients received radiation therapy and combination chemotherapy with vincristine, dactinomycin, and cyclophosphamide; certain patients also received Adriamycin (doxorubicin). All had ophthalmologic, otologic, growth, and cosmetic evaluations; 15 also had dental and maxillofacial examinations. The median age at diagnosis was 6 years (range, 7 months‐13 years). Median follow‐up from time of diagnosis was 5.5 years with a minimum of 3 years in all but four patients. The major problems encountered were related to the eyes (xerophthalmia and cataracts), ears (hearing loss), teeth (maleruption and caries), glandular structures (xerostomia, hypopituitarism), and development (craniofacial deformity). It is concluded that children treated for soft tissue sarcomas of the head and neck with combined modality therapy, including radiation enhancers, may show a variety of late treatment‐related adversities. These children require close multidisciplinary follow‐up for detection of late effects in order that appropriate prophylactic or symptomatic treatment can be instituted to minimize their consequences.

Choanal Atresia: A Twenty‐Year Review of Medical Comorbidities and Surgical Outcomes

Objective To review medical comorbid conditions and surgical outcomes for children treated for choanal atresia (CA).

Pediatric neck masses: guidelines for evaluation

Neck masses are frequent findings in the pediatric population. Unlike the adult, there are few established guidelines for evaluation of these children. The etiology of cervical masses includes many conditions. Knowledge of these conditions and their clinical presentations is essential. To elucidate the clinical characteristics which may help in establishing a correct diagnosis, the charts of 445 patients with biopsies of neck masses performed at the Childrens Hospital of Philadelphia were analyzed. There were 244 (55%) congenital lesions, 118 (27%) inflammatory lesions, 23 (5%) non-inflammatory benign masses, 12 (3%) benign neoplasms, and 48 (11%) malignancies. The preoperative diagnosis was correct in 270 (61%) patients. Guidelines are established for the evaluation of the child presenting with a neck mass.

Is outpatient tonsillectomy appropriate for young children

The current literature suggests that outpatient tonsillectomy is a safe, cost‐effective procedure. These reports have based their conclusions on the low rates of postoperative bleeding and dehydration. Generally, they have not examined other factors that may influence the postoperative course or identified groups of patients in whom outpatient management may not be appropriate. The literature regarding tonsillectomy in young children is conflicting. A retrospective analysis of the records of 223 children, 36 months of age and younger who had tonsillectomies, was performed. Postoperative airway complications including oxygen desaturation and airway obstruction developed in 115 patients. Seventeen (7.6%) children required postoperative care in an intensive care unit while an additional 117 (52.5%) patients received more than standard management. Preoperative apnea, an age of less than 12 months, and the presence of accompanying medical conditions were associated with a higher incidence of postoperative airway complications. It is recommended that tonsillectomy in patients under 36 months of age be planned as an inpatient procedure.

Bacteriology of tonsil surface and core in children

The tonsils of 97 children undergoing tonsillectomy were studied to determine the correlation between surface culture swab and culture of tonsillar core. In many cases, pathogenic organisms were found in the tonsil core, despite the fact that surface cultures revealed only normal respiratory flora. The tonsil core cultures showed a high incidence of Hemophilus influenzae and Staphylococcus aureus, which was rarely reflected on surface culture.

Salivary gland neoplasms in children: a 10-year survey at The Children's Hospital of Philadelphia☆

Fifteen salivary gland tumors were treated at The Childrens Hospital of Philadelphia between 1982 and 1991. Eight of these lesions were malignant and 7 were benign. All of the benign tumors were pleomorphic adenomas. For these, superficial parotidectomy or excision of the submandibular gland was the treatment of choice. One child had recurrence 2 years after her initial surgery. Among the malignant lesions, mucoepidermoid carcinoma was diagnosed in 5 children, and acinic cell carcinoma in 3. Six malignant tumors involved the parotid gland, while 2 originated in the submandibular salivary gland. Superficial or total parotidectomy, or excision of the submandibular gland was performed, according to the nature and the location of the lesion. The facial nerve was sacrificed in one patient because of extensive involvement of the nerve. A 2-year survival rate of 100% was achieved, and all the patients were free of disease at the end of the follow-up period. Successful management of salivary gland lesions in children requires a high index of suspicion of possible malignancy and complete surgical removal as the initial treatment. Radiation therapy is recommended in the management of those patients with microscopic residual tumor and/or nodal involvement.

Pilomatrixoma of the Head and Neck in Children

OBJECTIVE: Pilomatrixomas are benign skin neoplasms of hair follicle origin. They are one of the most common superficial masses of the head and neck excised in children. Although the entity has been well studied in the literature, few studies have been undertaken to evaluate the clinical characteristics of head and neck pilomatrixomas specifically in children. The purpose of this study was to review the clinical characteristics and management of children presenting with pilomatrixomas of the head and neck at a large tertiary care pediatric hospital. STUDY DESIGN: A retrospective chart review was performed of all patients with histologically confirmed pilomatrixoma of the head and neck excised during a 6-year period (1992–1997) at the Childrens Hospital of Philadelphia. RESULTS: Ninety-one cases of pilomatrixoma were confirmed in 86 patients. The age range was 5 months to 17 years. The median age at time of excision was 6.0 years. The most common sites of occurrence were the cheek (36%), neck (20%), periorbital region (14%), and scalp (9%). The male to female ratio was 1:1.5. Multiple lesions were found in 8.2% of patients. Surgical excision was curative in all cases. CONCLUSION: Pilomatrixoma is a cutaneous neoplasm that is one of most common causes of superficial head and neck masses in children. Although the presurgical diagnosis may be difficult in some cases, pilomatrixoma must be kept in the differential of superficial head and neck masses in children. Surgical excision is almost always curative.

Communication development in young children with long-term tracheostomies: preliminary report.

Communication development was studied in 77 subjects with long-term tracheostomies ranging in age from two months to 7 years. Children were categorized according to tracheostomy status (cannulated or decannulated), presence of speech practice prior to cannulation, and level of language development (prelinguistic or linguistic) at the time of decannulation. All were aphonic and consequently deprived of speech experience for extended periods while tracheostomized. Twenty-three children have been studied post-decannulation. Results for the children decannulated during the prelinguistic stage revealed that speech and language skills were attained commensurate with intellectual functioning. This evidence led to the conclusion that extensive, audible prespeech practice (cooing and babbling) was not needed for later spoken language development. All children decannulated during the linguistic stage exhibited specific spoken language delays including phonological impairment at the time of decannulation. The presence of speech practice prior to cannulation did not appear to be a factor in the severity of phonological impairment. The children who were cannulated for more lengthy time periods, extending into the linguistic stage, however, demonstrated more severe phonological impairment than those who were decannulated during the prelinguistic stage. With direct speech/language therapy, 20 of the 23 decannulated children eventually compensated for these difficulties, demonstrating appropriate spoken language skills. Alternative communication modalities were felt to be crucial in reducing communicative frustrations during cannulation.