Pectus excavatum in children with laryngomalacia

Evaluation of the risk factors for postoperative pectus excavatum and scoliosis in cystic lung disease

PURPOSE

To analyze the frequency and predictive factors of the development of postoperative pectus excavatum and scoliosis in children who underwent surgery for cystic lung disease.

METHODS

This study examined patients who underwent surgery for cystic lung disease (open and thoracoscopic) between July 2000 and December 2018 with a > 3-year follow-up period. Lesion size, surgical outcomes, and subsequent musculoskeletal complications were compared between the open surgery and thoracoscopic surgery groups. Univariate and multivariate analyses were performed to identify predictive factors.

RESULTS

Overall, 90 patients (19 and 71 patients in the open and thoracoscopic groups, respectively) were included in this study. There was no significant difference in the incidence of pectus excavatum or scoliosis between open and thoracoscopic surgery; however, Haller's index and Cobb angle were significantly higher in the open surgery group. In the univariate analysis, neonatal surgery and lesion size were substantial predictors of musculoskeletal malformations.

CONCLUSION

Postoperative musculoskeletal deformities emerge after surgical treatment for cystic lung disease, with thoracoscopic surgery showing advantages in selected dimensions. Neonatal surgery and lesion size are pivotal prognostic factors for musculoskeletal complications. Further corroborative multicenter studies are imperative to substantiate these findings and foster enhanced patient outcomes.

Co-existing obstructive sleep apnea reduces Nuss surgery efficacy in pectus excavatum

Nuss surgery is effective in correcting pectus excavatum (PE), with a recurrence rate of 1.2–27%. Re-do surgery is successful but still has a 6% failure rate. Patients with obstructive sleep apnea (OSA) experience repetitive PE-associated sternal depression during sleep. As the prevalence of OSA among PE patients is higher than the average, co-existing OSA in PE patients might negatively affect the efficacy of Nuss surgery. This study aimed to evaluate the impact of co-existing OSA on Nuss surgery in patients with PE. In total, 20 adult patients with PE only and 9 patients with PE and OSA were analyzed. Polysomnography was performed before Nuss surgery to evaluate OSA. Sternovertebral distance (SVD) and radiographic Haller index (RHI) were recorded before surgery and at 3, 6, and 24 months postoperatively. The results showed that percentage changes in SVD in patients with PE only at 3, 6, and 24 months postoperatively were significantly increased compared with those in the patients with PE and OSA (31.1% vs. 14.1% at 3 months; 37.5% vs. 21.4% at 6 months; 42.5% vs. 19.2% at 24 months). Meanwhile, percentage changes in RHI were significantly lower in patients with PE alone than in the patients with PE and OSA (-22.9% vs. -9.3% at 3 months; -27.9% vs. -18.7% at 6 months; -30.6% vs. -16.7% at 24 months). This study showed that co-existing OSA might reduce the efficacy of Nuss surgery for patients with PE. We recommend that patients with PE should be evaluated and treated for OSA before surgery to prevent surgical failure after bar removal.

[Analysis of clinical characteristics and surgical efficiency of severe laryngomalacia in children]

Objective:To analyze the clinical characteristics and factors affecting surgical efficiency in children with severe laryngomalacia. Methods:Retrospectively collect medical records of children with severe laryngomalacia who underwent supraglottoplasty in Children's Hospital of Chongqing Medical University between January 1, 2015 and May 1, 2019. And analyze the clinical characteristics, the improvement of main symptoms at different time points, and the influence factors on the surgical efficiency. Results:According to the anatomical classification of severe laryngomalacia, type Ⅳ accounted for the highest proportion（66.1%）, and type Ⅰ was the lowest（3.6%）. All children had stridor and dyspnea, 82.1% cases presented feeding difficulties, and 67.9% cases presented failure to thrive. The proportion of children with medical comorbidities was 62.5%, of which congenital heart disease had the highest incidence（39.3%） The surgical efficiency of severe laryngomalacia without comorbidities was 100.0%, with one type of comorbidity was 96.0%, with multiple comorbidities was 30.0%（P<0.01）. Stridor, dyspnea, feeding difficulties were significantly improved at one month after surgery in most cases. In the group of surgical age less than 3 months, the surgical efficiency were 61.5%, 61.5% and 69.2% at 1, 3, 6 months after surgery, respectively; the surgical efficiency of children without comorbidities were 100.0%（P>0.05） at 1, 3 ,6 months after surgery. In the group of surgical age older than 3 months, the surgical efficiency of children were 100.0% at 1, 3, 6 months after surgery regardless with or without comorbidities. The surgical failure rate and reoperation rate in children without comorbidities was 0, but in the children with comorbidities were 22.9%（P<0.05） and 20.0%（P<0.05）, respectively. The surgical failure rate and reoperation rate in children with multiple comorbidities was significantly higher than children with only one comorbidity（70.0% vs. 4.0%; 60.0% vs. 4.0%, P<0.01）. The overall operation success rate was 85.7% in severe laryngomalacia children in our hospital. Conclusion:Most children with severe laryngomalacia are associated with multiple medical comorbidities, and with more complex anatomical types. Supraglottoplasty can effectively improve the symptoms in most children with severe laryngomalacia. The existence of multiple comorbidities is the main cause of surgical failure.

Prevalence of comorbidities in a surgical pectus excavatum population

Background

Pectus excavatum is the most common chest wall deformity and is associated to various connective tissue, cardiopulmonary, and skeletal abnormalities. Several conditions and syndromes have been associated to pectus excavatum, although the overall health implications of the pectus excavatum phenotype are unclear. Therefore, in this study we aimed to examine the health implications of the pectus excavatum phenotype by assessing all comorbidities and previous medical conditions in a cohort of patients undergoing pectus excavatum surgery.

Methods

This single-centre retrospective prevalence study included 1,046 patients undergoing minimal invasive repair of pectus excavatum from 2001 to 2012. Hospital medical charts were assessed and comorbidities and previous medical conditions were registered systematically and categorized according to the affected organ system.

Results

In our study population of 1,046 patients, we registered 623 conditions. The median age was 17 years and the majority of patients (56%) had no previous or present conditions. Notable prevalence of asthma (8.8%), allergies (12.3%), previous hernia surgery (5.2%), and psychiatric conditions (4.9%) were found.

Conclusions

The majority of patients undergoing pectus excavatum surgery have no comorbidities or previous medical conditions. It seems that this patient category is comparable to the background population in this regard and our findings do not support screening this patient category for associated conditions.

Detection of Pepsin in Oral Secretions of Infants with and without Laryngomalacia

Objectives:

Laryngomalacia is a common cause of stridor in infants and is associated with laryngopharyngeal reflux (LPR). Although pepsin in operative supraglottic lavage specimens is associated with severe laryngomalacia, detection of pepsin in oral secretions has not been demonstrated in an outpatient setting.

Methods:

Children <2 years old with laryngomalacia diagnosed by flexible laryngoscopy and children without stridor were selected. Oral secretion samples were obtained in clinic from all subjects. Pepsin, IL-1β, and IL-8 enzyme-linked immunosorbent assays were performed to determine presence of LPR.

Results:

Sixteen laryngomalacia and sixteen controls were enrolled. Pepsin was detected more frequently in oral secretions of patients with laryngomalacia (13/16) than in controls (2/16; P < .001). Four patients with laryngomalacia developed symptoms requiring supraglottoplasty. Presence and level of salivary pepsin was not significantly associated with need for surgical management, nor were the levels or presence of IL-1β or IL-8 significantly associated with presence or level of pepsin, diagnosis of laryngomalacia, or need for operative management.

Conclusion:

Pepsin in saliva appears to be associated with laryngomalacia, suggesting a role for salivary pepsin as a noninvasive marker of LPR in patients with laryngomalacia. Future studies will determine the utility of this test in laryngomalacia.

Disorders of the Chest Wall: Clinical Manifestations

Chest wall disorders represent deformities and/or injuries that alter the rib cage geometry and result in pulmonary restriction, increased work of breathing, exercise limitations, and cosmotic concerns. These disorders are congenital or acquired and affect all ages. Disorders affecting the spine (kyphoscoliosis, ankylosing spondylitis), ribs (flail chest), and sternum (pectus excavatum) are discussed in this article, with emphasis on clinical presentations, pulmonary function abnormalities, diagnosis, and treatment.

Increased prevalence of obstructive sleep apnea in patients with pectus excavatum: A pilot study

OBJECTIVE

Laryngomalacia is the most common congenital laryngeal anomaly and is associated with pectus excavatum (PE). Patients with laryngomalacia and patients with obstructive sleep apnea (OSA) both experience upper airway obstruction, and patients with laryngomalacia had been found to have a higher prevalence of PE. However, no studies have established the prevalence of OSA in patients with PE. We conducted this pilot study to evaluate the prevalence of OSA in patients with PE.

MATERIALS AND METHODS

A total of 42 patients ≥20 years old with PE who were admitted for Nuss surgery to correct PE in Taipei Tzu Chi Hospital between October 2015 and September 2016 were invited to participate in the study; 31 of the 42 patients agreed. All 31 patients completed an Epworth sleepiness scale questionnaire to evaluate excessive daytime sleepiness (EDS) and underwent overnight polysomnography to evaluate OSA before Nuss surgery.

RESULTS

The prevalence of snoring in the study participants was 100%. Ten of 31 patients (32.3%) reported EDS. The overall prevalence of OSA with an apnea/hypopnea index ≥5/h was 25.8%, and all patients with OSA were men.

CONCLUSIONS

The prevalence of OSA in patients with PE seemed to be higher than that previously reported in the general population, implying that OSA might be a potential etiology or, at least, an aggravating factor for the development or progression of PE or might be responsible for the postoperative recurrence of PE in some patients. Further studies are needed to clarify this relationship.

Poorer sleep quality among adult patients with pectus excavatum in Taiwan: A pilot study

OBJECTIVES

Patients with pectus excavatum have a poorer quality of life than the general population. Sleep quality is a critical component of quality of life. This pilot study compared the sleep quality of adult patients with pectus excavatum with that of the general population in Taiwan.

METHODS

Participants comprised 30 healthy adults, 21 adult outpatients with pectus excavatum, and 33 adults with pectus excavatum receiving Nuss surgery. The Pittsburgh Sleep Quality Index measured subjective sleep quality; the Visual Analog Scale for Pain, Brief Symptom Rating Scale-5, Beck Depression Inventory II, and 36-Item Short Form Survey measured quality of life; and the Epworth Sleepiness Scale measured excessive daytime sleepiness. Outcome measurements were obtained at baseline for all groups and 6 months after Nuss surgery for inpatients.

RESULTS

Patients with pectus excavatum had poorer sleep quality and worse quality of life than controls. Poorer sleep quality was not related to the severity of pectus excavatum per se, but to psychologic issues (beta = 0.18, P < .001 in multiple linear regression analysis). Measurement time had no effect on sleep quality (beta = 0.31, P = .594 for outpatient group; beta = 0.27, P = .665 for inpatients). Sleep quality of patients with pectus excavatum improved after Nuss surgery (Pittsburgh Sleep Quality Index: 4 vs 7, P = .002).

CONCLUSIONS

Our findings suggested an association between poor sleep quality and pectus excavatum; thus, sleep quality should be evaluated before and after the Nuss procedure.

Effect on Chest Deformation of Simultaneous Correction of Pectus Excavatum with Scoliosis

Objective

This paper is to understand the effect of simultaneous correction of pectus excavatum with scoliosis and to provide some useful information for clinical orthopedic surgery design.

Methods

The method of a three-dimensional reconstruction has been used to the reconstruction of the chest model of pectus excavatum with scoliosis, and the numerical stimulation has been conducted to the process of minimally invasive correction. Three kinds of correction methods have been considered in the numerical simulation, stretch spine, stretch spine and minimally invasive correction at the same time, and release stretch spine after stretch spine and minimally invasive correction of pectus excavatum at the same time.

Results

It is found that stretch spine may help to correction of scoliosis but aggravate the sternum collapse, and release stretch spine after stretch spine and minimally invasive correction at the same time could not only be good at scoliosis but also improve the collapse of the sternum, which could help to improve the heartbeat and breath of the patients.

Conclusion

Among the three kinds of correction methods, release stretch spine after stretch spine and minimally invasive correction at the same time could help to improve both the scoliosis and the collapse of the sternum.

Risk factors for thoracic and spinal deformities following lung resection in neonates, infants, and children

Purpose

We aimed to identify the risk factors for thoracic and spinal deformities following lung resection during childhood and to elucidate whether thoracoscopic surgery reduces the risk of complications after lung resection.

Methods

We retrospectively examined the medical records of all pediatric patients who underwent lung resection for congenital lung disease at our institution between 1989 and 2014.

Results

Seventy-four patients underwent lung resection during the study period and were followed-up. The median age of the patients at the time of surgery was 5 months (range 1 day–13 years), and 22 were neonates. Thoracotomy and thoracoscopy were performed in 25 and 49 patients, respectively. Thoracic or spinal deformities occurred in 28 of the 74 patients (37%). Univariate analyses identified thoracotomy, being a neonate (age: <1 month) at the time of surgery, and being symptomatic at the time of surgery as risk factors for these deformities. However, a multivariate analysis indicated that only thoracotomy and being a neonate were risk factors for deformities.

Conclusions

Thoracoscopic surgery reduced the risk of thoracic and spinal deformities following lung resection in children. We suggest that, where possible, lung resection should be avoided until 2 or 3 months of age.

Pectus deformities and their impact on pulmonary physiology

Pectus excavatum (PE) and pectus carinatum (PC) are the most common anomalies of the thoracic cage and they have been recognized since ancient times [1-3]. The two conditions differ in their appearance, and their effect on lung function. There is no direct correlation between the appearance of the deformities and the clinical symptoms. Whether, and when these deformities should be corrected as well as with which method (surgical or conservative) remain controversial. The following article reviews the current concepts regarding the pathophysiology of both conditions as well as the advances in their evaluation and management.

Risk factors for failure of supraglottoplasty

OBJECTIVES

To assess for identifiable risk factors for failed surgical intervention in children with laryngomalacia.

METHODS

Retrospective case note review between September 2007 and March 2012. Case notes were reviewed for demographic data, symptoms, co-morbidities, operative technique, postoperative recovery, complications, length of hospital stay including intensive care unit (ICU) care, and resolution of symptoms.

RESULTS

148 children underwent supraglottoplasty. Case notes were available for 115 (78%) patients. 35% (41/115) of cases were females and 65% (74/115) were male. A bimodal age distribution was observed with peaks at 3 months and 3.5 years. Those over one year of age were more likely to have complications (p = 0.035). There was no significant difference in outcomes for age (p > 0.05). In patients less than one year, reflux symptoms were significantly associated with a higher likelihood of failure of the operation (p = 0.013). Patients under one year with pre-operatively identified comorbid conditions were less likely to have an improvement in breathing (p = 0.002). Cold steel was used in 55% (63/115) of cases, laser only in 17% (20/115) cases and a combination of the two techniques in 28%, (32/115). There was no association between the surgical technique used and complications (p = 0.558). There was no association between improvement in symptoms and surgical technique used (p = 0.560). There was a significant association between delayed post-operative neurological diagnosis and failure of the operation (p < 0.001). 21 (18%) patients required a second procedure.

CONCLUSIONS

Pre-operative predictors of failure were patients with reflux symptoms (p = 0.013). Patients that required a second procedure were 37 times more likely to have a delayed diagnosis of an underlying neurological condition. Failure of symptoms to improve after supraglottoplasty should alert the clinician to the possibility of an underlying neurological disorder.