Trevor J. McGill

Fulminant aspergillosis of the nose and paranasal sinuses: A new clinical entity†‡

Fulminant aspergillosis of the nose and paranasal sinuses represents a new clinical entity occurring in individuals with depressed immunological responses. It is marked by a rapid malignant course, requiring early recognition, aggressive surgery and chemotherapy. Clinical manifestations include a rapidly progressive gangrenous mucoperiostitis advancing relentlessly to destruction of the nasal cavity and the paranasal sinuses within a few days. The recent emergence of this form of aspergillosis appears to be directly related to the increased intensity of chemotherpay and immunosuppression in the treatment of previously fatal neoplastic diseases. Control of this disease process requires aggressive therapy. This may include radical sinus ablation, debridement of nasal structures, chemotherapy and possible correction of immunological deficits, i.e., bone marrow transplantation. Four cases are discussed in detail to present the clinical spectrum of this new disease entity.

A double-blind evaluation of ketorolac tromethamine versus acetaminophen in pediatric tonsillectomy: analgesia and bleeding.

The study was designed to compare intravenous ketorolac to rectal acetaminophen for analgesia and bleeding in pediatric patients undergoing tonsillectomy.We studied 50 patients, aged 2-15 yr undergoing tonsillectomy with or without adenoidectomy. In a randomized, prospective double-blind fashion, patients were assigned to receive either ketorolac (1 mg/kg) or rectal acetaminophen (35 mg/kg). Bleeding was evaluated by measuring intraoperative blood loss and noting extra measures required to obtain hemostasis. Bleeding times were also measured before and during surgery. Pain was evaluated using a standard objective pain score for the first 3 h. Persistent pain was treated with morphine, acetaminophen, and codeine and recorded for 24 h. Blood for determination of acetaminophen levels was drawn at 20 and 40 min after the administration of study drugs. Pain scores were not significantly different between the ketorolac and acetaminophen groups. The majority of patients in both groups required additional opioid in the postoperative period. Acetaminophen levels were all less than the therapeutic range. Intraoperative bleeding times were normal in all patients, but blood loss was significantly higher in the ketorolac group (2.67 mL/kg) compared to the acetaminophen group (1.44 mL/kg), P = 0.025. Significantly more measures to achieve hemostasis were required in the ketorolac group (P = 0.012). We conclude that ketorolac is no more effective than high-dose rectal acetaminophen for analgesia in the patient undergoing tonsillectomy. Hemostasis during tonsillectomy was significantly more difficult to achieve in patients receiving ketorolac. (Anesth Analg 1995;80:226-9)

Airway foreign bodies (FB): a 10-year review

A retrospective chart review of children who had airway foreign body removed via direct laryngoscopy and bronchoscopy (DLB) from 1987-1997 was conducted in Childrens Hospital, Boston. Patient characteristics noted included age, sex, and clinical presentation. Pre-operative radiographic findings, reason for delay in evaluation, DLB findings, length of procedure, reason for repeat DLB, and types of foreign body etc. were recorded. Serious complications from aspirated foreign bodies such as severe airway obstruction and death tend to occur in infants and younger children because of their small airway size. A history compatible with foreign body aspiration dictates diagnostic endoscopy with or without radiologic confirmation. Chest and airway radiographs supplemented by fluoroscopy can increase the ratio of correct and early diagnosis. Fluoroscopy should be universally accepted as an initial diagnostic technique in airway foreign body evaluation. Fluoroscopy is not a worthwhile investigation if a preceeding chest radiograph suggests the presence of a foreign body. Long-standing airway foreign bodies are associated with considerable morbidity, and early diagnosis remains the key to successful and uncomplicated management of foreign body aspiration. Education aimed at increasing diagnostic acumen of the physicians and heightening of public awareness are the most important steps needed to reduce the morbidity and mortality. Parents should be instructed to abstain from feeding nuts and seeds to young children and to keep small, potentially ingestible objects out of their reach.

The Biology and Management of Subglottic Hemangioma: Past, Present, Future†

Objectives/Hypothesis: Objectives were 1) to review the presentation, natural history, and management of subglottic hemangioma; 2) to assess the affect of five variables (age, gender, degree of subglottic narrowing, location and extent of subglottic hemangioma, and lack or presence of other hemangioma) and the outcome of six different treatment modalities (conservative monitoring, corticosteroid, laser surgery, tracheotomy, laryngotracheoplasty, and interferon) in the management of subglottic hemangioma; and 3) to present specific guidelines to help determine the best possible treatment modality at the time of initial presentation.

Subglottic hemangioma: ten years' experience with the carbon dioxide laser.

Patients with subglottic hemangioma present with biphasic stridor during infancy. The natural history of this lesion is characterized by progressive airway obstruction during the proliferative phase of the lesion, followed by resolution of symptoms during the subsequent involutive phase. Although this is a benign neoplasm, it can be associated with a fatal outcome. Treatment options have been directed at maintaining airway patency during the proliferative phase. The senior author (G.B.H.) originally described the role of the carbon dioxide laser in management of these patients in 1980. Thirty-one patients were treated for subglottic hemangioma at The Childrens Hospital, Boston, between 1980 and 1990. The 10-year experience of management of subglottic hemangioma with endoscopic vaporization using the carbon dioxide laser is reviewed to assess the efficacy of this technique.

Interferon Alfa-2A Therapy for Airway Hemangiomas

Hemangioma is a well-recognized cause of airway obstruction in the infant with stridor. Corticosteroid and laser therapy are effective in stabilizing the airway in most cases. There are, however, some extensive airway lesions that are not adequately managed by these modalities. This report describes the use of recombinant interferon alfa-2a in 15 patients with life-threatening airway hemangiomas. All patients had failed corticosteroid and/or laser therapy. Multiple upper airway sites were involved, including the base of the tongue, supraglottis, subglottis, trachea, and mediastinum. Eleven patients have completed therapy and are doing well. Four patients have resolving lesions on the drug regimen. Life-threatening airway lesions unresponsive to conventional treatment should be considered for a trial of interferon alfa-2a.

Transplantation of human central nervous system stem cells – neuroprotection in retinal degeneration

Stem cells derived from the human brain and grown as neurospheres (HuCNS‐SC) have been shown to be effective in treating central neurodegenerative conditions in a variety of animal models. Human safety data in neurodegenerative disorders are currently being accrued. In the present study, we explored the efficacy of HuCNS‐SC in a rodent model of retinal degeneration, the Royal College of Surgeons (RCS) rat, and extended our previous cell transplantation studies to include an in‐depth examination of donor cell behavior and phenotype post‐transplantation. As a first step, we have shown that HuCNS‐SC protect host photoreceptors and preserve visual function after transplantation into the subretinal space of postnatal day 21 RCS rats. Moreover, cone photoreceptor density remained relatively constant over several months, consistent with the sustained visual acuity and luminance sensitivity functional outcomes. The novel findings of this study include the characterization and quantification of donor cell radial migration from the injection site and within the subretinal space as well as the demonstration that donor cells maintain an immature phenotype throughout the 7 months of the experiment and undergo very limited proliferation with no evidence of uncontrolled growth or tumor‐like formation. Given the efficacy findings and lack of adverse events in the RCS rat in combination with the results from ongoing clinical investigations, HuCNS‐SC appear to be a well‐suited candidate for cell therapy in retinal degenerative conditions.

Chronic pediatric stridor: etiology and outcome.

Stridor in children is usually acute. This paper represents a chart review and telephone survey of 60 patients with chronic pediatric stridor. The most common etiology was laryngomalacia, which required airway intervention in 22% of the patients. The symptoms persisted beyond 18 months of age in 17% of the patients. Twelve percent of the patients had multiple lesions; 65% of the second lesions were below the vocal cords. It appears that the presence of cyanosis should increase physician suspicion of multiple lesions. There was not a higher risk of recurrent upper respiratory infections with any of the diagnoses.

Congenital cholesteatoma of the middle ear in children: a clinical and histopathological report.

Forty‐one children with congenital cholesteatoma of the middle ear seen from 1978 through 1989 are reviewed. The most common presentation was that of an asymptomatic white mass behind a normal intact tympanic membrane. Computed tomography (CT) scan was useful in documenting extension beyond the mesotympanum. Surgical removal was performed using an extended tympanotomy for lesions in the middle ear and tympanomastoidectomy for those that had extended into attic and mas‐toid air cells. Observation over an average 3.1‐year period indicated that 80% of children were free of disease after initial surgery. Residual disease that required further surgery was present in 20%.

Asbestos and laryngeal carcinoma.

Abstract One hundred male patients with squamous carcinoma of the larynx and one hundred matched controls with various non-malignant diseases were questioned about their exposure to asbestos. Thirty-one patients and three controls had experienced an important degree of exposure to asbestos. The difference between the two groups was statistically highly significant. The average latent interval between first exposure and development of laryngeal carcinoma was 30 years, and the average duration of exposure was 27 years.