Walter M. Belenky

Quantitative Impact of Pediatric Sinus Surgery on Facial Growth

Objective/Hypothesis To quantitatively evaluate the long‐term impact of sinus surgery on paranasal sinus development in the pediatric patient.

The incidence of gastroesophageal reflux in recurrent croup.

The incidence of gastroesophageal reflux in recurrent croup was evaluated by a retrospective analysis of patients at the Childrens Hospital of Michigan from 1986 to 1991. Sixty-six patients required hospitalization for recurrent croup during this 6-year period. Of the patients evaluated, 47% with recurrent croup had an additional diagnosis established of gastroesophageal reflux. In patients with three or more hospitalizations for croup, there was a 63% association with gastroesophageal reflux. Compared to all patients with recurrent croup, the patients with gastroesophageal reflux tended to be younger and had a shorter interval between episodes of croup. A prospective series of six cases of recurrent croup was seen in consultation. The diagnostic procedures involving lipid-laden macrophage quantitation, endoscopy, and gastroesophageal reflux scintiscans were utilized to establish the diagnosis of gastroesophageal reflux with tracheal aspiration. The results of these studies and the follow-up is discussed.

Pediatric tracheotomy: A review of technique

It is well documented that the morbidity, mortality, and complication rates for pediatric tracheotomy are significantly higher than for adult tracheotomy. IF4 With trends toward performing pediatric tracheotomies in an increasingly premature population with less emergent indications, it is essential that techniques be reviewed for any factors that may reduce complications. At Children’s Hospital of Michigan, the same tracheotomy technique has been used since 1985. The technique and experience with 141 patients are reviewed.

An analysis of the inferior based tracheal flap for pediatric tracheotomy.

In the past, various tracheotomy incisions have been used at the Childrens Hospital of Michigan with the occurrence of complications related to accidental decannulation and immediate recannulation. Since that time the inferior based tracheal cartilage flap has been used to minimize early complications. A retrospective study of 126 pediatric tracheotomies performed at the Childrens Hospital of Michigan from June 1986 to January 1991 was reviewed. Only tracheotomies performed by a staff otolaryngologist utilizing the inferior based tracheal cartilage flaps were reviewed. This study includes patients with a 6 month to 5 year follow up. The early complication rate was 4%, while the late was 50%. Stomal granulation tissue was comparatively increased in this series of patients but did not hinder decannulation. We consider the use of the inferior based tracheal cartilage flap in the pediatric population a safe and effective technique without increasing the morbidity of long-term tracheotomy.

A simple surgical technique using the plasma hook for correcting acquired nasopharyngeal stenosis.

INTRODUCTION Obstructive sleep apnea related to postsurgical scarring does not usually respond to continuous positive airway pressure therapies. In cases with mild scarring, some success has been observed with triamcinolone acetonide injections, but essentially, the only curative treatments for acquired nasopharyngeal stenosis (NPS) are surgical. All of these procedures are highly individualized and can be complex to perform; they are also associated with a significant recurrence rate. We propose a new, simple surgical approach for treating acquired NPS using the plasma radiofrequency-based (coblation) Plasma Hook (ArthroCare Corp., Sunnyvale, CA). Similar devices have been used successfully in otolaryngology for adenotonsillectomy, soft palate reduction, and inferior turbinate reduction. All three of our patients had severe NPS, demonstrating a classic clinical history consistent with problematic obstructive symptoms, including chronic mouth breathing, excessively loud snoring, and apneic episodes.

Nasal Packing with Strips of Cured Pork as Treatment for Uncontrollable Epistaxis in a Patient with Glanzmann Thrombasthenia

Objectives: Glanzmann thrombasthenia is a rare disorder of platelet function that may result in life-threatening hemorrhage, particularly from the nasal vaults. Various medical therapies (such as recombinant factor VII, antifibrinolytic agents, and blood transfusions) and surgical therapies (such as nasal packing, electrocautery, laser coagulation, septoplasty, and embolization) have been described with various degrees of success. Methods: We present a unique case report of a 4-year-old child with known Glanzmann thrombasthenia and two separate episodes of life-threatening epistaxis that were treated successfully by nasal packing with strips of cured pork because of special circumstances. Results: Cured salted pork crafted as a nasal tampon and packed within the nasal vaults successfully stopped nasal hemorrhage promptly, effectively, and without sequelae. In both applications, the patient had complete cessation of nasal bleeding within 24 hours, and was discharged within 72 hours after treatment. Conclusions: To our knowledge, this represents the first description of nasal packing with strips of cured pork for treatment of life-threatening hemorrhage in a patient with Glanzmann thrombasthenia.

Sequelae of Rapid Growing Mycobacteria Otomastoiditis in a Child

ycobacterium fortuitum and Mycobacterium peregrinum are nontuberculous mycobacteria (NTM). They belong to a subset of NTM known as rapid-growing mycobacteria (RGM), previously designated as Runyon class IV. Rapid-growing mycobacteria are saprophytic, ubiquitous in nature, and generally considered non-pathogenic. Several species of RGM, including M fortuitum and M peregrinum, are potentially pathogenic in humans. Mycobacterium fortuitum infections are typically cutaneous, occurring when the skin barrier has been breached. No pattern of infection by M peregrinum has been established. Herein, we discuss a pediatric case of otomastoiditis that progressed to petrous apicitis, intracranial empyema, and meningitis despite appropriate medical and surgical therapy. Initial laboratory identification in this case listed M fortuitum with a follow-up laboratory identification by the Centers for Disease Control and Prevention (CDC) listing the M fortuitum/M peregrinum group. Because the CDC did not classify to the species level we cannot be certain that this case was not caused by M peregrinum, which phylogenetically is very closely related to M fortuitum. It is a member of the M fortuitum group and was considered a biovariant of M fortuitum until 1992. There are no previous reports of M peregrinum causing an otologic infection in the literature. To our knowledge, only 2 cases of mastoiditis and 1 case of a subdural empyema in the pediatric population caused by M fortuitum are documented in the literature. Considering the aggressive nature and serious otologic and intracranial consequences of these rapid growing mycobacteria, it is important to document this in the literature.

Respiratory Support in Pediatric Surgery

This section covers five situations in surgical respiratory care that the busy surgeon may encounter only a few times each year. The authors are experts on the modern understanding of these conditions. The practice of pediatric surgery and neonatal intensive care is approaching the point at which a surgeon will deal with neonates all the time or not at all. Nonetheless, many of the respiratory care techniques that are currently routine procedures in adults came directly from the neonatal intensive care unit, so that every reader serves to gain by careful study of the clear descriptions by Philippart, Sarnaik, and Belenky. Likewise, patients with smoke inhalation and burns are usually referred to burn care centers, which are familiar with Moylan’s work. However, there are important lessons in his article for anyone who deals with disorders of the airway. By contrast, every surgeon lives with major trauma, aspiration, pulmonary embolism, and cardiac failure. Every reader will remember the last patient seen with these problems and anticipate the next with concern. These solid practical reviews will make that experience easier.

FESS versus Balloon Sinuplasty as Long-term Treatment for Pediatric Chronic Rhinosinusitis: A 2-Year Postoperative Analysis

Objectives: Chronic rhinosinusitis (CRS) is a common pediatric disease. For those affected, functional endoscopic sinus surgery (FESS) and balloon sinuplasty are surgical options for long-term relief. Our objective was to examine the efficacy of these treatments in overall symptom improvement >2-years post-operatively. Methods: A 2-group prospective blinded survey was conducted with 10 pediatric patients who underwent FESS and 11 treated with balloon sinuplasty from 2007-2010. All had previously been reviewed in a 6-month post-operative comparative study and were diagnosed with CRS through CT scans and symptomatology. At >2-years post-surgery, symptoms and medications were compared using 1-tailed independent t-tests. Results: Mean age at time of procedure was 9.9 years (range 4.1 – 16.0); 65% were male. Both groups had similar Lund-Mackay scores (FESS: Mean = 12.63; Balloon: Mean = 12.27) and overall symptoms prior to procedure (FESS: Mean = 4.78, SD = 2.73; Balloon: Mean = 4.60, SD = 1.26). Greater than 2-year post-operative follow-up surveys demonstrated a statistically significant long-term decrease in symptoms for balloon and FESS treatments (t = 4.34, P = <0.001). Balloon demonstrated a significant decrease in individual sinus symptoms (t=4.80, P = 0.001) when compared to FESS. Overall, a reduction in antibiotics and topical nasal spray was identified in both groups. Conclusions: FESS and balloon are both effective long-term options in the treatment of pediatric CRS. Both procedures can be performed with minimal short- and long-term complications. At >2-years post-sinus surgery, individuals who underwent balloon sinuplasty reported a greater decrease in overall sinus complaints when compared to FESS.

Functional Endoscopic Sinus Surgery (FESS) Alone vs FESS and Balloon Sinuplasty: A Comparative Outcome Analysis in a Pediatric Population with Chronic Rhinosinusitis

Objective: Chronic rhinosinusitis (CRS) is a common disease afflicting children. For those affected, conventional FESS and balloon sinuplasty are surgical options for those refractory to medical management. Our objective was to evaluate whether the addition of balloon sinuplasty would improve the treatment outcome in children who undergo FESS for CRS. Method: A 2-group, retrospective blinded chart review comparing 11 pediatric patients who underwent balloon sinuplasty to 15 undergoing FESS from 2007 to 2010 at the Detroit Medical Center. Preoperative CT scans as well as pre- and postoperative sinus symptoms and medications were compared. All group data were compared using 1-tailed independent t tests. Results: Mean age at the time of procedure was 8.74 (SD = 4.2 years; range, 2-19 years). Both groups had similar presurgical Lund-Mackay CT CRS scores (FESS: mean = 9.33, SD = 4.7; Balloon: mean = 10.5, t = -.61, p = .55). Analyses identified posttreatment differences in symptom reduction and needed intervention between the 2 groups. Postoperatively patients who underwent balloon sinuplasty reported fewer headaches (t = 2.51, P = .01), less postnasal drip (t = 1.88, P = .04), and reduced sinus congestion (t = 2.05, P = .03). A comparison of the amount of topical steroidal/saline and antibiotic use identified a reduction in the amount of topicals used in children who received balloon treatment (t = 2.66, P = .007) and a reduction of antibiotic use (t = 1.79, P = .04). Conclusion: Balloon sinuplasty directed at the frontal and maxillary sinuses resulted in better outcomes than those with traditional FESS techniques. Balloon sinuplasty patients had less sinus symptoms, required less antibiotics, and required less topical nasal steroids postoperatively. Preservation of the native anatomy in balloon sinuplasty may play a role in these findings.