Acute epiglottitis - 25 years' experience in management, The Montreal Children's Hospital

Acute epiglottitis is the most treacherous inflammatory process that can affect the respiratory tract. It can be a cause of sudden death in children. The clinical features of this entity are reviewed and our experience with its management at The Montreal Children's Hospital during the past 25 years is presented. The establishment of a "secure" airway by tracheostomy and in recent years, by nasotracheal intubation has decreased to practically nil the mortality of children who arrive alive at this hospital with acute epiglottitis.

Acute epiglottitis in children - the morbidity of management by elective tracheostomy

Acute epiglottitis is a pediatric airway emergency. No deaths occurred in 61 cases treated by elective tracheostomy at The Montreal Children's Hospital between 1966 and 1974. Seven patients (11.5%) showed evidence of aspiration pneumonia prior to tracheostomy and seven others developed pulmonary atelectasis in the first 24 hours following tracheostomy but only 9.8% of the total had a complication which continued in evidence 24 hours following surgery. A further 19.5% developed further complications unrelated to this earlier morbidity prior to discharge from hospital. The mean cannulation time was seven days and the mean hospital stay was nine days. Of these patients, 32 (52.4%) were seen between a year and seven-and-a-half years later. Twenty were completely asymptomatic with a small, neat scar. Twelve patients had experienced some upper respiratory problem or minor problems related to the tracheostomy incision.

Endoscopic differentiation of epiglottic entrapment and elongation of the soft palate: including surgical correction of epiglottic entrapment

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Mycophenolic acid for psoriasis

Mycophenolic acid is an antimetabolite used experimentally for the treatment of psoriasis. Thirty-eight patients were treated with mycophenolic acid. A double-blind, placebo-controlled study demonstrated the efficacy of mycophenolic acid (P less than .01). A long-term safety study showed the occurrence of hematologic abnormalities, viral infections, and carcinoma. The position of mycophenolic acid in the therapeutic treatment of psoriasis must await the results of a multicenter cooperative study.

[Primary coblat therapy and secondary surgery for supra-glottal carcinoma (author's transl)]

This statistical study concerned 218 carcinomas of the laryngeal vestibule and margin treated at the Curie Foundation between 1958 and 1967, by primary cobalt therapy followed when necessary by secondary total laryngectomy. It shows that cobalt therapy alone gives excellent results in early forms (T1 and T2) even in the presence of N1 or N2 nodes. By contrast, the proportion of cures is much lower in T3 and T4 forms. Secondary total laryngectomy was used in only 25 cases out of 127 failures. The postoperative course was often difficult (4 fatal complications and 3 pharyngostomies) but 7 of the patients were cured at 5 years. The use of a surgical technique with minimal trauma and in particular respecting the integrity of the carotid gutters has been associated, in a more recent series, with a notable improvement in the results obtained (one cure out of 2 at 3 years).

Pharyngeal colonization with Haemophilus influenzae type b: a longitudinal study of families with a child with meningitis or epiglottitis due to H. influenzae type b

A longitudinal study of pharyngeal colonization with Haemophilus influenzae type b included 264 members of families that had a child with meningitis or epiglottitis due to this organism. It was found that (1) 52 of 67 such families contained at least one carrier of H. influenzae type b, who was usually a sibling; (2) H. influenzae type b spread slowly in 39 families colonized continuously during a six-month period, with only eight of 19 uncolonized siblings acquiring the organism during that time; (3) 18 of 30 initially colonized families contained one or more carriers after 12 months, including 30% of initially colonized siblings; (4) the highest carrier rate of H. influenzae type b occurred in recovered patients, 80% of whom were colonized after hospital discharge; (5) titers of antibody in serum were higher in colonized than in uncolonized individuals (P less than 0.001); (6) levels of antibody in colonized children were lower in those younger than two years than in older children (P less than 0.001); and (7) prolonged or heavy colonization with H. influenzae type b was not associated with unusually high titers of antibody.

Pulmonary edema associated with croup and epiglottitis

Two children, ages 9 and 2 1/2 years, with clinical diagnoses of laryngotracheitis (croup) and epiglottis, respectively, developed florid pulmonary edema without evidence of cardiac enlargement. Both children responded to vigorous therapy, which included endotracheal intubation, mechanical ventilation with high oxygen concentrations and positive end expiratory pressure, diuretics, and support of the intravascular volume with colloid infusions. Swan-Ganz catheterization was performed in the child with epiglottitis to elucidate any hemodynamic malfunction. Pulmonary artery occluded pressure was found to be normal. We postulate that pulmonary edema may be the result of any of three major physiologic alterations: alveolar hypoxia, increased alveolar-capillary transmural pressure gradient, and a catechol-mediated shift of blood volume from the systemic to the pulmonary circulation. These alterations acting in concert would increase the volume of blood presented to the pulmonary capillaries, the pore size in those capillaries, and the hydrostatic pressure gradient promoting transduation. Failure of pulmonary lymphatics to effectively clear this fluid would result in pulmonary edema. Although pulmonary edema associated with acute upper airway obstruction is unusual, physicians should be altered to its possible appearance and the need for early and vigorous therapeutic measures.