Sukgi S. Choi

The Effect of Intranasal Fentanyl on the Emergence Characteristics After Sevoflurane Anesthesia in Children Undergoing Surgery for Bilateral Myringotomy Tube Placement

Children undergoing placement of bilateral myringotomy tubes (BMT) often exhibit pain-related behavior (agitation) in the postanesthesia care unit. We compared the emergence and recovery profiles of pediatric patients who received sevoflurane with or without supplementary intranasal fentanyl for BMT surgery. By using a prospective, double-blinded design, 150 children 6 mo to 5 yr of age, scheduled for routine BMT surgery, were anesthetized with sevoflurane (2%–3%) in a 60% N2O/O2 gas mixture. Patients were randomized to receive equal volumes of intranasal saline (Control), 1 &mgr;g/kg fentanyl or 2 &mgr;g/kg fentanyl. A blinded observer evaluated each patient using a previously described 4-point agitation scale and the Steward recovery scale. Response to parental presence was observed after a score of six (full recovery) was achieved on the Steward recovery scale. There were no significant differences among the three groups regarding age, weight, surgeon, duration of anesthesia, or ear condition. Recovery times and emergence characteristic scores were not statistically different. Agitation scores were significantly reduced in the 2-&mgr;g/kg Fentanyl group as compared with the Control group (P = 0.012). Fentanyl 2 &mgr;g/kg is recommended to reduce the incidence of agitation seen in these patients.

Intracranial Complications of Sinusitis in Childhood

Complications of sinusitis in children, such as intracranial abscess formation, are uncommon and are often clinically unremarkable in comparison to similar disease processes in adults. Between 1983 and 1991, 443 children were admitted to Childrens National Medical Center in Washington, DC, for treatment of sinusitis. Fourteen of these children presented with intracranial extension of the infection and abscess formation. A retrospective review of these patients revealed that the risk of developing an intracranial abscess secondary to sinusitis was 3%. The management of these patients included surgical drainage of the infected sinuses and intracranial surgical exploration. Cranialization and exenteration of the frontal sinus proved to be effective single-stage procedures. While not indicated in all patients, these procedures eliminated the sinus as a source of continued or potential infection and obviated the need for a second obliterative procedure. Combined antimicrobial therapy and surgical drainage should be the management protocol.

Arytenoidectomy in children

Arytenoidectomy is a rare operation in children. Airway obstruction following a difficult delivery of a newborn with cardinal symptoms of laryngeal obstruction should arouse suspicion of laryngeal paralysis. Midline paralysis in children has varied causes. A tracheotomy is almost always necessary for its initial treatment. When spontaneous recovery fails to occur, arytenoidectomy in the pre‐grammar school age is an effective, safe and successful procedure. This is a report of 11 cases treated by the external surgical approach of arytenoidectomy, following which decannulation was possible. In all cases the voice was better than expected.Vocal cord paralysis is the second most common cause of stridor in early infancy, and as many as 52% of patients will not recover spontaneously. Bilateral vocal cord paralysis often requires a tracheotomy for airway distress. If resolution of the bilateral vocal cord paralysis does not allow for decannulation, arytenoidectomy is an option. A retrospective review of 30 children with bilateral vocal cord paralysis who underwent an arytenoidectomy was undertaken. An external arytenoidectomy via laryngofissure was performed in 19 patients, a laser arytenoidectomy in 12 patients, and a Woodman procedure in 1 patient. Twenty-five of the 30 patients (83%) were decannulated. Decannulation was more likely after a laryngofissure (84%) than after a laser arytenoidectomy (56%). The probability of decannulation was related to the presence of concomitant conditions and the need for other airway procedures. While breathiness, hoarseness, and pitch change were common, all patients had an adequate voice postoperatively and demonstrated little change from the preoperative voice disturbance. Aspiration was a rare complication. After an adequate period of observation for spontaneous resolution, arytenoidectomy via external laryngofissure is recommended to aid in the decannulation of children with bilateral true vocal cord paralysis.

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.

Management of pediatric orbital cellulitis in patients with radiographic findings of subperiosteal abscess

Objective: Controversies remain regarding the management of orbital cellulitis (OC). The objective of this study was to examine the outcomes of patients admitted to our institution for orbital cellulitis during a 7-year period. Study Design: Case series with chart review. Setting: Tertiary referral pediatric hospital. Subjects and Methods: Charts of 465 consecutive OC admissions were reviewed for presentation, imaging, medical and surgical treatment, and outcome. Results: Of these patients, 189 were treated in the emergency room and 276 were admitted. CT scan was performed on 240 patients. Subperiosteal abscess (SPA) was noted in 68 patients. Of these, 47 were treated medically and 21 had surgery. Surgical patients were older (8.3 vs 6.2 years, P = 0.039), had larger abscesses (>10 mm, P < 0.001), required a longer admission (10.2 vs 6.6 days, P < 0.001), and had higher temperatures on admission (38.0°C vs 37.3°C, P = 0.03). Conclusion: The majority of small SPAs as diagnosed on CT scans in younger children can be successfully treated medically. Surgery, however, should be considered for a worsening clinical examination. Our findings confirm those of previous reports on this clinical entity.

Changing trends in neonatal subglottic stenosis.

OBJECTIVES To determine whether there are any changes in the incidence and management of neonatal subglottic stenosis (SGS). METHODS A retrospective chart review of 416 infants who were admitted to the neonatal intensive care unit of the Childrens National Medical Center between July 1, 1995, and June 30, 1996, was carried out. The incidence of airway obstruction requiring anterior cricoid split or placement of tracheotomy tube was determined and compared with the incidence studied 10 years ago at the same institution. RESULTS One of 416 neonates required surgical intervention for airway obstruction caused by SGS, for an overall neonatal SGS incidence of 0.24%. When only the neonates who were intubated for 48 hours or longer were considered, the incidence of SGS was 0.49% (1/204). In neonates who were intubated for 48 hours or longer and survived, the incidence of SGS was 0.63% (1/160). This is in comparison with the incidences of 0.65% (3/462), 1.5% (3/195), and 1.9% (3/159), respectively, seen in a study done at the Childrens National Medical Center 10 years ago. Five infants in this current study required placement of a tracheotomy tube for reasons other than SGS. Two infants needed tracheotomy tube placement for micrognathia, and 3 others for central hypotonia, an omphalocele that required multiple surgical procedures, and choanal atresia with a serious heart anomaly, which was a manifestation of CHARGE association. None of these 5 infants had evidence of SGS at rigid endoscopy preceding the tracheotomy tube placement. CONCLUSION The incidence and management of neonatal SGS remain unchanged during this study period when compared with those of 10 years ago. (Otolaryngol Head Neck Surg 2000;122:61–3.)

Coblation Adenotonsillectomy: An Improvement Over Electrocautery Technique?

OBJECTIVES: To compare postoperative complication rates of coblation and electrocautery adenotonsillectomies. STUDY DESIGN: Retrospective chart review. RESULTS: From January 2000 to June 2004, 1997 pediatric patients underwent adenotonsillectomy. 745 coblation, and 1252 electrocautery tonsillectomies were performed. Primary bleed, secondary bleed, and dehydration were seen in 3, 35, and 23 coblation, and 9, 41, and 64 electrocautery tonsillectomies, respectively. Data analysis revealed no significant difference in primary and secondary hemorrhage rate, but a higher dehydration rate in the electrocautery group (P = 0.0423). A total of 602 coblation, 763 curette/cautery, and 632 electrocautery adenoidectomies were performed. Neck pain was seen in 0, 17, and 3 patients, respectively. Data analysis showed a higher incidence of neck pain with the curette/cautery technique compared with coblator and cautery techniques (P = 0.0006 and P = 0.0119, respectively). CONCLUSIONS: Coblation tonsillectomy had similar rates of primary and secondary hemorrhage when compared with electrocautery tonsillectomy but a lower incidence of postoperative dehydration. Coblation adenoidectomy caused less postoperative neck pain than curette/cautery adenoidectomy without significant advantage over cautery adenoidectomy. EBM rating: B-3b

Clinical Consensus Statement: Pediatric Chronic Rhinosinusitis

Objective To develop a clinical consensus statement on the optimal diagnosis and management of pediatric chronic rhinosinusitis (PCRS). Methods A representative 9-member panel of otolaryngologists with no relevant conflicts of interest was assembled to consider opportunities to optimize the diagnosis and management of PCRS. A working definition of PCRS and the scope of pertinent otolaryngologic practice were first established. Patients of ages 6 months to 18 years without craniofacial syndromes or immunodeficiency were defined as the targeted population of interest. A modified Delphi method was then used to distill expert opinion into clinical statements that met a standardized definition of consensus. Results After 2 iterative Delphi method surveys, 22 statements met the standardized definition of consensus while 12 statements did not. Four statements were omitted due to redundancy. The clinical statements were grouped into 4 categories for presentation and discussion: (1) definition and diagnosis of PCRS, (2) medical treatment of PCRS, (3) adenoiditis/adenoidectomy, and (4) endoscopic sinus surgery (ESS)/turbinoplasty. Conclusion Expert panel consensus may provide helpful information for the otolaryngologist in the diagnosis and management of PCRS in uncomplicated pediatric patients.

Perioperative Airway Complications following Pharyngeal Flap Palatoplasty

This study was performed to determine the incidence and types of perioperative airway complications after pharyngeal flap palatoplasty. We conducted a retrospective chart review of 88 patients who underwent correction of velopharyngeal insufficiency between April 30, 1983, and April 30, 1997, in a tertiary care hospital. Some degree of airway obstruction developed in 7 patients. One child developed laryngobronchospasm and required immediate endotracheal intubation. He was successfully extubated without sequelae. Another patient developed severe obstructive sleep apnea and required flap revision. A third patient was found asystolic and apneic. She was immediately intubated; however, she subsequently died. Two patients aspirated blood, presumably resulting in pneumonia. They were managed with parenteral antibiotics. Another child developed worsening sleep apnea and required flap revision. One patient developed nasal obstruction that resolved with time. Airway compromise in patients who undergo pharyngeal flap palatoplasty can be a potentially fatal complication. Careful surveillance should be maintained over patients with underlying neurologic, craniofacial, or cardiopulmonary disorders.

Airway Abnormalities in Patients with Arnold-Chiari Malformation

OBJECTIVES: The goal was to determine the incidence and types of airway abnormalities in patients with Arnold-Chiari malformation (ACM). METHODS: The study was a retrospective chart review of 24 patients with ACM who were evaluated and treated between November 1991 and August 1997. RESULTS: Eighteen (75%) and 6 (25%) of the 24 patients had types I and II ACM, respectively. Three (12.5% of 24 patients) of the type II ACM patients had vocal cord impairment: 1 bilateral paralysis, 1 bilateral paresis, and 1 unilateral paralysis. None of the type I ACM patients had vocal cord impairment. Tracheotomy was necessary in 3 of the 24 patients and all in patients with type II ACM. Central sleep apnea was found in 5 of 6 type II ACM patients, but not in any of the type I ACM patients. CONCLUSIONS: Vocal cord impairment and sleep apnea were found in 12.5% and 21%, respectively, of this ACM Population. When type II ACM patients were considered separately, the incidences of vocal cord impairment and sleep apnea were 50% and 83%, respectively. Type II ACM patients tend to have a higher incidence of airway abnormalities and other neurologic dysfunctions. Flexible fiberoptic laryngoscopy is recommended in the airway evaluation of ACM patients. Early recognition, diagnosis, and management of these abnormalities may be lifesaving.