Udayan K. Shah

Use of intranasal fentanyl in children undergoing myringotomy and tube placement during halothane and sevoflurane anesthesia.

BackgroundMany children are restless, disoriented, and inconsolable immediately after bilateral myringotomy and tympanosotomy tube placement (BMT). Rapid emergence from sevoflurane anesthesia and postoperative pain may increase emergence agitation. The authors first determined serum fentanyl concentrations in a two-phase study of intranasal fentanyl. The second phase was a prospective, placebo-controlled, double-blind study to determine the efficacy of intranasal fentanyl in reducing emergence agitation after sevoflurane or halothane anesthesia. MethodsIn phase 1, 26 children with American Society of Anesthesiologists (ASA) physical status I or II who were scheduled for BMT received intranasal fentanyl, 2 &mgr;g/kg, during a standardized anesthetic. Serum fentanyl concentrations in blood samples drawn at emergence and at postanesthesia care unit (PACU) discharge were determined by radioimmunoassay. In phase 2, 265 children with ASA physical status I or II were randomized to receive sevoflurane or halothane anesthesia along with either intranasal fentanyl (2 &mgr;g/kg) or saline. Postoperative agitation, Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) scores, and satisfaction of PACU nurses and parents with the anesthetic technique were evaluated. ResultsIn phase 1, the mean fentanyl concentrations at 10 ± 4 min (mean ± SD) and 34 ± 9 min after administering intranasal fentanyl were 0.80 ± 0.28 and 0.64 ± 0.25 ng/ml, respectively. In phase 2, the incidence of severe agitation, highest CHEOPS scores, and heart rate in the PACU were decreased with intranasal fentanyl. There were no differences between sevoflurane and halothane in these measures and in times to hospital discharge. The incidence of postoperative vomiting, hypoxemia, and slow respiratory rates were not increased with fentanyl. ConclusionsSerum fentanyl concentrations after intranasal administration exceed the minimum effective steady state concentration for analgesia in adults. The use of intranasal fentanyl during halothane or sevoflurane anesthesia for BMT is associated with diminished postoperative agitation without an increase in vomiting, hypoxemia, or discharge times.

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).

Predicting airway risk in angioedema: Staging system based on presentation☆☆☆★

Angioedema is an immunologically mediated, anatomically limited, nonpitting edema that can lead to life-threatening airway obstruction. To predict the risk of airway compromise in angioedema, we retrospectively reviewed 93 episodes in 80 patients from 1985 to 1995. Intubation or tracheotomy was necessary in 9 (9.7%) cases. Angiotensin-converting enzyme inhibitor use in 36 cases (39%) was associated with intensive care unit (ICU) admission (P = 0.05). ICU stay correlated significantly with presentation with voice change, hoarseness, dyspnea, and rash (P < 0.05). Voice change, hoarseness, dyspnea, and stridor were present in patients requiring airway intervention (P < 0.05). On the basis of our data, we propose a staging system by which airway risk may be predicted from the anatomic site of presentation. Patients with facial rash, facial edema, lip edema (stage I), and soft palate edema (stage II) were treated as outpatients and on the hospital ward. Patients with lingual edema (stage III) usually required ICU admission. All patients with laryngeal edema (stage IV) were admitted to the ICU. Airway intervention was necessary in 7% of stage III patients and in 24% of stage IV cases. No deaths were caused by angioedema. Airway risk in angioedema may be predicted by anatomic site of presentation, allowing appropriate triage with preparation for airway intervention in selected cases.

Melanotic neuroectodermal tumor of infancy (MNTI) of the hard palate: presentation and management

OBJECTIVE To discuss the presentation and management of melanotic neuroectodermal tumor of infancy (MNTI) of the hard palate. METHOD Case presentation and literature review. CASE A 6-month-old girl presented with a slow growing, non-tender anterior oral hard palate mass. Radiologic imaging revealed a well-circumscribed cystic lesion containing teeth. After excision, histopathologic and electron microscopic evaluation revealed MNTI. No recurrence was seen at 12-month follow-up. CONCLUSIONS This case and a review of the literature reveal MNTI to be a rare, benign hard palate tumor, which may present as a smooth, firm, painless, slow-growing anterior palatal lesion. Imaging reveals a well-circumscribed cystic lesion. Complete excision should be curative. Management requires attention to the potential need for palatal reconstruction, orthodontic care and correction of secondary nasal deformities.

Chronic Pseudomonas infections of cochlear implants.

Objective: To discuss chronic, refractory Pseudomonas infections of cochlear implants and their management. Design: Retrospective case series. Setting: Two university-based cochlear implant programs. Patients: Twenty-eight-year-old (Case 1) and 4-year-old (Case 2), different devices. Interventions: Medical and surgical management. Main Outcome Measures: Clinical course. Results: Both patients had delayed presentations, 4 months and 3 years postimplantation, respectively, with fluctuating scalp edema and pain resistant to multiple courses of oral antibiotics. Infections began as localized granulation and progressed to complete encasement of both devices with rubbery, poorly vascularized tissue. In each case, two different strains of multiresistant Pseudomonas aeruginosa were cultured. Infections progressed despite local debridement and targeted antipseudomonal antibiotic coverage, and sensitive organisms continued to appear in cultures of refractory granulation tissue. Both patients underwent partial explantation, with the electrode array left in the cochlea, then received 2 to 3 more months of further medical therapy and observation and then were reimplanted successfully with new devices. Both have shown excellent performance and no sign of recurrent infection. Conclusions: Infections of cochlear implants are uncommon, and cases of successful conservative management without device explantation have been reported. However, our experience and the implanted device literature suggest that chronic Pseudomonas infections may represent a distinct clinical entity, likely to fail protracted therapy and ultimately require device removal. Fortunately, successful reimplantation is possible.

Otologic management in children with the CHARGE association

OBJECTIVES To characterize otologic management of two patient groups, those with the CHARGE association and those not strictly labeled as CHARGE but with several features of the disorder (CHARGE-like), in order to determine: (1) the clinical validity and utility of managing CHARGE-like children in a similar manner to patients with the strictly defined CHARGE association, (2) the progression and prognosis of hearing loss and (3) the identification of factors that may predict the degree of hearing loss. DESIGN Case series. SETTING Tertiary care urban childrens hospital. PATIENTS 37 children, 22 in the CHARGE group and 15 in the CHARGE-like group. INTERVENTIONS Otorhinolaryngologic and audiologic management. MAIN OUTCOME MEASURES Otorhinolaryngologic and audiologic evaluation. RESULTS All patients required otologic and/or audiologic care. Bilateral hearing loss was found in 32 patients (86%) and unilateral hearing loss in five patients (14%) when hearing was assessed in the absence of otitis media. Among the 32 patients with bilateral hearing loss, 31 (97%) were able to be fit with useful hearing aids. External ear anomalies were present in 25/37 (68%) patients, and middle ear and ossicular anomalies were identified in four cases (4/37, 11%), 36/37 (97%) patients required surgical management of otitis media. Three patients (3/37, 8%) exhibited radiographic evidence of inner ear deformity. Facial nerve dysfunction was noted in the records of 14/37 (38%) patients. No statistically significant difference was found when CHARGE and CHARGE-like patients were compared for degree of hearing loss (P = 0.5964), type of hearing loss (P = 0.2657), worsening of hearing level (P = 0.7908), or anomalies of the external ear (P = 0.6921), ossicles (P = 0.7908), inner ear (P = 0.7908) or facial nerve (P = 0.6409). Patients with external ear anomalies did not exhibit statistically different degrees (P = 0.3125) or types (P = 0.1515) of hearing loss from patients without auricular anomalies. The presence of facial nerve anomaly correlated significantly (P = 0.0021) with profound hearing loss. CONCLUSIONS Children who are CHARGE-like may be may be considered equivalent in terms of otologic and audiologic management to children strictly defined as CHARGE patients. These children all require otologic care due to the high prevalence of middle ear disease and the underlying permanent hearing loss that is both stable and aidable. The degree of hearing loss cannot be predicted by external ear morphology, but may be predicted by facial nerve palsy.

Isolated endobronchial atypical mycobacterium in a child: a case report and review of the literature.

Isolated endobronchial lesions caused by Mycobacterium avium are rare, especially in the pediatric population. We share the case of a 10-month-old boy who, after 1 week of cough and low-grade fever, had a radiographic examination showing endobronchial obstruction. At bronchoscopy, a granuloma of the left bronchus intermedius was found. Histopathologic examination revealed necrotizing granulomatous inflammation. Kinyoun Acid Fast stain revealed acid fast bacilli. Cultures were positive for M. avium. Current treatment options and controversies are presented. The roles of antibiotics and steroids in preventing progressive disease are discussed. The need for serial bronchoscopy and the potential benefits of surgical resection are discussed. Isolated endobronchial M. avium infection remains a rare and challenging problem. The paucity of clinical experience, and variation in patient presentation, obligates a high index of suspicion, and frequent follow-up with bronchoscopic examination and pulmonary assessment, for the child diagnosed with isolated endobronchial atypical mycobacterial infection.

Effects of Clarion electrode design on mapping levels in children.

The design of the placement of the Clarion cochlear implants intracochlear electrode array has undergone 2 revisions since its introduction, each to improve modiolar proximity. Stimulation with modiolar proximity may reduce current requirements for threshold levels and most comfortable levels of stimulation. This study analyzed the effects of electrode design on programming levels for deaf children implanted with the 3 cochlear implant designs and followed at The Childrens Hospital of Philadelphia. Psychophysical data were reported if measurements were taken approximately 3 months after initial activation, and programming parameters included nonsequential monopolar stimulation of 75-μs-per-phase biphasic pulses presented at 813 Hz per electrode. The threshold level and most comfortable programming level were measured by standard clinical techniques appropriate for children. The results indicate that the 2 electrode placement revisions have each significantly reduced threshold levels and most comfortable stimulation levels. These results are discussed in the context of device aesthetics, safety, and function.

Resource analysis of tonsillectomy in children.

To analyze variables that affect time and cost parameters of pediatric adenotonsillectomy.

Risk Factors Associated With Postoperative Tympanostomy Tube Obstruction

IMPORTANCE Myringotomy and tympanostomy tube placement for chronic otitis media with effusion is the most common reason for a child to undergo anesthesia in the United States. Postoperative tube obstruction occurs in 1.4% to 36.0% of cases and remains a challenge in achieving middle ear ventilation. OBJECTIVE To identify risk factors associated with tube obstruction. DESIGN, SETTING, AND PARTICIPANTS Retrospective medical record review of 248 patients, mean age 2.54 years, seen between March 2007 and June 2011 in a tertiary care pediatric hospital. INTERVENTIONS Tympanostomy tube placement and postoperative otic drop therapy. MAIN OUTCOMES AND MEASURES Tube patency at postoperative visit, number of tube removals and revisions, age, sex, body mass index (BMI), middle ear fluid type at time of surgery, and time between surgery and first postoperative visit were examined. Type of surgery (tympanostomy tube placement alone, adenoidectomy + tympanostomy tube placement, tympanostomy tube placement + adenoidectomy + tonsillectomy) and its effect on tube patency were also reviewed. RESULTS At first follow-up, 10.6% of patients had occlusion of one or both tubes. No significant association was found between tube patency and a patients BMI percentile, sex, or procedure type. Patients with no middle ear fluid were more likely to have patent tubes than those who had serous fluid (odds ratio [OR], 3.5; 95% CI, 1.2-10.6; P = .02). A significant inverse correlation was found between patency and time between surgery and follow-up in that patients who had longer follow-up after surgery were less likely to have patent tubes (OR per day of follow-up delay, 0.990; 95% CI, 0.981-0.999; P = .01). CONCLUSIONS AND RELEVANCE Tympanostomy tube obstruction was seen in 10.6% of patients. Serous fluid and increased time to postoperative visit were statistically significant indicators for tube occlusion.