Yoram Stern

Partial Cricotracheal Resection with Primary Anastomosis in the Pediatric Age Group

The traditional approach to severe subglottic stenosis (SGS) in the pediatric age group is laryngotracheal reconstruction (LTR). This approach may be complex and multistaged, with variable and unpredictable success rates in the individual patient. Excellent results have been reported in adults who had severe SGS and underwent partial resection of the cricoid and primary thyrotracheal anastomosis. This procedure has not been widely reported in infants and children. We report our experience with this procedure in 16 pediatric patients with grade III or IV SGS. Eleven patients had multiple previous LTR operations. The preoperative evaluation, surgical techniques, postoperative care, complications, and final results are described and discussed. Fourteen patients were decannulated after the procedure, 1 patient needed a second open procedure prior to decannulation, and 1 patient with concomitant bronchopulmonary dysplasia remains cannulated, for an overall 94% decannulation rate. Fourteen patients have no limitation of respiration, and 1 patient has moderate exercise intolerance. The results of this series suggest that partial cricotracheal resection with primary anastomosis is a relatively safe and effective procedure for pediatric patients with severe SGS.

Role of laryngoscopy, dual pH probe monitoring, and laryngeal mucosal biopsy in the diagnosis of pharyngoesophageal reflux

There is no standard for determining significant pharyngoesophageal reflux. This prospective blind comparison study compared dual pH probe studies, direct laryngoscopy, and mucosal biopsy in children without symptoms of gastroesophageal reflux who underwent airway evaluation. Significant reflux to the lower esophageal probe did not correlate with statistical significance with reflux to the upper probe. In this group of asymptomatic patients, a positive lower pH probe finding did not correlate with upper or lower esophageal mucosal inflammation. Eosinophilia in the esophageal mucosa is diagnostic of gastroesophageal reflux disease, and was seen in 5 of the laryngeal biopsies. A weak correlation was seen between positive findings at laryngoscopy and positive posterior cricoid biopsy in this group. There may be no consistent way to predict significant pharyngoesophageal reflux in asymptomatic patients. Single-probe pH testing will not predict significant pharyngoesophageal reflux with mucosal changes. Laryngoscopy and upper pH probe findings only weakly correlate with significant histologic findings. Laryngeal and posterior cricoid biopsy may be the only sensitive test for mucosal injury. Clinical trials of empiric antireflux therapy should be used to determine whether the laryngeal changes seen in these patients are reversible.

Vocal cord palsy: possible late complication of radiotherapy for head and neck cancer.

Cranial nerve palsies are uncommon complications of radiotherapy for head and neck cancer. A review of the literature reveals that cranial nerve damage after radiotherapy has been reported for the optic, oculomotor, trigeminal, abducens, cochlear, vagus, spinal accessory, and hypoglossal nerves. The hypoglossal nerve appears to be the most commonly affected, and the recurrent laryngeal nerve is seldom involved. The case histories of three patients who developed vocal cord palsy from 21 to 34 years after a course of curative or postoperative radiotherapy for carcinoma of the head and neck are presented. Two patients had bilateral palsy, and in the third patient, bilateral damage cannot be excluded. Physical examination and radiographic investigations on admission and on follow-up did not demonstrate any evidence of tumor recurrence, cervical or distant metastases, or second primary tumors. The distinction between irradiation-induced palsy and that due to malignancies is emphasized.

Computerized Scoring System for the Diagnosis of Foreign Body Aspiration in Children

Objectives: Foreign body aspiration (FBA) is a life-threatening event in children. The gold standard for diagnosis is bronchoscopy, but there is no consensus regarding indications for the procedure. The aim of this study was to formulate a predictive model for assessing the probability of FBA in suspected cases as an aid in the decision to perform diagnostic bronchoscopy. Methods: The files of 150 patients who underwent bronchoscopy for suspected FBA at our center between 1996 and 2004 were reviewed for medical history, physical examination, and radiologic studies. The findings were analyzed by logistic regression. Results: Using the file data, we formulated a predictive model wherein each parameter received a numeric coefficient representing its significance in evaluating suspected FBA. The most significant parameters were age 10 to 24 months, foreign body in the childs mouth and severe respiratory complaints during the choking episode, hypoxemia, dyspnea or stridor following the acute event, unilateral signs on lung auscultation, abnormal tracheal radiogram, unilateral infiltrate or atelectasis, and local hyperinflation or obstructive emphysema on chest radiogram. Conclusions: In our predictive model, every case of suspected FBA can be assigned a score based on the specific parameters present, which is then entered into a probability formula to determine the likelihood of a positive diagnosis. This model may serve as a useful tool for deciding on the use of bronchoscopy in all children with suspected FBA.

Margins of Partial Cricotracheal Resection in Children

Objective: To review the surgical margins of partial cricotracheal resection in our series of patients. This includes specific anatomic detail as to each superior and inferior resection margin. To apply this information and access the utility of partial cricotracheal resection for the treatment of subglottic stenosis.

Spontaneous Respiration Anesthesia for Respiratory Papillomatosis

Several anesthetic techniques for microlaryngeal laser surgery in children have been advocated. The objective of this study was to evaluate the operative conditions and safety of the spontaneous respiration anesthesia technique for carbon dioxide laser surgery in children with recurrent respiratory papillomatosis (RRP). The anesthetic and operative records of 60 pediatric patients with RRP who underwent microlaryngeal laser surgeries between 1991 and 1997 were reviewed. Papilloma location, severity of involvement, oxygen saturation, airway stability, need for intubation, duration of procedure, and complications were recorded. The patients underwent 744 surgical procedures. Two hundred two procedures were randomly studied (statistical power ≥ 80%). The supraglottis and glottis were most commonly involved. Most of the papillomas were graded as moderate or severe disease. Complications occurred in 11 procedures. The surgical procedure was completed in all cases. No variable had predictive value regarding the outcome. Spontaneous respiration anesthesia is an efficient and relatively safe technique for microlaryngeal laser surgery in children with RRP.

Malignant external otitis in nondiabetic patients

The purpose of this study is to point out that contrary to traditional belief, there is a small but significant group of nondiabetic patients with malignant external otitis. Thirty patients with a diagnosis of malignant external otitis were treated and followed up at the Department of Otolaryngology—Head and Neck Surgery, Beilinson Medical Center, between 1987 and 1991. Nine of these patients did not have clinical or laboratory evidence of diabetes. This study analyzes this group and concludes that the diagnosis of malignant external otitis should be considered by the treating physician in nondiabetic patients presenting with a Pseudomonas aeruginosa infection of the external ear canal. Severe pain and edematous closure of the canal, together with typical granulation tissue and failure to respond to medical treatment, are specific characteristics of this group.

Management of Persistent Tracheocutaneous Fistula in the Pediatric Age Group

Different surgical methods have been advocated for closure of persistent tracheocutaneous fistula (TCF) in children. The objective of this study was to compare different methods of repair and postoperative care that were used for management of TCF in children. The charts of 98 children with persistent TCF who were surgically managed in our department between January 1990 and April 1997 were reviewed retrospectively. Excision of the fistulous tract and healing by secondary intention was employed in 18 patients. Eighty patients were managed by tract excision followed by primary closure. Sixty-three patients remained intubated for 18 to 24 hours postoperatively, while 17 patients were extubated in the recovery room. One patient had a large tracheal granuloma on follow-up endoscopy. Three patients needed a second procedure. No significant correlation was found between the method of surgical repair or the length of postoperative intubation and outcome. In our experience, TCF repair, either by primary closure or secondary intention, is a relatively safe and effective procedure in the pediatric age group. Preoperative evaluation and possible indications for selecting the method of repair are discussed.

Potential role of growth factors and extracellular matrix in wound healing after laryngotracheal reconstruction

Laryngotracheal reconstruction (LTR) has been used for more than 20 years to treat infants and children with subglottic stenosis. Results after pediatric LTR have been satisfactory; however, approximately 10% of children have recurrent airway narrowing after LTR. The purpose of our study was to determine whether a correlation existed between specific growth factors and extracellular matrix in patients with adequate wound healing capability as compared with patients with poor wound healing capability. Histologic sections from 27 patients who underwent LTR were cut, and immunohistochemical staining was performed for transforming growth factor-β, platelet-derived growth factor, fibronectin, tenascin, transforming growth factor-α, and vascular endothelial growth factor. Results showed that patients with adequate wound healing capability had a positive correlation with vasculature fibronectin, vasculature tenascin, and stromal fibronectin. Patients with poor wound healing capability had a positive correlation with stromal vascular endothelial growth factor.

Expression of Ki-67, tumor suppressor proteins, growth factor, and growth factor receptor in juvenile respiratory papillomatosis: Ki-67 and p53 as predictors of aggressive disease.

The enhanced proliferation of epithelial cells is a typical feature of respiratory papilloma. The mechanism or mechanisms leading to abnormal epithelial proliferation remain unclear. Overexpression of growth factors and their receptors and inactivation of tumor-suppressor proteins are known to cause cell transformation and proliferation. The objectives of this study were to evaluate the expression of these factors in juvenile respiratory papillomas with correlation to cellular proliferation activity, and to determine whether such expression is associated with the clinical course of the disease. The expression of transforming growth factor-alpha, epidermal growth factor receptor, p53 protein, retinoblastoma proteins and Ki-67 was quantified by immunohistochemistry in paraffin-embedded biopsy specimens taken at the initial surgical excision from children in whom respiratory papillomatosis was diagnosed. Clinical information regarding the number of disease sites, tracheobronchial spread, malignant transformation, and frequency of recurrences was reviewed. Thirty-five specimens were suitable for immunohistochemical evaluation. Ki-67 expression was significantly higher in patients with multiple sites of disease and frequent recurrences. High p53 expression was significantly associated with malignant transformation. We concluded that Ki-67 and p53 expression may be predictive of the clinical course in children with respiratory papillomatosis.